A Patient‐Centric Web‐Based Approach to Improve Hypertension Management: A Lesson Learned From Postmenopausal Women

Awareness, treatment, and control of hypertension are characterized by different prevalence according to sex and race. Although women demonstrate higher rates of awareness and treatment of hypertension as compared with men, they are less frequently controlled with the administered antihypertensive treatment.1 Moreover, as shown in the same survey, non‐Hispanic black women compared with their non‐Hispanic white and Mexican American counterparts, were characterized by higher rates of hypertension awareness, treatment and control.1

Despite these epidemiologic observations, hypertension remains still nowadays largely uncontrolled, despite improved treatment, a condition occurring also in women and defined as the hypertension paradox by Chobanian.2

Such a paradox requires more efforts to address a number of yet unmet needs in this field. First, the commonly recommended but largely neglected lifestyle modifications should be more effectively promoted. Second, the doctor's time spent with the patients has to be improved, both quantitatively and qualitatively. Finally, the issue of inadequate hypertension control should also be revisited through a patient‐centric approach. This approach might be particularly important in postmenopausal women because of the accelerated age‐related increase in the incidence of hypertension, in the progress of arterial stiffening, and in the rate of fatal cardiovascular events, especially after the age of 65 years.1

In the present issue of The Journal of Clinical Hypertension, Doner Lotenberg and colleagues3 describe the results obtained by mapping the journey of postmenopausal women going through the steps required to diagnose and manage a high blood pressure (BP) condition. Authors, through analysis of an online survey, examined the experiences in this regard of 300 postmenopausal women with at least 6‐year lasting hypertension. These data were extracted from a structured questionnaire focusing on hypertension diagnosis and monitoring, on hypertension treatment, and on long‐term disease management.

The main findings of the present study3 confirm the low adherence of these women to treatment, the inadequate rate of lifestyle intervention counseling by health care providers, and the limited use of home BP monitoring to measure routinely out‐of‐office BP levels, especially in the elderly. Additionally, the finding that the diagnosis of hypertension was made in the majority of women (77%) during a check‐up or a sick visit also demonstrates that prehypertension is not regularly searched. This omission to follow the increasing BP changes with aging are partially driven by the inadequacy of educational programs focusing on regular BP measurements and by the widespread belief that prehypertensive BP levels should generally be overlooked. The authors also report that a high clinical suspicion of hypertension or the identification of patients with prehypertension should be corroborated by out‐of‐office BP measurements (eg, measurements in pharmacies, grocery stores, or health clubs) that are more easily accessible in the general population setting than measurements by physicians.

The study by Doner Lotenberg and colleagues3 further supports the notion that almost 70% of hypertensive postmenopausal women taking antihypertensive monotherapy have their BP uncontrolled and this phenomenon was not only related to inadequate treatment strategies (ie, doctor's inertia) but also to patient reluctance to receive more than one drug (ie, patient's poor adherence to prescriptions). Furthermore the coexistence of additional risk factors in almost 80% of these women indicates that the diagnosis of hypertension may unravel additional cardiometabolic risk factors, which, in turn, further increase cardiovascular risk. However, awareness of the detrimental effect of other risk factors in the context of hypertension was very low in this survey. Currently, this latter finding should not be considered as an indication to achieve tighter BP control in patients with established cardiorenal disease or diabetes mellitus, but rather it should stimulate increased medical surveillance to control BP and plasma glucose levels within the limits of the traditionally recommended goals, possibly with closer follow‐up visits.

An online survey represents an optimal tool to perform qualitative studies aiming to unmask the attitudes of patients affected by common diseases including hypertension, because it is easy to complete and the data extraction procedure is straightforward. Previous studies on the same topic were mainly undertaken in the context of focus groups or of research interviews and were also limited to a small number of participants.4, 5

The study by Doner Lotenberg and colleagues,3 in spite of its interest, is affected by some important limitations. First, the main investigational barriers found with online surveys are advanced age and the low education level of most potential participants. Indeed, these factors may partially explain the high rate of incomplete data (70 of 571 [12.2%]) in the study by Doner Lotenberg and colleagues.3 In addition, although the eligible women who participated in the survey were well balanced across different age ranges, those with lower education level were less likely to participate in the survey as compared with their more educated counterparts.

Second, as acknowledged by the authors, this study is of a relatively small sample size. Third, a test‐retest reliability assay was not performed in the present study, thus preventing the assessment of how much of the information provided was solid and reproducible or was, on the contrary, characterized by significant variations overtime.

Conclusions

Taken together, the results of this Web‐based and of other qualitative studies on hypertension3, 4, 5 strongly suggest that giving consideration to attitudes and perceptions of hypertensive patients would result in better organization and implementation of preventive hypertension strategies. This “anthropocentric approach” should also be extended to different developing countries6 because disease perceptions in these settings can be completely different from those in developed countries and also might represent significant barriers for hypertension clinical management in populations where hypertension is rapidly increasing in prevalence.

Disclosures

None for all authors.