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He was already late to arrive at the office. A slick, dark circle with a bluish hue extended from somewhere under the front of his 3-year-old sedan. Touching a finger to it, he confirmed that it was oil. Leaking oil is never good, and the car’s warranty had expired. He remembered the car’s high price, and he worried what an oil leak repair would cost and whether the engine had already been damaged. He told his office that he would be late, checked the engine oil level, and drove slowly to the dealership, where he explained the problem to the smiling service manager who greeted him by name.

“Doc, an oil leak in this model car can be very serious,” said the manager. “You know, it is so hard to get at the leak. Last week, we had a car just like yours with a leak. It cost more than $400 to fix—it takes so much time to get to the place that usually leaks. But look, don’t worry. I know we can find the problem. We’ll take you to your office, and I’ll call you later today once we know what’s going on.”

“Service manager on three,” the clinic operator announced that afternoon. “Great news!” exclaimed the service manager. “We fixed the leak, and it only cost $128. Also, we washed your car, and we will bring it to your office.”“Thank goodness,” sighed the happy and satisfied physician (customer). The service manager had exceeded the physician’s expectations with a lower than expected repair cost, an unexpected free car wash, and time saved by returning the car.

In the business world, to develop and maintain returning customers, much effort is made to know and to exceed customers’ expectations.1 Customer satisfaction correlates directly with corporate earnings and consumer spending.2 The customer’s expectations are defined not only by personal experience and the experience of friends and colleagues but also by mass marketing or direct to consumer advertising (product education). Successful businesses spend large amounts of time and resources on learning customers’ expectations and building customers’ expectations regarding product and/or service (educating). Business knows that by meeting and hopefully exceeding these expectations, customers can be retained.3

In this story, the physician initially had negative expectations of a high repair cost and lost professional time to deal with the repair. The service manager, sensitive to the physician’s concerns, set the physician’s expectation for a potentially high repair cost and simultaneously minimized the physician’s time loss concern by having him taken to his office. The manager then exceeded the customer’s expectations with a lower repair cost than estimated, saved the physician additional time by returning the car to him, and gave added value with a free car wash. The physician was pleased with the experience and was likely to tell his friends about it.

The value of meeting and exceeding customer expectations has been shown also to apply to health care. Patients’ satisfaction with the health care they receive, effective health care professionals’ communication, and receiving care that meets the patient’s expectations reduce malpractice risk.4 In hospital, pain control, good physician and nurse communication, a quiet and clean room, and complete discharge instructions are patient expectations that relate to patient satisfaction and the likelihood that the patient would recommend the hospital to others.5 Health care providers treating hypertension can learn from these business and hospital customer satisfaction strategies to achieve better blood pressure control.

Patients develop expectations from personal experience, the reported experience of friends and family, and at times from self-education. Today in health care, there is a growing influence of the media in setting consumer (patient) expectations about therapeutic outcomes and health care quality through health care provider performance reports. There is little media effort to educate patients as to what will be required of them or their health care provider to achieve a desired outcome in many disease states, including hypertension control.6 Success in exceeding expectations can only be achieved if expectations are first either identified or established.

Reports of physician inertia in treating hypertension demonstrate that a significant number of providers do not have appropriate expectations of what is needed to reach blood pressure goals in many patients.7,8 Similarly, rates of nonadherence or lack of persistence with prescribed antihypertensive therapy suggests that many hypertensive patients do not know what they have to do to achieve hypertension control. While there is a large body of information in the medical literature concerning hypertensive patients’ awareness of their high blood pressure, there is a paucity of information concerning what knowledge (or expectations) hypertensive patients have about what is necessary to control their blood pressure. Some information does exist on primary care patient expectations for needed diagnostic test(s) or additional medication, but none exists on what hypertensive patients expect (or what will be expected of them).9

