Take-home messages

1. Patient-centred care encourages active collaboration and shared decision-making between patients and medical providers to design and manage a customised and comprehensive care plan which takes into consideration not only the clinical point of view, but also emotional, mental, spiritual, social, and financial perspectives.
2. Empowering hypertensive patients to play a role in their treatment improves outcomes.
3. Recognition of barriers to patient-centred care aids collaboration between medical providers and patients.
4. Providing healthcare services that respect and meet patients’ and caregivers’ needs is essential for optimal quality of care.

Impact on practice        

The high prevalence of hypertension and its associated comorbidities and mortalities is a major public health challenge.

Even if the benefits of patient-centred care have not been conclusively documented, person-centred quality improvement strategies were effective in improving blood pressure outcomes. 

Introduction

Hypertension is a leading global health risk, significantly contributing to cardiovascular diseases such as stroke and heart failure and affecting mortality and morbidity rates worldwide.

Despite the effectiveness of lifestyle modifications and availability of antihypertensive medications [1], patient adherence varies widely, with non-adherence rates between 10-80%, challenging the achievement of optimal blood pressure control [2].

The World Health Organization (WHO) has advocated since 1977 for the participation of patients in their own healthcare, and in the Vienna Recommendations on Health Promoting Hospitals, the WHO recognised the necessity of an active and participatory role for patients to improve both the quality and efficiency of healthcare in chronic diseases [3].

Self-management is critical in chronic diseases like hypertension, requiring patients to take an active role in their health care, yet many patients do not start, or do not maintain, partly or completely, lifestyle changes and pharmacological therapy.

In 1998, Valerie Billingham suggested the motto for the patient-centred movement - “Nothing about me, without me.” So, it should be our duty as medical caregivers to involve patients and adapt medication to patients’ needs, and the duty of patients to be aware of the important role and responsibility they have for their health and quality of life.

The benefits of patient-centred care have not been conclusive, but positive influences on patient satisfaction, better adherence to lifestyle recommendations and drug prescriptions, greater improvement in symptom burden and in achieving treatment targets, particularly in the management of chronic illness such as hypertension, have been reported [4,5].

In the field of hypertension, the involvement of patients, based on good teaching and written instructions, is easy to improve and is extremely important for correct diagnosis and monitoring of the effect of pharmacological and non-pharmacological treatment.

Accordingly, the ESC Guidelines for elevated blood pressure and hypertension [5] dedicates a chapter to patient-centred care in hypertension, defined as “an attitude of the healthcare professional that closely aligns with the patient’s preferences and needs”.

Patients shouldn’t be considered as passive receivers of doctors’ suggestions but motivated to recognise themselves as an active part of a team together with healthcare professionals, caregivers, and relatives.

Empowerment of hypertensive patients

The involvement of patients or persons with elevated blood pressure starts with the monitoring of blood pressure (BP) measurement as an instrument of diagnosis and monitoring.

Self-monitoring allows elevated BP and hypertension to be detected early and enables patients to co-manage therapy with their healthcare providers. The Guidelines suggest: “Home BP measurement for managing hypertension by using self-monitored BP is recommended to achieve better BP control” (I B); and “Self-measurement, when properly performed, is recommended due to positive effects on the acceptance of a diagnosis of hypertension, patient empowerment, and adherence to treatment” (I C) [5].

Self-monitoring is often also a good instrument to improve adherence and avoid long intervals of uncontrolled BP despite therapy [6].

The basis of correct self-monitoring is that the measurement is done according to precise written instructions, avoiding measuring in case of symptoms (such as pain) or in conditions which modify blood pressure (e.g., sport, consumption of tobacco/nicotine, caffeine, or other vasoactive substances) [7].

Only suitably validated and correctly used digital devices should be used. Plenty of new devices are offered for measuring blood pressure, but not all those devices measure blood pressure correctly [8].

