TThe U.S. has regressed in controlling high blood pressure, despite easy access to medications and other tools to reduce its risks. Dan Jones, former president of the American Heart Association, thinks the nation can learn from China.
Researchers there recently described the success of community health workers—well-trained people but not doctors—who are helping thousands of people with high blood pressure in rural areas. People who received a combination of blood pressure monitoring, medication adjustments, and health coaching from these non-clinicians saw their blood pressure levels drop significantly over the four years of the study, a testament to the impact of people known as “village doctors” who went above and beyond than normal care in the healthcare system.
Why can’t we do that here? Jones asks this question in light of the crucial role of hypertension in heart attacks, strokes, heart failure and sudden cardiac arrest.
Despite safer, cheaper, more effective and better-tolerated drugs, “it is quite clear that efforts to control blood pressure and reduce the risk of cardiovascular disease are inadequate,” he wrote in an article. editorial appear with the study. “Our efforts are failing for patients.”
These patients are not well served by a physician community that limits the scope of practice for other practitioners, said Jones, a general internist who has focused on cardiovascular disease prevention and racial disparities in cardiovascular outcomes. He has visited China since 1985 and also practiced medicine in South Korea for seven years. He spoke to STAT about why the US isn’t doing better with the tools available to improve control of blood pressure rates, which have worsened since 2014, after several years of improvement before that. This conversation has been lightly edited for length and clarity.
Where does the problem of poor blood pressure control begin?
There are many challenges, but one of the most important is clinical apathy. You know, doctors simply don’t pay enough attention to controlling blood pressure. There is certainly also patient apathy.
Why is prevention so difficult in the US?
We’re just not built to deal with prevention. We like fast results. We love high tech, and as a culture we are not very interested in simple things and things that take a long time to produce results. We have a healthcare system built on rewarding innovation and the end of disease in the treatment of cardiovascular disease.
So if you have a new catheter to put in the coronary arteries, or a new drug that affects lipid levels or clotting, there’s a lot of interest in that, so there’s a lot of money in it. But when you talk about treating high blood pressure, there’s just not a lot of interest in health care systems and not enough interest among doctors and other health care providers.
High blood pressure is the ‘silent killer’. Is that also what makes it difficult?
It is the fact that the risk factors for both elevated cholesterol and blood pressure are not associated with symptoms. So you find it difficult to get people to do lifestyle-related things and constantly use medications to control those problems. In today’s healthcare world, doctors have less and less time to deal with the patient and are more likely to focus on the complaint at hand, rather than on the long term of trying to help that person live a longer, healthier life.
What is the history of this model in China, both in terms of healthcare and outcomes?
From the mid-1980s to the present, life expectancy in China has been 10 to 15 years lower than the US, and in some respects perhaps even slightly better than the US. And they do this with much less investment in healthcare. but with smarter investments.
In the mid-1980s I became fascinated by the concept of the ‘village doctor’, which at the time focused mainly on infectious diseases, with a major emphasis on tuberculosis and on immunization for preventable diseases. They would take a minimally trained person and make him responsible for 300 people at the time I first started looking at the village doctor model.
As the study authors noted, the model they use can be replicated in other countries with few resources. And I pointed out that the model would also be useful in resource-rich countries.
How did that work there?
In the first attempts to use someone other than a doctor and to do something other than coming to an acute care center for a visit, community health workers initially measured blood pressure and told patients that their blood pressure was not under control. “Well, you need to go to your doctor and have something done.” Those models made little difference.
What was missing in China and in an American process?
Started about ten years ago, researcher Ron Victor – now deceased – started doing this kind of thing among African-American men in the US, using barbershops as a place to engage the community to measure blood pressure and educate patients about their blood pressure.
In the first few studies he reported very little difference in blood pressure control. And then he used the same model in barbershops, but added pharmacists specially trained in blood pressure management. It was a protocol developed by physicians, but the pharmacist had the authority to change the dose of medication.
That was the secret: not just understanding what the blood pressure was, but responding to it immediately.
Is that practiced elsewhere in the US?
We replicated it using telemedicine with fully remote interactions, using nurses instead of pharmacists. The key is to have a protocol that can be followed. We have been doing this for years in our blood pressure research.
In my practice at the University of Mississippi Medical Center, I recruited patients to participate in clinical trials, testing new medications or lifestyle therapy. I would have nurses who were two years graduates of a community college and have RNs at the interface with the patient, following the protocol I developed. They measure blood pressure and then make decisions per protocol. In that model, blood pressure was controlled much better than waiting for the patient to see me at the next three-month visit to make the change.
Will this idea meet resistance from doctors?
Part of the problem in the US will be the scope of practice. I don’t want to be too hard on my own profession, but the physician community has been very successful in limiting the scope of practice for other practitioners. This is part of the problem that needs to be addressed in our healthcare structure, to find a way to accept a broader scope of practice for pharmacists, nurses, nurses and perhaps even community health workers when applying a protocol developed by doctors. or someone else who has enough knowledge to develop a protocol.
What are other barriers to seeing more “village doctors” in the US?
In some places it is easier to make decisions. I don’t want to be overly political. I’m a big fan of democracies, but in autocratic countries like China it’s much easier to make changes than in a democratic society like the United States. A central authority can make the decision: let’s do it this way and get it done. It changes the healthcare model. Healthcare delivery is a very complicated process in the United States and to some extent in Europe as well.
How has this approach come across to your patients?
Acceptance has been good. Patients actually enjoy being able to talk to someone at a different level than a doctor. They like someone they can go to for questions. And the model that we used in one of our studies in Mississippi was completely telehealth. The patients responded very well to being given an iPad to report their blood pressure, and the nurse came back to them later in the day with a note saying you’re doing well, keep up the good work or we’ll have to work on sodium restriction or we need to increase the dose of your calcium channel antagonist.
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