The Burden and Barriers of Negative Expectations

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References

Providers and patients often have negative expectations concerning antihypertensive management. Health care providers continue to expect that monotherapy might achieve hypertension control.7,8 While lifestyle changes can contribute to blood pressure reductions, patients frequently have difficulty with adherence. So health care providers often assume that lifestyle changes will not be made and will have little impact on hypertension control. Many providers assume that most patients will not keep appointments, as evidenced by clinics overbooking in anticipation of a predictable number of no-shows. Patients often are reluctant to give up foods they enjoy or reduce daily alcohol intake, are concerned about the cost of antihypertensive medications, and assume that antihypertensive medications will cause adverse effects.8 Providers must educate hypertensive patients about long-term lifestyle changes and prescribe treatment that the patient can adhere to over the long term. A 36-year-old hypertensive man, when seen in the clinic, is asking the provider to prescribe an antihypertensive treatment regimen that he can adhere to for at least 30 or more years. Such a treatment must not only be one with antihypertensive efficacy but be one with the least number of daily pills, with the fewest adverse effects, and that is affordable.

The expectant model of hypertension management is based on the patient and the provider having similar expectations derived from evidence-based information. The provider must identify the patient’s expectations, both correct and incorrect, at the first visit. There must be a strategy to correct the patient’s incorrect expectations and educate him or her regarding appropriate ones, and the provider must know what to expect from the prescribed treatment.

Currently, lifestyle modifications may be recommended and then one antihypertensive agent prescribed. At the follow-up visit, the physician and patient are often disappointed that monotherapy did not achieve the desired goal blood pressure value. Additional serial antihypertensive agents are added, often without maximizing the dosage of the previous medication. Usually, by the third medication the patient begins “pushing back” with concerns about the seemingly never-ending increasing cost of blood pressure control.

Aligning the hypertensive patient’s treatment expectations with those of the provider can be “expected” to improve the patient’s blood pressure control, the patient’s adherence to the prescribed care regimen, and the provider’s satisfaction with the patient’s outcomes. Unfortunately, all too often, neither the patient nor the provider is aware of the other’s expectations so that their mutual efforts are often doomed to limited success and mutual frustration. Each should know the other’s expectations. The expectations of each should be based on the evidence-based facts concerning hypertension control.

The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References
  •  Controlling hypertension by adjusting blood pressure values to the recommended goal can reduce the risk of cardiovascular morbidity and mortality.10
  •  Lifestyle modifications including the Dietary Approaches to Stop Hypertension (DASH) diet, reduction in daily alcohol use, weight reduction for the overweight patient, and dietary sodium restriction can assist in hypertension control and reduce the number of classes of antihypertensive agents needed to achieve goal blood pressure levels.10
  •  Exercise initially increases systolic blood pressure, and it is unrealistic for a patient to believe that he or she can exercise his or her way to normotension.
  •  In stage 1 hypertension, 2 classes of antihypertensive medications may be needed to reach blood pressure goals.11
  •  In stage 2 hypertension, in particular in black patients with renal insufficiency, ≥3 classes of antihypertensive medication may be needed to reach blood pressure goals.12
  •  Getting blood pressure to the recommended goal level within 3 months reduces the risk of cardiovascular events more than reaching goal levels over a longer period of time.13
  •  To promote long-term adherence with antihypertensive therapy, pharmacologic therapy should be designed with use of the least number of pills per day.14
  •  Fixed combinations of medications that can achieve goal blood pressure values quicker than monotherapy and that have complementary mechanisms of action, demonstrated efficacy, and a lower incidence of adverse effects than monotherapy should be used.14
  •  Certain classes of antihypertensive medication are associated with better long-term adherence (persistence) and cause fewer adverse effects than others.7
  •  Using an antihypertensive treatment algorithm rather than random selection of antihypertensive agents will achieve blood pressure control.12
  •  A disease management approach to hypertension management, including prescribed self-monitoring of blood pressure and allied health professional support, will improve long-term hypertension control and adherence.15

Using the Expectant Model of Hypertension Management

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References

While this model of hypertension management needs to be tested as to whether it can improve initial and long-term hypertension control compared with the usual current approach, there are certain benefits that can be predicted based on experience in the business world. On the first visit of a hypertensive patient, the health care provider should ask the patient what his or her expectations are of what will be needed to achieve hypertension control, and the provider should explain his or her expectations. Negative expectations of both should be identified and discussed.

