Authors

  1. FELDMAN, PENNY HOLLANDER PhD
  2. McDONALD, MARGARET V. MSW

Abstract

The summaries that follow capture important, research-based work that has been published recently and that we think may hold special interest for home healthcare nurses. The information provided is only a sample of the available findings. For additional information and insights, we suggest that readers go to the original articles. This month we focus on hypertension and heart failure, prevalent conditions in the home healthcare patient population.

 

Article Content

Lloyd-Jones, D. M., Evans, J. C., & Levy, D. (2005). Hypertension in adults across the age spectrum: Current outcomes and control in the community.Journal of the American Medical Association, 294,466-472.

 

Debate over the use of antihypertensive therapy among the "oldest old" is ongoing. Controversy revolves around the risk/benefit ratio of drug treatment in patients 80 years old and older. Safety concerns and increased mortality have been reported in a few studies (Amery et al., 1986;Gueyffier et al., 1999). On the other hand, there is concern about under-treatment of hypertension (HTN) in this group. In this study of 5,296 Framingham Heart Study participants (56% female and more than 36% 80 years of age or older), the investigators specifically evaluated the use of antihypertensive agents and cardiovascular risk among older patients.

 

* Analyzing data collected throughout the 1990s, the study found that HTN rates increased with age and that the prevalence of HTN in the 80+ population exceeded 70%.

 

* Only 38% of men and 23% of women in the older-age category had their blood pressure (BP) under control as defined by the recommendations of the Joint National Committee on the Prevention, Evaluation, and Treatment of High Blood Pressure (JNC7) (National Institutes of Health/National Heart, Lung, and Blood Institute [NIH/NHLBI], 2003) target of less than 140/90 mm Hg.

 

* Despite significant evidence on the benefits of thiazide diuretics for BP reduction, especially among the elderly, fewer than 25% of men and fewer than 40% of women received this class of drug, suggesting underuse.

 

* Newer, more expensive, yet less-studied antihypertensive agents (e.g., such as angiotensin-converting enzyme [ACE] inhibitors) seemed to be underused.

 

* Only 9.5% of elderly patients with normal BP experienced a cardiovascular event, compared with 20.3% of those with stage 1 HTN and 24.7% of those with stage 2 HTN.

 

 

Physicians and home care nurses sometimes question the benefit of treating high BP among their oldest patients. Lloyd-Jones and colleagues support the use of JNC7 HTN (NIH/NHLBI 2003) guidelines that are essentially the same for all age groups: medications should be initiated at low doses, supplemental medications that can work synergistically at low doses should be added as necessary, and doses should be gradually increased to attempt to reach target BP. Home care nurses can help their elderly patients with HTN by educating them on the risks of uncontrolled hypertension, supporting the patient's self-management of this condition and, as necessary, advocating for improved medication management.

 

REFERENCES

 

Amery, A., Birkenhager, W. H., Brixko, P., Bulpitt, C., Clement, D., de Leeuw, P., et al. (1986). Influence of antihypertensive drug treatment on morbidity and mortality in patients over the age of 60 years: European Working Party on High Blood Pressure in the Elderly (EWPHE) results: subgroup analysis based on entry stratification. Journal of Hypertension, 4( Suppl 6), S642-S647. [Context Link]

 

Gueyffier, F., Bulpitt, C., Boissel, J-P., Schron, E., Ekbom, T., Fagard, R., et al. (1999). Antihypertensive drugs in very old people: A subgroup meta-analysis of randomised controlled trials. Lancet, 353, 793-796. [Context Link]

 

National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI). (2003). Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Express. Available at: http://www.nhlbi.nih/gov/guidelines/hypertension. [Context Link]

 

Okonofua, E. C., Cutler, N. E., Lackland, D. T., & Egan, B. (2005). Ethnic differences in older Americans: Awareness, knowledge, and beliefs about hypertension.American Journal of Hypertension, 18,972-979.