As an alternative to self-monitoring measurement of blood pressure at home, some studies reported the success of BP monitoring in the pharmacy [9] or other places where people have open access [10,11]. BP devices placed in kiosks are designed to offer opportunities to the general public and to patients with hypertension for convenient unsupervised self-measurement of BP. This method may provide a hypertension screening opportunity for many apparently healthy people who may not have had a BP measurement for many years [11].

The second step is the empowerment of patients in self-care and self-responsibility to make lifestyle changes (e.g., diet, exercise, modifying use of tobacco/nicotine products, reducing alcohol consumption), and adherence to prescribed medications.

Adherence to blood pressure-lowering lifestyle changes and drugs in clinical practice is often disappointingly low [12], and many cases of difficult-to-treat hypertension/treatment-resistant hypertension are simply due to non-adherence [13].

A systematic review and meta-analysis of studies on adherence from 2010 to 2020 involving 27 million patients found that, whatever the method used to assess drug adherence, the global prevalence of anti-hypertensive medication non-adherence ranged between 27-40% and, as expected, non-adherence was associated with poor control of BP, complications from hypertension, all-cause hospitalisations, and all-cause mortality [14].

Various methods are available to assess adherence, namely patient self-reporting, prescription fill data from pharmacy databases, pill count, biochemical detection of hypertension medication levels, electronic drug monitoring, smart technology, and direct observation. In half of the cases, non-adherence was found to be non-intentional [15]. A key recommendation for any of these methods is always using a no-blame approach [5].

Adherence is not only a decision by patients based on patient beliefs/attitudes about hypertension and medication; factors such as the complexity of therapy, socio-economic aspects, and the physician-patient relationship may also play a role [5].

As such, non-adherence may be overcome by using an optimal therapeutic regimen, using single-pill, long-acting drugs covering 24 hours, identifying drug-related adverse events, and personalising doses whenever feasible, taking into account the financial capacity of the patient to pay for a given regimen in the longer term, and offering support in case of physical or cognitive impairment [16].

Barriers to patient-centred care

Few studies evaluate personalised barriers in hypertension self-management.

The study by Yang and colleagues [17] employs the TASKS framework to identify personalised barriers from interview transcripts. Data was sourced from Global Hypertension Practice Guidelines [1] and anonymised interview transcripts from a prior study.

The authors identified 69 personalised barriers, distributed as follows: emotional barriers (49%), knowledge barriers (24%), logical barriers (17%), and resource barriers (10%) [17].

Emotional barriers were the most prevalent, indicating significant stress and anxiety related to self-management tasks, such as monitoring blood pressure at home or following healthier lifestyle and medication plans, each presenting substantial obstacles due to emotional and knowledge barriers. The least encountered barriers involved creating a support system with other healthcare professionals.

Managing elevated blood pressure and hypertension in teamwork

Team-based care among physicians, nurses, pharmacists, dietitians, physiotherapists and family, offers significant benefits over physician-only care and is associated with lower systolic and diastolic BP and improved outcomes [5].

After diagnosis it is important to have an open discussion with the patient about the risk of untreated high blood pressure, including on the potential, rationale, and benefits/harms of pharmacological and non-pharmacological hypertension treatment.

New technologies, including telemonitoring, as well as measurements via mobile phone of BP and pulse, and reports of well-being, symptoms, lifestyle, medication intake and side effects, may contribute [18]. The long-term effect of such intervention needs to be determined.

Conclusions

Elevated BP and hypertension diagnosis can be easily done, and treatment is accessible and affordable; nevertheless, many people fail to stay on track. 

Implementation of a patient-centred hypertension care model could improve the quality of care for hypertension patients. There is still plenty of room for improvement in empowering patients themselves to diagnose elevated BP and hypertension and in treating this medical condition appropriately.

Adherence to clinical practice guidelines for treatment of hypertension both by patients and providers leads to improved health outcomes and delivery of care.

Identifying barriers which render patient-centred care less efficient and evaluating solutions in clinical studies are future frontiers which aim at a better diagnosis and control of hypertension.