Clinician Communication Key for Hypertension Control

Norra MacReady

February 18, 2019

Successful management of chronic conditions such as hypertension may depend on the clinician's ability to engage patients and build relationships with them, a study found.

In a survey of providers working in small primary care practices, use of communication techniques such as active listening was associated with a higher proportion of patients who kept their blood pressure under control, compared with clinicians who did not use these methods.

The healthcare providers all used similar fundamental clinical strategies, including patient education and providing self-management tools. The differences in outcomes seemed to be related more to the way in which they interacted with their patients than to any differences in clinical approach.

Jenny R. Smolen, MPH, from the New York City Department of Health and Mental Hygiene, and colleagues published their findings online ahead of print February 8 in Family Practice.

Overall, clinicians with high blood pressure control used active engagement and listening to patients as "the foundation of how these providers interact with their patients and govern their implementation of the clinical strategies," the authors write. Clinicians with lower control rates expressed less confidence in their ability to affect patient outcomes and pointed to external issues such as lack of time, insufficient staff, or factors outside of their control such as patient behavior.

Other skills associated with better outcomes included offering actionable recommendations relevant to the context of patients' lives, the authors explain. For example, one clinician tells patients who eat in fast food restaurants, that "the big Mac has more salt per day than we require. So if you go to Mickey D today, don't get it tomorrow. Let's be real."

The findings suggest that "future quality improvement initiatives should consider including training participants in effective communication," co-author Jason J. Wang, PhD, an associate professor of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, told Medscape Medical News. He participated in the research while he was the senior director of evaluation, research, and analysis at New York City Department of Health and Mental Hygiene.

When asked to provide an example of active listening, Wang described how a "high control provider" promoted patient engagement "by asking about family history to give a concrete example that shows the consequences of non-adherence and therefore increases motivation to take medication." He contrasted that with the experience of a "low control provider" who referred to the patient education process as "just a conversation," but one in which the provider did most of the talking, lecturing the patient on the importance of maintaining normal blood pressure to avoid stroke, heart attacks, and kidney disease.

Wang also cited other research in which he participated showing that use of intervention programs such as Meaningful Use, Patient-Centered Medical Home, and a pay-for-performance program called eHearts "can positively impact small practices' performance on hypertension control. So participating in these programs can motivate providers to improve their skills at patient engagement."

In addition, he said, clinicians should consider other patient factors, such as culture, attitudes toward or access to healthy food and exercise, and health literacy. He suggested that "practices should find ways to meet patient needs that are culturally and linguistically appropriate, especially around medication management, as well as connecting patients to healthier foods and opportunities for physical activity."

The researchers collected data on patient blood pressure control from the Hub Population Health System, which aggregates nonidentifiable patient information from the electronic health records of more than 700 participating practices. From this system they identified small practices, defined as those with five clinicians or fewer, and categorized them as high control (good blood pressure control achieved by at least 80% of patients), average control (60% - 80% of patients achieving control), and low control (fewer than 60% of patients achieving control). Across practice categories, the average number of adult patients with hypertension was 594.

The authors then conducted on-site interviews on hypertension management with clinicians randomly selected from each practice category, with recruitment capped at 10 practices per group. The final sample consisted of clinicians from seven high control, 10 average control, and six low control practices. Of the 23 clinicians, 22 were physicians and one was a nurse practitioner.

Participants in all groups cited medication adherence and the silent nature of hypertension as two of the greatest challenges in hypertension control. Similarly, a majority listed relationship building, patient education, and patient self-management as key clinical strategies.

However, providers with lower control rates "attributed their ability to manage patients' hypertension to factors outside provider or practice control," whereas high control providers "described actively engaging and listening to patients, considering patients' context and motivation and giving actionable recommendations."

The study was limited to small, primary care practices in New York City so the findings may not be transferable to other care settings, the authors warn. Also, the findings reflect only the opinions of the individual providers and did not take into account other factors such as patient population characteristics.

Nevertheless, the researchers conclude that "future quality improvement initiatives should consider including training participants in effective communication" techniques such as motivational interviewing and increased empathy. "Communication training could benefit any member of the care team who interacts with patients and helps support management of chronic conditions."

The authors have disclosed no relevant financial relationships.

Fam Pract. Published online ahead of print February 8, 2019. Abstract

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