What Expectations Should Be Set?

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References

In a patient with uncomplicated stage 1 hypertension, the patient and provider should expect:

  •  To achieve a blood pressure goal of <140/90 mm Hg.
  •  To achieve goal blood pressure within ≤5 additional visits (every 2 weeks or within 3 months of the first visit).
  •  That lifestyle modifications can help reach blood pressure goals and reduce the number of antihypertensive medications needed.
  •  That 2 antihypertensive medications may be needed (that could be combined into one fixed-dose combination product).

In a patient with stage 2 hypertension who has diabetes or renal disease, the patient and provider should expect:

  •  A blood pressure goal <130/80 mm Hg.
  •  To achieve goal blood pressure within ≤5 additional visits (every 2 weeks or within 3 months of the first visit).
  •  That lifestyle modifications can help reach blood pressure goals and reduce the number of antihypertensive medications needed.
  •  That 3 or 4 antihypertensive medications may be needed (that could be combined into 2 fixed-dose combination products).

If expectations such as these are set at the beginning of treatment, the provider should expect less patient resistance in subsequent visits with regard to additional medication. This approach establishes a basis for exceeding treatment expectations. If in the patient with stage 2 hypertension, goal blood pressure is reached by the fourth follow-up visit with 3 medications, the patient should recognize that the provider exceeded the original expected number of medications needed. If, on the other hand, 4 medications are needed, the patient should see that the provider had accurately predicted what would be needed. In addition, knowing what will be needed for hypertension control (such as the possibility of 4 medications) should motivate patients to work harder at lifestyle changes.

There is also benefit for the provider. The provider should be motivated to choose antihypertensive medications with complementary actions so as to achieve blood pressure control within the expected 3-month time frame with as few medications as possible.

If the provider recognizes that as many as 4 antihypertensive medications are needed to achieve the goal blood pressure level of <130/80 mm Hg in a patient with stage 2 hypertension who has evidence of target organ damage, particularly black patients with renal insufficiency, then the provider should not become frustrated when fewer medications do not achieve that goal.

What Is Needed?

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References

A prospective randomized clinical trial of the expectant model of hypertension management compared with traditional management that does not specifically define and set expectations is needed. Experience from the business world, however, suggests that this treatment approach would promote patient adherence and reduce provider inertia. While there is some information defining the incorrect expectations of health care providers in achieving hypertension control, more needs to be known of the expectations hypertensive patients bring with them on the first visit. There is likely a spectrum of expectations depending on the patient’s social/educational level, health care literacy, and previous health care experience. Patient expectations should be assessed on the first visit, and the provider’s expectations (based on evidence-based medicine) should be discussed. Mutually agreeable expectations should be defined. Then, both the patient and provider can realistically measure each other’s success at meeting and hopefully exceeding expectations.

Conclusions

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References

The expectant model of hypertension management can be expected to provide hypertension control in a manner that meets or exceeds the expectations of the patient, the provider, and the health care system. Exceeding these expectations should contribute to long-term hypertension control, which is the goal of both the patient and provider in hypertension management.

References

  1. Top of page
  2. The Burden and Barriers of Negative Expectations
  3. The Evidence-Based Data That Should Be Used to Set Expectations for Patients and the Health Care Provider to Control Hypertension
  4. Using the Expectant Model of Hypertension Management
  5. What Expectations Should Be Set?
  6. What Is Needed?
  7. Conclusions
  8. Acknowledgments:
  9. References