 

Developing cultural sensitivity in clinical practice enhances the home health nurse's ability to relate to diverse patient populations and can lead to more effective care (Clemen-Stone et al., 2002). Despite ample evidence of ethnic differences in the prevalence of disease, specific differences in disease knowledge and beliefs are not widely documented. This study, based on a national survey conducted in 2000 by the National Council on the Aging, explored ethnic differences in awareness, knowledge, and beliefs about HTN among older Americans (>50 years). HTN is one of the most common diagnoses of home healthcare patients, accounting for 8% of all listed admission diagnoses in 2000 (Centers for Disease Control and Prevention [CDC], 2004), and sensitivity to differences in ethnic beliefs about HTN can potentially be an important tool in helping patients improve blood pressure self-care management and control.

 

* The study provides information on a nationally representative sample of 880 whites, 313 African Americans, and 290 Hispanics (77% response rate).

 

* Reflecting national epidemiological data, the self-reported prevalence of HTN was greater among African Americans than Hispanics or whites.

 

* Individuals with more accurate overall HTN knowledge and beliefs had significantly lower systolic BP levels and higher BP control rates.

 

* There were no differences across ethnic groups in the overall number of correct responses to HTN knowledge and belief questions. However, t here were significant differences in beliefs about effective ways to lower BP.

 

* African Americans and Hispanics were more than twice as likely as whites to report that medications are the only way to control high BP (50.5% and 55.5% versus 23.3%, respectively). Whites were more likely to agree that lifestyle changes, including decrease in weight, alcohol use, tobacco use and stress, as well as an increase in exercise, would result in lower BP. Furthermore, belief that medication is the only way to lower BP was associated with poorer BP control.

 

 

These findings reinforce the importance of understanding cultural differences in patients' health knowledge and beliefs, a critical issue that home health nurses must address in their daily practice. In particular, they point to the value of targeting nursing interventions to address different patient beliefs about the efficacy of lifestyle modification and medication to lower BP and reduce associated cardiovascular risks.

REFERENCES

 

Centers for Disease Control and Prevention (CDC). (2004). Current home health care patients. Available at: http://www.cdc.gov/nchs/data/nhhcsd/curhomecare.pdf. [Context Link]

 

Clemen-Stone, S., McGuire, S., & Eigsti, D. (2002). Comprehensive community health nursing: Family, aggregate and community practice (6th ed.). St. Louis: Mosby. [Context Link]

 

Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2005). ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation, 112,1825-1852.

 

Heart failure (HF) is one of the most common diagnoses of home healthcare patients and a significant cause of potentially preventable hospitalizations. The 2001 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the evaluation and management of chronic HF in the adult have been updated. The guidelines incorporate information on new pharmacologic and non-pharmacologic approaches to the treatment of HF and reflect the increasing recognition of HF in people with normal ejection fraction. Because not all patients have volume overload as a symptom, the term "heart failure" is used in these guidelines and is preferred to the older term of "congestive heart failure." Guideline statements that have been added or clarified include the following.

Preventing HF

 

* Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) can be useful in preventing HF in high-risk patients--those with a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension.

 

* Beta-blockers and ACEI should be used in all patients with a recent or past myocardial infarction event, regardless of the presence of HF.

 

* Patients should be regularly evaluated for:

 

1. Ability to perform routine and desired activities of daily living;

 

2. Volume status and weight; and

 

3. Current use of alcohol, illicit drugs, alternative therapies, and chemotherapy drugs, as well as diet and sodium intake.

 

4. Repeat measures of ejection fraction should be done for patients who have a change in clinical status.

 

Patients With Current Symptoms of Heart Failure

 

* Three beta-blockers with proven efficacy for reducing mortality (bisoprolol, carvedilol, sustained-release metoprolol succinate) are recommended for stable patients with symptoms of HF.

 

* Calcium channel-blocking agents are not recommended as routine treatment.

 

* Hormonal therapies other than to address specific deficiencies may be harmful.

 

* Digitalis can be useful in preventing hospitalizations.

 

* Exercise training is a beneficial adjunct to improve clinical status.

 

* Options for end-of-life care, including hospice, should be discussed with patients with severe, refractory end-stage HF.

 

 

In addition to those listed above, the guidelines present many suggestions with extended explanations of recommended practices. The updated full-text guidelines can be found at http://www.acc.org or http://www.americanheart.org. Review of this update will provide home health-care care nurses with the latest information on treatments that may be beneficial to their patients with HF. Such information can be critical in assessing and reconciling patient medications, communicating with physicians, helping patients engage in effective self-care management, and informing patients of palliative care options.

