EXPECTATIONS OF BLOOD PRESSURE MANAGEMENT: DISCUSSION

Posted by James

We elicited expectations of treatment in 93 hypertensive African-American patients followed in a primary care practice. This is the only study, to our knowledge, that explored expectations of blood pressure treatment in this patient population. Our findings indicate that patients had multiple, varied expectations of their blood pressure treatment that were grouped into three major categories and the theme underlying these categories was role identification, such that patients attributed specific roles or functions in the course of treatment to themselves (patient’s role), to their physicians (physician’s role), and to their medications (medication effects). Contrary to previous beliefs, the majority of patients actually expected to follow their physi­dans’ recommendations, such as taking their medications, being proactive in their care, and seeking prognostic information. They expected their physicians to serve as sources of information; they wanted their physicians to educate them about the side effects of their medications as well as their mechanism of action; and they expected appropriate physiologic response from medications, such as blood pressure lowering and prevention of complications.

Although the expectations of treatment elicited from this group of patients fit within appropriate treatment guidelines for hypertension, a considerable proportion of patients (65%) had at least one nonbiomedical expectations of their treatment regarding the duration of treatment for hypertension, the cure of hypertension, and whether or not medications should be taken only with symptoms. This finding is consistent with that of other investigators who have shown that hypertensive African-American patients have misconceptions about the nature and treatment of hypertension. For instance, in the study by Wilson et al., hypertension was perceived as an episodic, symptomatic illness often associated with stress, and patients’ decisions to take or not take medications depended upon the presence of such symptoms. As such, in communicating with this group of patients about treatment options, it is important to elicit the role patients expect to play in their care, the role they expect their physicians to play, and what effects they expect the medications to have on their blood pressure. Such understanding may enhance the interaction between patients and their physicians with a resultant development of mutual treatment goals.  silagra 100

Another interesting finding in our study relates to the issue of trust. For instance, some patients thought their doctors prescribed medications for them despite been cured of their hypertension, while others felt that hypertension is curable for European Americans but not for African Americans. This finding parallels the lack of trust in the healthcare system noted in African Americans both in receiving care and participating in clinical trials. For example, in the study by Rose et al. of the social, cultural, and personal contexts of adherence in hypertensive African-American men in Baltimore, participants identified their race/ethnicity as a major cause of their hypertension, and they also attributed frequent adjustment of their medications to being “studied” with experimental drugs. Similarly, mistrust of the medical establishment by African Americans was a strong predictor of willingness to serve as organ donors or participate in clinical trials. Such mistrust of the medical establishment (perhaps due to events, such as the Tuskegee Syphilis Study), may eventually lead to poor compliance and subsequent poor outcomes noted in this patient population. As such, it important for physicians and other healthcare providers to have a frank discussion around the issues of blood pressure treatment with their patients before initiating treatment. Part of such discussion may include allaying patients’ fear about being experimental subjects; emphasizing to patients that medications are equally good for blacks, more so given the plethora of clinical trial evidence of the blood-pressure-lowering effects of both pharmacologic and nonpharmacologic interventions in black patients. It is important to note some limitations of our study. First, our results may not be generalizable to other settings because the participants in this study were predominantly women—middle aged and low-income. Perceptions of younger and more affluent patients may be different from what we report here. Second, the qualitative nature of our findings does not allow us to draw valid conclusions about the true prevalence of the identified categories in the broader populations. This will require the conduct of larger, population-based surveys. Third, regarding measurement of expectations, we recognize that patients provide more expectations when offered self-administered questionnaires than when interviewed face-to-face, as we did in this study. As such, the range of expectations we elicited from this group of patients may not be comprehensive enough. Finally, the interviews in this study were conducted by only one interviewer, whose field notes served as the basis for the qualitative analysis. This approach may be limited in its ability to capture relevant themes that may have been captured by audio-taping of the interview sessions or use of multiple interviewers. As such, as with the previous limitation, the range of the expectations cited in this study may be broader than what we reported here. antibiotics online pharmacy

Practice Implications

The results of this study have important and pragmatic clinical implications for primary care providers who take care of hypertensive African-American patients. Healthcare providers would do well to identify patients’ expectations of treatment before prescribing antihypertensive medications. The taxonomy of expectations of treatment that we generated in this study provides a useful framework for eliciting such expectations as well as initiating communication with patients about the treatment they receive for their high blood pressure. It also allows for a systematic discussion of the nonbiomedical expectations or misconceptions patients may have by providing a medium for counseling patients about treatment. Specifically, patients could be asked the following brief questions: 1) Do you expect to take your medications for life? 2) Do you expect a cure of your high blood pressure? 3) Do you take your blood pressure medicine only when you have symptoms of high blood pressure? Those patients that do not respond in any meaningful manner could then be probed along the dimensions of the taxonomy as one would in the review of systems. For instance, with respect to patients’ role, they could be asked what their expectations are regarding weight loss, reduction in dietary fats, engagement in physical activity, and adherence to prescribed medications. With respect to medication effects, patients could be asked what their expectations are regarding duration of treatment, taking medications in the absence or presence of symptoms, and medication side effects.

Those with misconceptions are then educated about their beliefs, while those patients with appropriate responses are reinforced. Such patient-centered interviewing approaches have been shown to be effective communication tools in primary care practices, where the majority of hypertensive patients receive their care. canadian pharmacy viagra

In summary, we have outlined a taxonomy of patient expectations of treatment in a group of hypertensive African-American patients followed in a primary care practice. Though patients’ expectations, for the most part, conform with the traditional biomedical model of hypertension, a considerable proportion of patients had nonbiomedical expectations regarding cure of hypertension, duration of treatment for hypertension, and whether or not medications should be taken only when patients have symptoms. In future work, the role of patients’ expectations as independent predictors of medication adherence and blood pressure medication should be assessed in this patient population. Furthermore, behavioral and educational interventions aimed at addressing nonbiomedical expectations that patients have of their hypertension treatment are necessary.