COMMENTARY
Routine Screening for High Blood Pressure Outside of Primary Care: An Idea Whose Time Has Come David S. Kountz, MD, MBA From the Jersey Shore University Medical Center/Meridian Health, Neptune, NJ
In the past, a study from an integrated health-care delivery system would impact only the very few of us. I for one would sigh in envy as they often demonstrated fantastic results but would be removed from “the real world.” Well, the real world has changed––more than 80% of us in primary care use an electronic health record (EHR), and the majority of us have been or soon will be approached to join some type of integrated care system, such as an Accountable Care Organization (ACO). It is with this lens that the potential for broad benefit of the study in this issue of The Journal of Clinical Hypertension by Handler and colleagues1 is so appealing. During a 26-month period from 2009 through 2011, more than 1,000,000 patients were screened for high blood pressure in primary care and nonprimary care offices. Nurses and medical assistants were trained using a standardized protocol to measure blood pressure in specialists’ offices, most notably optometry/ophthalmology, neurology, and dermatology––sites where patients often receive longitudinal care and do not see a primary care provider. During the study period almost 112,000 patients were found to have blood pressure >140/90 mm Hg, with 19,000 identified in nonprimary care settings. These patients tended to be older, male, non-Hispanic whites, and less likely to be obese but more likely to smoke or have a Framingham risk score >20%. There was a high rate of false-positive readings (>80%, which is problematic), but this was comparable between primary care and nonprimary care settings. Hypertension is a critical and common underlying condition seen in neurologic, ophthalmologic, and even dermatologic conditions (psoriasis). It makes intuitive sense for these specialties to measure blood pressure,
Address for correspondence: David S. Kountz, MD, MBA, Jersey Shore University Medical Center/Meridian Health, 1945 Route 33, Neptune 07754, NJ. E-mail: [email protected] DOI: 10.1111/jch.12514
440
The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
although it is rarely done on a routine basis.2 Reasons include, but are not limited to, lack of reimbursement for screening, lack of staff training, and lack of protocols to address elevated readings and ensure appropriate follow-up. However, as the world of reimbursement for medical practice changes, we will revisit this paradigm. In an ACO world, it benefits everyone to identify and address hypertension to prevent a catastrophic complication. It will be cost effective to train staff and efficient to communicate these findings across the system via an EHR. There is good evidence of the role that community health workers3 and pharmacists4 play in screening for high blood pressure. Neither group, however, has the potential impact of a physician in influencing a patient to obtain follow-up care. As we enter this new world of reimbursement, broadbased screening for common conditions will be an important strategy to coordinate care and reduce costs. It is those physicians and health system leaders who read the paper by Handler and say “why not” rather than “why bother” who will be successful in the future. References 1. Handler J, Mohan Y, Kanter M, et al. Screening for high blood pressure in adults during ambulatory nonprimary care visits: opportunities to improve hypertension recognition. J Clin Hypertens (Greenwich). 2015;17:431–439. 2. Ma J, Stafford RS. Screening, treatment and control of hypertension in US private physician offices, 2003–2004. Hypertension. 2008;51:1275– 1281. 3. Brownstein JM, Bone LR,Dennison CR, et al. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J Prev Med. 2005;29(suppl 1):128–133. 4. Snella KA, Canalas AE, et al. Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high risk individuals. J Am Pharm Assoc. 2006;46:370–377.
Routine Screening for High Blood Pressure Outside of Primary Care: An Idea Whose Time Has Come David S. Kountz, MD, MBA From the Jersey Shore University Medical Center/Meridian Health, Neptune, NJ
In the past, a study from an integrated health-care delivery system would impact only the very few of us. I for one would sigh in envy as they often demonstrated fantastic results but would be removed from “the real world.” Well, the real world has changed––more than 80% of us in primary care use an electronic health record (EHR), and the majority of us have been or soon will be approached to join some type of integrated care system, such as an Accountable Care Organization (ACO). It is with this lens that the potential for broad benefit of the study in this issue of The Journal of Clinical Hypertension by Handler and colleagues1 is so appealing. During a 26-month period from 2009 through 2011, more than 1,000,000 patients were screened for high blood pressure in primary care and nonprimary care offices. Nurses and medical assistants were trained using a standardized protocol to measure blood pressure in specialists’ offices, most notably optometry/ophthalmology, neurology, and dermatology––sites where patients often receive longitudinal care and do not see a primary care provider. During the study period almost 112,000 patients were found to have blood pressure >140/90 mm Hg, with 19,000 identified in nonprimary care settings. These patients tended to be older, male, non-Hispanic whites, and less likely to be obese but more likely to smoke or have a Framingham risk score >20%. There was a high rate of false-positive readings (>80%, which is problematic), but this was comparable between primary care and nonprimary care settings. Hypertension is a critical and common underlying condition seen in neurologic, ophthalmologic, and even dermatologic conditions (psoriasis). It makes intuitive sense for these specialties to measure blood pressure,
Address for correspondence: David S. Kountz, MD, MBA, Jersey Shore University Medical Center/Meridian Health, 1945 Route 33, Neptune 07754, NJ. E-mail: [email protected] DOI: 10.1111/jch.12514
440
The Journal of Clinical Hypertension
Vol 17 | No 6 | June 2015
although it is rarely done on a routine basis.2 Reasons include, but are not limited to, lack of reimbursement for screening, lack of staff training, and lack of protocols to address elevated readings and ensure appropriate follow-up. However, as the world of reimbursement for medical practice changes, we will revisit this paradigm. In an ACO world, it benefits everyone to identify and address hypertension to prevent a catastrophic complication. It will be cost effective to train staff and efficient to communicate these findings across the system via an EHR. There is good evidence of the role that community health workers3 and pharmacists4 play in screening for high blood pressure. Neither group, however, has the potential impact of a physician in influencing a patient to obtain follow-up care. As we enter this new world of reimbursement, broadbased screening for common conditions will be an important strategy to coordinate care and reduce costs. It is those physicians and health system leaders who read the paper by Handler and say “why not” rather than “why bother” who will be successful in the future. References 1. Handler J, Mohan Y, Kanter M, et al. Screening for high blood pressure in adults during ambulatory nonprimary care visits: opportunities to improve hypertension recognition. J Clin Hypertens (Greenwich). 2015;17:431–439. 2. Ma J, Stafford RS. Screening, treatment and control of hypertension in US private physician offices, 2003–2004. Hypertension. 2008;51:1275– 1281. 3. Brownstein JM, Bone LR,Dennison CR, et al. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J Prev Med. 2005;29(suppl 1):128–133. 4. Snella KA, Canalas AE, et al. Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high risk individuals. J Am Pharm Assoc. 2006;46:370–377.