 

Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance.Journal of the American Medical Association, 295(6), 716-724.

 

In this era of evidence-based practice, home care clinicians are increasingly aware of the emergence of clinical practice guidelines (CPGs) to assist decision making about the treatment of people with specific diseases. Nationally promulgated CPGs are now available for many chronic conditions, including diabetes, HTN, chronic heart failure (CHF), osteoarthritis, chronic obstructive pulmonary disease (COPD), and osteoporosis (National Guideline Clearinghouse, 2002). Yet none of the widely promulgated CPGs have been adapted specifically to home care. Moreover, home care nurses, like other clinicians, often are stymied by the multiple comorbid conditions of any one patient and the difficulty of distilling multiple CPG recommendations to achieve the best care plan for that patient. This study examined the feasibility of treatment recommendations from relevant national CPGs for a hypothetical 79-year-old woman with osteoporosis, osteoarthritis, type 2 diabetes mellitus, HTN, and COPD of moderate severity. The authors were concerned about patient self-care burden, medication costs, possible adverse events, and whether or not sensible pay-for-performance indicators could be put in place for primary care practitioners. They found that:

 

* Only two CPGs relevant to the hypothetical patient (diabetes and osteoarthritis) discussed older patients and comorbid conditions.

 

* Even combining medications, dosages, and self-care activities as appropriate, the patient would still have to take 12 separate medications, involving 19 different doses at 5 times in a typical day, assuming that albuterol "as needed" was taken twice daily, and alendronate was taken weekly. Annual medication costs for 2006 were estimated to range from $3,800 to $4,800, depending on whether the patient purchased Medicare part D coverage. In addition, 14 nonpharmacological activities (involving both the patient and the physician) were recommended if all nutritional recommendations were pooled into one.

 

* Numerous potential interactions could occur between different medications, between medications and diseases, and between medications and foods, leading to the conclusion that the complex medication recommendations for the patient's condition presented "attendant risks of medication errors, adverse drug events, drug interactions and hospitalization" (p. 720).

 

* The treatment burden involved in the recommended regimens was potentially "unsustainable" and would therefore make "independent self-management and adherence difficult" (p. 720).

 

* The CPGs as written failed to account for the large numbers of patients with multiple conditions and would create inappropriate incentives if they were used to evaluate physician quality of care or to determine physician payment.

 

 

This research, conducted from the perspective of patients and physicians in primary practice, has important implications for the current and future practice of home health-care. First, as a facilitator of patient self-care management, the home health nurse has a critical role to play in treating the patient "as a whole person"--not as a specific "diagnosis"--and in working with both the physician and the patient to reduce, insofar as possible, the burden associated with patient adherence to multiple, complex medical and behavioral regimens. Second, given the multiplicity of chronic conditions that the typical older home care patient must manage, the home health nursing profession has a critical role to play in advocating for the development of CPGs that provide specific, evidence-based recommendations for older patients and those with comorbid conditions. Third, all home care stakeholders should work to gain national support for adapting chronic care CPGs to the particular circumstances of home care patients and to the opportunities and constraints inherent in the practice of home healthcare nursing.

REFERENCE

 

National Guideline Clearinghouse. Web site. Accessed October 2002. Available at: http://www.guideline.gov. [Context Link]

Consider Writing for HHN

 

Changes in home care demand that everyone think in new ways about patient care, managing your agency, and managing your own practice. You have something valuable to share with everyone and HHN wants you to contribute an article. Feel free to share the ideas and topics you'd like to see in the journal, or what you'd like to write, by contacting the Editor, Tina M. Marrelli, via e-mail: news@marrelli.com, fax: (941) 697-2901, or telephone: (941) 697-2900.

 

These ideas will help jump-start your thoughts:

 

[black small square] Wound and Ostomy Management

 

[black small square] Home Infusion Therapy

 

[black small square] Oncology & Chemotherapy in the Home

 

[black small square] Evidence-Based Practice Clinical Tools

 

[black small square] Telehealth Programs and Outcomes

 

[black small square] OBQI Strategies that Decrease Adverse Events

 

[black small square] Documentation & Productivity