HYPERTENSION AMONG AFRICAN AMERICANS
The prevalence of hypertension among African Americans is among the highest rates in the world. Approximately 700 000 to 1000 000 Americans die each year due to hypertension-related complications (Cohen & Cesta, 2018). Hypertension in AA is developed in early age and is more severe compared to the Whites. It is associated with obesity, smoking, alcohol consumption, inactivity, poor socioeconomic status, and high sodium diet. More than 49.1% have uncontrolled hypertension with non-drug adherence. There is a need to utilize evidence-based practice derived from nursing research, clinical expertise, and patient experience to develop effective health interventions that lower blood pressure. Researchers established that the AA has a gene that makes them salt sensitive, therefore the DASH diet with sodium restriction was recommended.
Evidence-based practice
Evidence-based practice has been integrated into clinical practice in the management of chronic diseases to improve patient outcomes. Hypertension is associated with stroke, end-kidney disease, and congestive heart diseases, thus there is a need to implement evidence interventions to reduce the disease burden. Case management studies and evidence-based practice go hand-in-hand to improve the effectiveness of health interventions. Approximately 78 million adults aged 18-65 years are affected by hypertension and have modifiable risk factors for cardiovascular disorders (Melnyk, & Fineout-Overholt, 2011). A comprehensive approach that integrated EBP interventions is crucial to address multiple comorbidities and associated risk factors.
The interventions adopted by most health systems are an interdisciplinary and customizable approach that permits health departments or clinical areas to connect practice and policy change to occur locally to improve the management of chronic diseases and care coordination (Melnyk, & Fineout-Overholt, 2011). This helps address the rising cases in underserving populations and meet the needs of individuals. The evidence-based interventions widely used by Federally Qualified Health Centers (FQHCs) are referral, team-based care, self-management, and self-monitoring (Unger, et al., 2020). Medication alone cannot help lower blood pressure levels. African American smoke, have a poor diet, and engage in sedentary lifestyles that predispose them to hypertension. Thus, health behavioral interventions through nurse-led education, physical exercise, reduced salt intake, and medication adherence is recommended.
Current best and published guidelines
The goal of the management of hypertension is to maintain optimal blood pressure levels. The International Society of Hypertension (2020) recommended lifestyle modification, pharmacological treatment, and drug adherence as the practice guidelines. Lifestyle modifications are the first-line treatment of hypertension. It entails salt reduction, a healthy diet (DASH diet), and health drinks: increased intake of vegetables reduces BP due to nitrates, low fatty foods, and reduced salt will reduce blood pressure levels (Unger et al., 2020). Also, avoiding alcohol consumption, weight reduction to maintain appropriate BMI, smoking cessation, and physical activity is recommended. Several studies recommend that regular aerobic and resistance exercises are helpful in the prevention and treatment of hypertension.
Non-adherence to antihypertensive treatment affects 10-80% of the patients and is responsible for suboptimal blood pressure control (Armstrong, 2017). Poor adherence correlates with the degree of BP rise and is an indicator of poor prognosis. It is linked with the healthcare system, illness factors, patients, and socioeconomic factors. The recommended guidelines in ensuring compliance to treatment are: evaluating adherence at each visit, reducing poly-pharmacy, connecting adherence with everyday behaviors, and providing a response to the patients to motivate them (Unger et al., 2020). Also, encouraging home blood pressure monitoring, reminder packing of medications, empowerment-based counseling for self-management, automated aid, and multidisciplinary team approach. Effective management combines counseling, self-management, reinforcement, and continuous supervision.
