Frequent doctor visits help diabetics lower blood pressure more quickly

The impact of doctor visit frequency on managing high blood pressure is unknown. Current guidelines from the Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommend that patients with high blood pressure be reevaluated within one month. However, intervals between doctor visits are often longer, which could pose challenges for treating high blood pressure, said Alexander Turchin, M.D., M.S., lead author of the study, assistant professor of medicine at Harvard Medical School and director of Informatics Research at the Division of Endocrinology at the Brigham and Women's Hospital in Boston, Mass.

Turchin and his team examined the relationship between visiting a primary care physician and the effect on patients' blood pressure. The study included 5,042 diabetics with high blood pressure; the majority were women (average age 65). The patients were followed between January 2000 and August 2005. During the study, their blood pressure was above the recommended levels more than 60 percent of the time.

Researchers found:

• Patients who visited their primary care physicians at intervals of one month or less saw their blood pressure decline to normal after an average 1.5 months at a rate of 28.7 mm Hg/month. Patients who waited more than a month to visit the doctor had their blood pressure to normal after 12.2 months at a rate of 2.6 mm Hg/month.
• Patients who visited their primary care physicians every two weeks or less experienced the greatest benefits. The average time for their blood pressure to reach normal levels was 0.7 months when physician visits were less than or equal to two weeks apart compared with 1.9 months when visits were two weeks to one month apart.
• Longer periods between physician visits were associated with decreased rates of change in blood pressure. When visiting the doctor every one to two weeks, the rates of decrease for systolic and diastolic blood pressure were 43.8 and 13.1 mm Hg/month, respectively. Visits every six months resulted in rates of 0.9 (systolic) and 0.4 mm Hg/month (diastolic).

Primary care physicians are typically the first line of defense in detecting and helping patients manage their blood pressure, so the researchers reviewed only visits to primary care physicians and excluded specialists, such as endocrinologists, who treat diabetes. Researchers defined "encounter intervals" as the time between physician visits.

High blood pressure, also known as hypertension, in an adult is systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. In the United States, one in three adults have high blood pressure, which is more common among people with diabetes and is a major risk factor for heart disease and stroke. Known as the "silent killer" -- hypertension often has no symptoms.

Despite recommended guidelines for treating high blood pressure, there is a lack of information about what is the optimal period between physician visits. There is also a shortage of primary care physicians in the United States at a time when more people are living longer and need more support in managing multiple chronic medical conditions, such as high blood pressure and diabetes, researchers said. "It is practically impossible to implement all care recommended by the guidelines in the time that the primary care physician has available," said Turchin who is also senior medical informatician at Partners HealthCare System.

The researchers suggest that, for diabetic patients, decreasing the time between physician and patient encounters could shorten the time needed to lower their high blood pressure.

"Both the physicians and the patients with elevated blood pressure should take steps towards more frequent communication -- whether face-to-face or otherwise," Turchin said.

He said patients could measure their blood pressure at home and report to their physicians; physicians should encourage them to do so and also see them more frequently when needed. Telemedicine -- communication through e-mail, telephone, fax or Internet-based tools -- could also be helpful. Another approach could be to enlist help from non-physician providers, such as physician assistants, nurse practitioners and clinical pharmacists.

"More frequent visits could also impose higher co-payment costs on the patients but these again could be mitigated by utilizing telemedicine and/or non-physician providers," Turchin said.

Turchin and his team are studying whether educational interventions can encourage busy primary care physicians to see patients with high blood pressure more frequently and whether lifestyle counseling -- such as promoting a healthy diet and exercise -- could be combined with medical management to help treat blood pressure.

Co-authors are Saveli I. Goldberg, Ph.D.; Maria Shubina, Sc.D.; Jonathan S. Einbinder, M.D., M.P.H.; and Paul R. Conlin, M.D. Author disclosures are on the manuscript.

The Agency for Healthcare Research and Quality and the Diabetes Action Research and Education Foundation funded the study.