Managing hypertension with home blood pressure measurements

- Kenny Lin, MD, MPH

Several of my hypertensive patients always have significantly higher blood pressures at the office than at home. Even after verifying the appropriate size cuff, and re-measuring blood pressure several minutes into the visit, the numbers don't change. Since treating these patients based solely on office blood pressures risks overtreatment (prescribing too high a dose or too many drugs), I encourage them to keep logs of their home blood pressures for us to review at each followup visit. However, as outlined in this home blood pressure measurement protocol from a previous AFP article, interpreting the results can be complex and challenging to carry out in a time-constrained primary care visit.

In a recent study published in the Annals of Family Medicine, a team of Australian researchers monitored 286 patients with uncomplicated hypertension to determine a more efficient method for interpreting home blood pressure measurements. They found that participants with 3 or more of their last 10 home systolic blood pressures greater than or equal to 135 mm Hg were the most likely to have elevated 24-hour ambulatory blood pressures and signs of end organ disease on echocardiography. This correlation held even if patients did not follow the recommended home monitoring protocol. The researchers concluded that using this "3 in 10" threshold may be a more practical way to assess blood pressure control with home measurements.

Although this study only included patients with established hypertension diagnoses, the U.S. Preventive Services Task Force has emphasized the importance of obtaining blood pressure measurements outside of the clinical setting in its 2015 recommendation statement on screening for high blood pressure in adults. According to this Figure, 6 studies found that home blood pressure monitoring confirmed elevated office blood pressure readings only 45 to 84 percent of the time.

In light of recent trial findings that setting lower blood pressure goals may improve outcomes in patients at high risk for cardiovascular events, it will be even more critical to verify office blood pressure measurements with measurements outside of the office to maximize treatment benefits and minimize adverse effects.

Who should be screened for type 2 diabetes - and when?

- Jennifer Middleton, MD, MPH

The current issue of AFP reviews screening recommendations for type 2 diabetes in both a review article ("Diabetes Mellitus: Screening and Diagnosis") and a discussion of the United States Preventive Service Task Force (USPSTF)'s recommendation to screen all overweight and obese adults aged 40-70 for diabetes. These screening recommendations are at odds, however, of the practices of many employers and health insurers seeking to gather more data about their insured employees. 

Last year, the USPSTF released a "B" recommendation that non-pregnant adults aged 40-70 who are also overweight or obese should be screened for type 2 diabetes. A fasting glucose, a glucose tolerance test, or a serum hemoglobin A1C are all reasonable options for screening. The USPSTF recommends repeating screening, if initial results are normal, every 3 years. Treatment of patients with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) can forestall the development of type 2 diabetes, and identifying asymptomatic individuals with IGT or IFG is a laudable goal. 

These recommendations, however, are quite different than the practice of my current employer regarding biometric screenings. Once a year, I either submit to a fasting glucose level and lipid profile or forfeit several hundred dollars in health insurance premiums. These biometric screenings do not take into account risk factors, and they don't care what the evidence base says about whom we should be screening and when. (For the record, I do not meet USPSTF guidelines to be screened for diabetes or lipid disorders.) Employers and health insurers are indiscriminately testing everyone as a way to measure its insured population, assess its risks, and encourage individuals with abnormal results to engage in treatment and lifestyle changes. 

Those aims are not unreasonable, but they come at a cost. Applying these screening tests more often than currently recommended is not inexpensive and can also create the risk of false positive results. It also requires employees to share what should be protected health data with employers; although these screenings are often touted as "optional," the risk of forfeiting what may be hundreds of dollars may border on coercive. 

These complex issues can put family physicians in a difficult spot. Although I don't want to order annual lipid profiles and fasting glucose levels for my patients who don't need them, I also don't want my patients to suffer unnecessary healthcare costs. It seems unlikely that these programs are going away, but what can we, as family physicians and healthcare providers, do to orient these programs more in the direction of the evidence base? It may be time for us to speak up on this issue, both as individuals and our organized medical societies.

Efforts to do so to date have had mixed results. Last year, employees at one university protested vehemently against their employers' new biometric screening and health survey policy, and, in 2014, the United States Equal Employment Opportunity Commission brought a lawsuit against a large U.S. employer for their penalty-heavy requirement for employees to undergo biometric screenings. Although the EEOC lost their suit, those university employees succeeded in delaying the new biometric screening policy and creating a task force to examine the issue in greater depth. 

Certainly, there can be benefits to employees of incentivizing healthy lifestyles. Providing coverage for smoking cessation classes and medications, for weight loss programs and gym memberships, even for lactation support services are all worthwhile. Ensuring that employer health programs are meeting both employees' and employers' needs, however, will likely continue to be a balancing act. As long as the financial power of the equation lies with the employers, we will need to advocate for our patients, the employees.

