Friday, June 12, 2009

The Lake Wobegon effect in the treatment of hypertension

Not all docs are above average but, according to this study, most of us tend to think we do a better job of treating HT than we actually do. Moreover, when the patient doesn’t reach goal we blame it on “noncompliance.”

Is it a case of pure self deception or are there external factors at work? Lack of familiarity with the HT guidelines and the barriers inherent in treating all of patients’ multiple problems to “goal” were cited in this Medscape report on the study:

"The JNC guidelines are 60 to 70 pages long. In primary care, we treat a vast variety of diseases, all of which come with their own guidelines, and we then run into the problem of competing demands. The reality is that if primary-care physicians did all the screening and preventive recommendations that are out there, there would be about 20 to 30 minutes left in the day to do everything else. So it becomes a matter of focus. And in our attempts to focus on a lot of things, we're not seeing the forest for the trees," said Wexler.

Or, as DB recently put it, when patients have multiple problems we have to prioritize:

We are unlikely to do enough research to develop guidelines for each situation. As physicians we must make difficult decisions about which diseases to treat aggressively and which diseases deserve less aggressive measures.

On a related note one expert interviewed for the Medscape piece said that doctors would be more likely to embrace guidelines calling for different targets in different comorbid conditions if they were supported by more research on what targets are best:

In answer to Wexler's plea for more concise recommendations for the treatment of blood pressure, Nicholls said more evidence-based studies to answer the "really important question--what is the ideal blood pressure that our patients at various levels of risk should be at?" are essential.

"If we do those studies, and we get more and more evidence, the blood-pressure guidelines will become a lot clearer, and then, I think, clinicians will feel that they are
in a much more comfortable position to be able to embrace the guidelines and follow them."

What‘s better, 140/90, 130/80 or 120/70? Ask those questions for each of several comorbidities and age ranges. We’re doing that with lipid control now (where the field has reached some degree of maturity), ambulatory diabetes control (where we have more questions than answers) and in patient glycemic control (where our knowledge is in its infancy). Think of the research possibilities! It could be a whole new agenda: comparative target research!

1 comment:

Chuck Brooks said...

Hypertension has been around for quite a while, and the wonder is why guidelines keep comming and going. Not to mention expert(s) A says 'X', and expert(s) B says 'not X'.
Chuck Brooks
FutureWare SCG