Family Practice Vol. 19, No. 3, 310
© Oxford University Press 2002
Shared decision making in Hypertension
Battersea Research Group Alfriston Road London SW11 6NW UK
Montgomery and others looked at the impact of patient preferences on choice of treatment for hypertension.1They suggested that patient preference influences the recommended treatment more than cardiovascular risk assessment. However, busy GPs may not have time to involve patients in sufficiently detailed discussion of their care. This may be particularly true for older patients. They often have complex health and social problems and also problems with hearing and understanding, especially when the consultation is hurried. Although nurses may be able to offer more time to individual patients, it is unclear whether nurse-led care is better than routine GP care in the treatment of hypertension.2
In September 2001, we conducted a feasibility study of a nurse-led hypertension clinic for those aged over 65 in an inner city practice. Using Emis, we ran a search to find patients over 65 with a computer diagnosis of hypertension. We excluded the housebound and those in residential care. From these, we randomly selected 10%, giving us 16 patients, whom we invited to attend for a blood pressure check. We also randomly selected 14 patients over 65 who were not known to be either hypertensive or diabetic, whom we invited for a health check. Both groups of patients were invited to complete a health questionnaire, which was sent with the invitation to the clinic.
The planned 20 minute consultation would include a review of patient's cardiovascular history and present medication; three blood pressure readings using an automatic Omron cuff and taking the average of the last readings, and the introduction of a A5 sized patient-held folder, with diet and lifestyle diary, list of medication, appointment card and record of investigations.
Thirteen patients (43%) made an appointment but 69% (11/16) of those from the known hypertensive group. Eleven of them (85%) attended (and one patient brought her hypertensive husband). All attendees completed at least part of the one-page questionnaire, brought a urine sample and took away the patient-held record. Nine of 12 hypertensives (75%) had a recorded blood pressure outside NSF guidelines (140/85 mmHg) of whom three were of African ethnic origin. Four patients with systolic blood pressure >160 mmHg were referred back to their GP. We found that a minimum of 30 minutes per patient was needed. Patients brought many issues including bereavement, loneliness, multiple pathology, complex medication and varying degrees of confusion concerning treatment.
The main role of the nurse emerged as co-ordinator of care. This involved call/recall, accurate measurement and monitoring of blood pressure, reviewing adherence to treatment and ensuring the patient understood the need for lifelong care with the aim of preventing strokes and heart trouble. We found the patient-held record, although popular, was not used much in practice and might need to be simplified to be of practical value.
The high number of hypertensive patients attending and the initial positive response to the patient-held folder suggest that older patients are keen to be involved in their treatment and lifestyle modifications. People of this age may be a neglected group who are at particular risk of the adverse effects of hypertension and easily lost to follow-up. In the light of Montgomery's observations on shared decision making, we suggest the possible benefits of nurse-led hypertension clinics in primary care warrant further investigation.1
Acknowledgments
We thank the patients and staff at Manor Health Centre Clapham, SW4 for their help with this project. The feasibility study was funded by Battersea Research Group.
References
1
Montgomery AA, Harding J, Fahey T. Shared decision making in hypertension: the impact of patient preferences on treatment choice. Fam Pract 2001; 18: 309–313.
2 Ebrahim S. Detection, adherence and control of hypertension for the prevention of stroke: a systemic review. Health Technol Assess 1998; 2: 11.
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