Is Vitamin D supplementation good for anything?

- Kenny Lin, MD, MPH

For as long as I can remember, throughout medical training and clinical practice, the message from my mentors and colleagues about vitamin D supplements was the same: the sooner patients started taking them, the better to prevent osteoporosis and fractures later in life. And that wasn't the only benefit: in 2012, the U.S. Preventive Services Task Force even recommended vitamin D supplementation in community-dwelling adults age 65 and older to prevent falls.

But the very same Task Force soon began to raise doubts about the value of vitamin D supplements. In 2014, it found insufficient evidence to recommend calcium and vitamin D to prevent fractures in premenopausal women or men, and recommended against postmenopausal women using daily vitamin D supplements containing 400 IU or less because these increased the risk of kidney stones without affecting fracture rates. What about a strategy of selective supplementation in vitamin D "deficient" persons? The USPSTF also found insufficient evidence that screening for vitamin D deficiency in adults improves health outcomes, and the American Society for Clinical Pathology recommended against screening for vitamin D deficiency in the Choosing Wisely campaign.

So what is vitamin D supplementation good for? Recognizing the vitamin D deficiency in older adults has been associated with functional decline, Dr. Heike Bischoff-Ferrari and colleagues recently performed a randomized controlled trial comparing high-dose (60,000 IU per month or 24,000 IU per month plus calcifediol, a liver metabolite of vitamin D) to low-dose (24,000 IU per month) vitamin D supplements in 200 community-dwelling men and women 70 years and older with a history of falls. After 12 months, participants receiving the high-dose supplement did not have better lower extremity function and were more likely to have experienced falls than participants in the low-dose group. The authors of an accompanying editorial noted that after many similar trials, vitamin D supplementation has only been shown to reduce fractures and falls in institutionalized older adults.

Putting this all together, the next time a healthy adult of any age asks me if he or she should be taking a vitamin D supplement, I plan to answer: we don't know for sure, but probably not - and we don't need to know what your vitamin D level is, either.

Predictions for 2016 practice-changers

- Jennifer Middleton, MD, MPH

2015 brought us many provocative medical headlines, and 2016 will likely continue to provide us with a lot to discuss here on the AFP Community Blog. Here are some headlines that we may see in 2016:

SPRINT part 2
Although enrollment in the Systolic Blood Pressure Intervention Trial (SPRINT) was halted last year, data collection is still ongoing regarding two components of the trial: the effect, if any, of intensive blood pressure control on dementia and cognitive function (SPRINT MIND), and continued follow-up on renal function in participants (as an increased rate in renal function decline was noted in participants in the trial's intensive treatment arm). According to the SPRINT website, the researchers plan to complete data collection for both by mid-2016. Given how quickly the initial SPRINT study went to press after enrollment was closed, I wouldn't be surprised to see SPRINT MIND and the follow-up renal function data publicized before the end of 2016.

New hypertension treatment guidelines (again)
The publication of SPRINT last year conflicts with some of the JNC 8 hypertension treatment recommendations from 2013; although JNC 8 advocates for a systolic blood pressure (SBP) goal of 140 for all patients under age 60 and for patients over 60 with CVD risk factors, SPRINT suggests that some patients at high risk of cardiovascular disease (CVD) may benefit from an SBP goal of 120. The National Heart, Lung, and Blood Institute (NHLBI), which sponsored the JNC, is no longer issuing treatment guidelines, but a task force from the American College of Cardiology (ACC) and the American Heart Association (AHA) is currently at work developing new recommendations. Though they've provided no expected publication date, I suspect the desire by many to resolve this SBP goal discrepancy will push them to finish their work sooner rather than later.

USPSTF: dyslipidemia screening & treatment
The United States Preventive Services Task Force (USPSTF) is currently soliciting public comment on 2 topics related to dyslipidemia: dyslipidemia screening and "Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication." While both of these topics will be relevant to primary care, the second may have the most far-reaching consequences. Dr. Kenny Lin has written before on this blog on the current conflicting recommendations regarding treatment with statins for the primary prevention of CVD; it will be interesting to see what the USPSTF determines.

USPSTF: weight loss medications
I've written previously about the pros and cons of using prescription medications for weight loss on the blog, and the USPSTF is currently drafting its stance on this topic as well.  Will they be finished with this one before the end of 2016? Only time will tell.

Personal health tech goes mainstream?
Dr. Lin wrote last fall about the Family Medicine for America's Health (FMAH)'s technology "tactic team" and their strategies for increasing the use of technology to help patients. In that post, he described a study showing that text messaging to patients with heart disease helped them to reduce CVD risk factors. I'm hoping to see both a lot more studies like this one along with more from FMAH about how to practically implement these technologies in our offices.

Well, those are some of the stories I'll be watching for in 2016. What medical news are you anticipating in the next year?