The role of patient education in improving treatment compliance in hypertension

Budbrooke Medical Centre
Hampton Magna, Warwick

Interview with H. White, United Kingdom

Current guidelines on hypertension management continue to emphasize the importance of hypertension awareness. More effort should be placed on increasing patient education and the willingness of patients to cooperate with physical examinations in order to improve treatment efficacy. Published meta-analyses suggest that improved patient education will bring about a reduction in systolic blood pressure of up to 11 mm Hg; such a reduction in 10 million hypertensives would prevent about 150 000 cardiovascular events over 5 years. Health services struggling to contend with aging populations and risingmorbidity need to reduce the toll of cardiovascular disease. This article examines a novel and cost-effective approach to educating patients about hypertension and cardiovascular disease, in which key opinion leaders have collaborated with professional documentary makers. They have produced a viewer-friendly resource modeled on TV documentaries and dramas, which health professionals can give to their patients on DVD to watch at home. In effect, this will be an extension of the traditional consultation, enhancing its messages as well as saving clinicians’ time. A clinical audit has shown that because the DVD has been physically handed to them by a trusted professional, uptake is nearly 100%. As a result, over three quarters of patients improve their lifestyle. This level of engagement is greatly superior to that of the more “fashionable” Internet-based resources. Cardiovascular disease is the world’s biggest killer, accounting for 41% of deaths in the USA, and hypertension is a major cause. Yet even in the UK where primary care is relatively well organized, only 22% of hypertensives are controlled to target. The author and his collaborators have targeted their DVD directly at patients, with the aim of better equipping them to act as partners in their own care.

Medicographia. 2010;32:290-293 (see French abstract on page 293)

As a practicing GP treating hypertensive patients every day, would you say that you and your patients are on the “same side of the barricade” in the fight against high blood pressure?

There is certainly a lot of work to do to persuade patients that the investment of time and effort in lifestyle change and the perceived drawbacks of medication are worth it in the long run. Our job as health professionals is to raise people’s awareness of their future health so that it becomes a daily consideration on a par with other long-term goals, such as financial wellbeing, career, family commitments, and so on. If we do succeed in persuading them, then the majority will work with us and reduce their risk, but it involves a lot of input. If we only use traditional consulting techniques, we will usually not have sufficient time.

In your opinion, why do some patients who are motorists readily heed traffic lights yet fail to consider elevated BP as a “red light”?

High blood pressure (BP) is usually asymptomatic and the hazards are perceived as lying some years in the future, so the danger is not as clear and immediate as more quotidian hazards, such as driving. A driver approaching a red traffic light pays close attention and believes (sometimes wrongly!) that he is in control of the outcome. Patients with high BP, on the other hand, sometimes fail to appreciate the extent to which they can take control and reduce their risk of cardiovascular disease either by sustainable lifestyle change or by closer collaboration with their clinician. There is a tendency to regard BP as a matter for their doctor to deal with.

Our task as health professionals is to gradually raise people’s awareness not only of the risk, but also of the fact that it can be significantly reduced if people become personally involved in their own care. Individuals quite often have a superficial understanding of the issues. For example, they have heard on the radio that “salt is bad,” but they lack a deeper understanding of the science behind it all to either appreciate the extent to which it applies to them or to recognize what practical steps they can take. Part of a primary care clinician’s work is to fill these gaps in patients’ knowledge; I believe that modern media technology will enable us to do that much more effectively if the right resources can be devised and deployed.

What could be done or are you doing already to encourage patients to take an active part in the management of their hypertension?

As professionals we need to establish a relationship of trust if we are to persuade patients to focus on their long-term health. That trust will be reinforced by sharing as much of our knowledge as possible.

For any of us to actually alter our diet, go to a gym, or take a tablet every day amounts to a substantial investment. No one will do that unless they are confident that they understand all the facts; and so the key to success is to help people to have as deep an understanding of their condition as possible. If we succeed, they will take their problem seriously without being too frightened to think about it and will realize that better outcomes are possible at minimal cost. Furthermore, we will enable them to make correct decisions on a daily basis.

Traditional consultation is still the cornerstone, but the issues are so complex that they cannot be covered, let alone absorbed, in the 10 to 20 minutes available in primary care. In collaboration with Professor Neil Poulter and Professor Peter Sever of Imperial College London, I have made a DVD for patients that employs a full range of documentary techniques to take the patient through explanations of high BP, its treatment, and its causes and of cardiovascular disease prevention. The principal advantages over Web-based resources are that it is given by a known and trusted health professional as an extension of a consultation and that it can be watched in comfort and in company. The aim of the DVD is to help patients deepen their understanding of their condition so that they can work more effectively with us as partners in their own care. We have completed an independent clinical audit of the DVD in UK general practices that shows that 95% percent of patients watch it after their doctor or nurse has asked them to. All of them said they would recommend the DVD to others. Eighty-one percent reported a change in lifestyle, and we were delighted to find that about a third of the smokers in the group had actually quit after 6 weeks.

The audit supports our own perception that in-depth education in this format really does work, and of course it is very cost-effective when compared to labor-intensive counseling.

How would you evaluate the impact of lifestyle adaptation in hypertension management?

There are several meta-analyses which help us here. In 2003, Boulware et al1 conducted a meta-analysis of studies comparing patient counseling to ordinary care. Pooled data from 15 studies showed that counseling led to an additional systolic blood pressure (SBP) reduction of 11.1 mm Hg. In 2003, Roumie et al2 conducted a study in the USA on 1341 patients that evaluated the effect of adding targeted patient education (a letter plus the offer of counseling) to the care package. Patient education resulted in an additional SBP reduction of 8 mm Hg. It seems that if a special (and costly) effort is made, then a reduction of about 10 mm Hg can be achieved. Our intention inmaking the DVD was to offer firstclass patient education and advice at a very low cost.

