Non-Pharmacological Interventions for Hypertension Management: An Initial Pilot in Primary Care Behavioral Health Integration

Aaronson Y Chew, Ph.D., David Talavera, M.A.,
AnnaMarie Vu, M.A., Kate Zona, Ph.D., & Jean M. Bakey, D.O.

Roughly a third of US adults have hypertension, and surprisingly only 54% of these individuals have their hypertension under control (Centers for Disease Control, 2018). Hypertension is often referred to as a “silent killer” because untreated hypertension increases the risk of heart disease and stroke, which are respectively the first and fifth leading causes of death in the U.S. (U.S. Department of Health and Human Services, 2016).  Moreover, managing blood pressure in patients with hypertension decreases patient risk of medical complications and mortality, while simultaneously decreasing future costs and burdens on healthcare systems (Lawes, Hoorn, & Rodgers, 2008).  At the Cambridge Health Alliance/Harvard Medical School in the Malden Family Medicine Center, we are implementing cost-effective, multimodal behavioral health interventions to improve uncontrolled hypertension in our patient population.

Cambridge Health Alliance is a safety-net network of three hospitals and twelve primary care clinics that serves the greater Boston area. We serve a racially, linguistically, and socioeconomically diverse population, in which there is a high proportion of chronic co-morbid physical and psychiatric disorders.  The Malden Family Medicine Clinic located in Malden, MA is the largest of our twelve primary care sites with approximately 23,000 empaneled patients.  After looking at our clinic data for healthcare accountability metrics, we noticed that meeting our goals for hypertension has been an ongoing challenge.

First, we took a look at a list of our patients with hypertension that had uncontrolled blood pressure readings. We found that the majority of our patients with uncontrolled hypertension had blood pressure readings ranging from 140 to 150 mm Hg systolic and 80 to 90 mm Hg diastolic (U.S. Department of Health and Human Services, 2004).  In short, they were patients that had multiple recent visits to our clinic and had moderately elevated blood pressure readings.  With this information, we decided to focus on in-reach interventions and started looking at non-pharmacological multimodal approaches to hypertension management in hopes of reducing patients’ blood pressure by even a couple of points, which could have significant implications for their health.

Given that the average wait time for a primary care visit is approximately twenty minutes, we saw this as an opportunity to add value by utilizing patients’ wait time in the clinic to implement our intervention (Vitals, 2018).  Hence, we are piloting a quality improvement project that delivers a 15-minute audio-recorded, biofeedback-based, deep breathing exercise to patients who arrive for their hypertension specific nursing visits. Our rationale is that it would make use of the “wasted” time patients spend in the clinic, increase exposure to non-pharmacological interventions for hypertension management, and further integrate our behavioral health presence in the clinic.

We have been able to incorporate the diverse skill set of members on our medical teams by having our postdoctoral fellow compose an original musical score, having our behavioral health providers write and read a mindfulness script, and having another behavioral health provider structure the paced breathing consistent with the biofeedback heart-rate-variability literature. Together, the audio-recording incorporates components of mindfulness, diaphragmatic breathing with metronome-guided extended exhales, biofeedback (i.e., pre and post blood pressure readings), and an original background musical score at the tempo of 70 bpm with a 4/4 time signature.

Patients with a hypertension diagnosis who present at the beginning of their primary care visit with a same-day systolic blood pressure over 140 and/or diastolic blood pressure over 90 will be recruited to participate in the pilot study. Prior to taking the initial, same day, pre-visit blood pressure reading, nurses and medical assistants will gather information regarding patients’ behaviors that day, including caffeine intake, tobacco use, and hypertension medication adherence.  Eligible patients who consent to participate will complete the mindful diaphragmatic breathing and music intervention: a standardized recording that they will listen to in an exam room for 15 minutes during the time that they would be waiting to see their medical providers.  Finally, participants will receive another blood pressure reading shortly after completing the audio-recorded intervention.  After patients are notified of their blood pressure results directly following the intervention, they are asked to rate their likelihood of using a similar intervention in the future to assess their receptivity and feasibility to the intervention.

Given the high economic downstream costs of uncontrolled hypertension and the increased need for better hypertension management, this multi-component mindful breathing intervention is an attempt to determine the feasibility and utility of a cost-effective, non-pharmacological intervention for reducing uncontrolled hypertension in a primary care setting. The project is currently in the initial stage of assessing the feasibility of the workflow in our busy primary care clinic. If the pilot intervention shows promise, we will then collaborate with medical team members to develop and implement a randomized control trial comparing the multi-component mindful breathing exercise to treatment as usual for hypertension. Our pilot provides an example of the potential for seamless integration within medical settings of innovative behavioral health tools designed to address difficult-to-treat medical disorders that have serious and costly consequences, thereby improving the health and well-being in our served population.

References

Centers for Disease Control. (2018, February). High Blood Pressure. Retrieved from
https://www.cdc.gov/bloodpressure/index.htm

U.S. Department of Health and Human Services. (2016). Health, United States, 2016 with Chart
book on Long-term Trends in Health
. U.S. Washington, D.C.: Government Printing Office

Lawes, C.M., Hoorn, S., & Rodgers, A. (2008). Global burden of blood-pressure-related
disease, 2001. Lancet, 371(9623), 1513-1518. doi:10.1016/S0140-6736(08)60655-8.

U.S. Department of Health and Human Services. (2004). The seventh report of the Joint
National Committee on prevention, detection, evaluation, and treatment of high blood
pressure. National High Blood Pressure Education Program, 4(5230), 1-66.

Vitals. (2018, February). Vitals Wait Time Report. Retrieved from https://www.vitals.com/about/wait-time.