I would recommend patient and family education, follow-up activities, and using a team approach to improve the management of hypertension and adherence. The Journal of Clinical Hypertension provides a framework to increase accuracy in measuring BP. It outlines a MAP approach that emphasizes “measure accurately, act rapidly, and partnering with patients” and encourages primary physicians to collaborate with assistants, nurses, and other health providers (Armstrong, 2017). The current emphasis on management focuses on self-measuring of blood pressure and enhanced HPI. The use of technology and evidence-based practice interventions to manage chronic diseases has increased over time. The use of mobile health app is increasing and it incorporates a team approach. The patient can monitor their blood pressure levels, weight, and heart rate, document them, evaluate, and seek medical attention in case of abnormalities. They receive reminders or notification on appointments and drug refills, health education, and can interact with other patients through the provided platform.
Clinical pathways influence on case management
Clinical pathways are defined as special packages that comprise multiple, complex, and integrated health services (Cohen & Cesta, 2018). It designs specific processes of care that focus on best management attainable, rather than acute events. Clinical pathways shift the healthcare system from the focus on acute care to improve chronic and long-term care. The main aim is to reduce the progression of the disease and improve prevention services. It integrates clinical guidelines, evidence-based guidelines, and protocols for common diagnoses, conditions, and procedures into algorithms used by a multidisciplinary care team in planning and implementing patient-centered care (CMSA, 2016). Clinical pathways addresses: patient assessments and monitoring, diagnosis, treatment, consultations, and medications. Besides, engaging activities, nutritional measures, health education, outcome criteria, and targeted hospital stay. This results in improved care coordination, and a greater quality of care and reduces health costs.
“Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. (CMSA, 2016, p. 8).” Clinical pathways target specific processes and sequence of care designed to monitor patients’ progress step by step until they regain optimal levels of functioning. They aid in the implementation of the guidelines or protocols developed during case management studies. They provide a comprehensive direction on each step of the management of hypertensive patients over the specified time and include the improvement and consequences of care (CMSA, 2016). Clinical pathways are essential in improving the steadiness and coordination of care across different health departments. The algorithms are viewed as models of decision-making regarding the care of the patient implemented through a stepwise sequence.
The components of clinical pathways are timeline, activities and interventions, transitional and long-term outcome measures, and variance tracking. They vary based on the strategies, protocols, and algorithms utilized by the multidisciplinary team to achieve quality and optimum outcomes (Unger et al., 2020). The case managers use these components as a means of identifying problems, where it arose, and collect data that can aid in improving the care processes. They use objective data obtained to monitor patients’ progress, as clinical pathways provide a broad view of the implemented care processes. The case managers can continuously assess the patient to establish if the expected goals of the clinical pathway are achieved (Cohen & Cesta, 2018). If the goals are not attained, it is documented as a variance by the case manager.
Conclusion
The utilization of evidence-based practice in managing chronic conditions is aimed at attaining goals by establishing control. Integrating the use of technology in the health system will help the health providers instantly access current information on practice guidelines, and verify the provided information. The high prevalence and incidences of chronic illness mandate the integration of EBP and technology. 80% of hospitals in the U.S. utilize clinical pathways in the management of their patients (Cohen & Cesta, 2018). The main aim of clinical pathways and case management is to improve the quality of care, reduce variation, and optimize health outcomes.
References
Armstrong, C. (2017). JNC8 guidelines for the management of hypertension in adults. American family physician, 90(7), 503-504. Retrieved from: https://www.npnewbies.com/uploads/1/1/9/3/119356249/jnc_8.pdf
Case Management Society of America. (2016). Standards of practice for case management.
Retrieved from www.cmsa.org/Home/CMSA/OurHistory/tabid/225/Default.aspx
Cohen, E., & Cesta, T. G. (2018). Nursing case management: From essentials to advanced practice applications. Elsevier Health Sciences. Retrieved from: https://www.nursingworld.org/~4ae0a9/globalassets/catalog/sample-chapters/nursingcasemgmt-samplechapter.pdf
Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins. Retrieved from: https://books.google.co.ke/books?hl=en&lr=&id=hHn7ESF1DJoC&oi=fnd&pg=PT15&dq
Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., … & Wainford, R. D. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334-1357. Retrieved from: https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120.15026