Can you tell us how you have structured the DVD?

We realized that the DVD had to cater for the whole population and cover a wide range of knowledge and interests. We deployed the filmmaker’s art not only to save the clinician time, but to convey a depth of understanding that face-to-face consultation simply cannot do.

Figure 1
Figure 1. Depiction of the increase in 10-year risk
of heart attack in the United Kingdom as
total cholesterol level increases.

The first item on the menu is a light-hearted 15- minute drama with a celebrity actor, which covers the key messages in a way that holds the attention of almost everybody. Our “hero” is an unreformed gourmand.We meet him guzzling pork pies (Figure 1) and mocking his more careful neighbor over the garden fence. As the story progresses, he is found to have high BP and has to come to terms with it, accepting treatment and finding the process much easier than he expected. There is a twist to the story; the reason his neighbor turns out to be taking such good care of his diet and lifestyle is because he has a strong family history of heart disease. His problems could have been avoided had he known more and had modern screening and treatments.

Next on the list is a 70-minute documentary, broken into 3 manageable sections of 20 to 25 minutes. These cover the nature and causes of high BP, the other causes of cardiovascular disease (including dyslipidemia, smoking, and type 2 diabetes), the concept of cardiovascular risk, and finally treatment with lifestyle change and medication. In this last section, we talk the audience through a standard approach to a newly diagnosed hypertensive patient, basing treatment on overall cardiovascular risk, employing lifestyle change first and then medication. Animation shows the mode of action of the major drug groups, including angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, diuretics, aspirin, and statins. Our documentary makers were keen to avoid the commonly used format of doctors in white coats “lecturing” patients on what to do. They worked with us to craft a story, using animation, footage from all over the world, patient interviews, and extracts from discussions with the experts to take the viewer on a tour of the subject.

After the documentary is a 15-minute section that covers the particular needs of different ethnic groups and the elderly. Some patients like to know as much as their doctor, or more, and so we finish up with a 30-minute seminar in which we discuss the management guidelines that have been produced by the UK, the USA, Europe, and the World Health Organization. We also cover practical topics, such as home monitoring, when to refer, hypertension in pregnancy, and treatment of resistant hypertension. We have found that this last section, which we call “the doctor’s cut,” is particularly useful for primary care health professionals and can be used as a teaching aid in its own right.

The role of home BP monitoring is currently being widely discussed. What is your opinion of this type of monitoring?

It is very useful provided that the patient uses a properly validated device (the UK charity the Blood Pressure Association advises patients on which devices to use on their Web site: ) and that their technique is checked. Taking the readings keeps the patient focused on their management and provides the doctor or nurse with valuable corroborative data. One should take into account the fact that home systolic readings are on average 12 mm Hg less than those obtained in clinic (diastolic readings are 6 mm Hg less).

Most patients find it very hard to come to terms with the fact that treatment is lifelong and won’t make their hypertension disappear after a few months. What could improve patient adherence to treatment?

First and foremost, we need to foster a good long-termrapport between the patient and their primary care health professional, where management and counseling are tailored to the patient’s individual concerns. Helping them understand the science is a key step in the process of alleviating any misconceptions and motivating the patient to make lifestyle changes. Patients usually take a few weeks to come to terms with the idea of medication, so unless the risk is very high it pays to focus on explanation and lifestyle change initially. Using drugs or drug combinations that minimize side effects is a great help. For example, we know that calcium channel blockers are less likely to cause ankle swelling if administered along with drugs that inhibit the renin-angiotensin system (ACE inhibitors or angiotensin receptor blockers).

How do you see the role of the medical community and society in general in the fight against hypertension?

Health professionals remain very much at the centre of efforts to focus government policy. We know that collective action, such as a smoking ban, can assist individuals in making lifestyle changes.

Figure 2
Figure 2. Representation of how the prevalence
of high blood pressure changes with average daily
salt intake in different populations worldwide.

The cost effectiveness argument for large-scale, inexpensive public health education about cardiovascular disease is overwhelming. The studies quoted above show that additional patient counseling reduces SBP by 10 mm Hg, and our audit showed a similar effect to that of our DVD. Professor Neil Poulter of Imperial College London estimates that if you achieved that reduction in 10 million hypertensive patients, you would prevent about 150 000 heart attacks and strokes over 5 years. If public health organizations could do it with something as cheap as a DVD for, say, 30 pence per patient, in huge numbers, then they would prevent one event for each £20 spent; that is very attractive when you consider what a stroke costs to treat. Government public health departments work on the basis that £20 000 per event prevented is good value.
Aside from education, various lobbies, including the UK’s Blood Pressure Association and the Scottish High Blood Pressure Foundation, are trying to persuade governments to extend collective action to achieve a reduction in the salt content of processed food (Figure 2). The more support they receive from health professionals and other patient groups, the more likely they are to succeed. _

1. Boulware LE, Daumit GL, Frick KD, Minkovitz CS, Lawrence RS, Powe NR. An evidence-based review of patient-centered behavioral interventions for hypertension. Am J Prev Med. 2001;21:221-232.
2. Roumie CL, Elasy TA, Greevy R, et al. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Ann Intern Med. 2006;145:165-175.

Keywords: patient education; treatment compliance; hypertension; DVD; television documentary