Prevention, Treatment, Control and Sodium Reduction Policy

Transcription

1 Prevention, Treatment, Control and Sodium Reduction Policy Mary G. George MD, MSPH, Medical Officer Janelle Gunn MPH, RD, Policy Lead Division for Heart Disease and Stroke Prevention U.S. Department of Health and Human Services Centers for Disease Control and Prevention

2 Overview of this Module Hypertension and the impact on population health Assessment of hypertension Challenges in hypertension control JNC-VII treatment guidelines System-based initiatives to improve control Hypertension and sodium connection Community and population based changes to promote prevention

3 Discrepancy Between Health Determinants and Spending of $1.7 Trillion, 2007 Health Behaviors 50% Prevention 4% Environment 20% Medical Services 96% Genetics 20% Access to Care 10% Factors Influencing Health National Health Expenditures Source: Prevention Institute Reducing Healthcare Costs Through Prevention. Available at

4 EPIDEMIOLOGY

5

6 Hypertension Mortality Rates

7 The Magnitude of the Problem Hypertension is the single largest risk factor for cardiovascular disease mortality, accounting for 45% of all CVD deaths 1 INTERSTROKE Study concluded that hypertension provides 34.6% of the population-attributable risk (PAR) for stroke 2, while INTERHEART found it provides 17.9% of the PAR for myocardial infarction 3 The PAR is the reduction in incidence that would be observed if the population were entirely unexposed (did not have hypertension). 1. IOM (Institute of Medicine) A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. 2. O Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case control study. The Lancet 2010; 376: Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, Alvaro Avezum, Fernando Lanas, Matthew McQueen, Andrzej Budaj, Prem Pais, John Varigos, Liu Lisheng, on behalf of the INTERHEART Study Investigators, Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study, The Lancet, 2004: 9438,

8 Comprehensive Approach to Hypertension Control Focused clinical interventions for those at high risk Lifestyle advice Population-based strategies

9 Stages of CVD Intervention Primordial Before risk factors develop Primary Treatment of risk factors Secondary After a CVD event occurs

10 Primordial Prevention Preventing Risk Factors from Developing In 1978, Strasser introduced the concept of primordial prevention. Once a risk factor has developed, it can be difficult to reduce the risk it contributes to overall health Medications and lifestyle interventions cannot reduce CVD event rates to levels seen in those who maintain optimal risk factor profiles (ideal cardiovascular health) into middle and older ages. Lloyd-Jones DM. Improving the cardiovascular health of the US population. JAMA. 12 ;

11 Population Strategy WHO, Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk., 2007

12 Major Shifts in Population Risks and Expanded Treatment, U.S. Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, NEJM 2007; 356: Change in numbers of deaths ,745 fewer deaths in Risk Factors worse: +17% Obesity (increase) +7% Diabetes (increase) +10% Risk Factors better: -65% Population BP fall -20% Smoking -12% Cholesterol (diet) -24% Physical activity -5% Treatments: -47% AMI treatments -10% Secondary prevention -11% Heart failure -9% Angina: CABG & PTCA -5% Hypertension therapies -7% Statins (primary prevention) -5%

13 What Can You Do to Make a Difference? Approximately 68 million U.S. adults (1 in 3) have hypertension Only 46% of adults with hypertension had adequately controlled blood pressure. The Million Hearts initiative has set a goal of 65% control by 2017 overall, and 70% in the clinical setting Valderrama A, et al. Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors. MMWR. 2011; 60(36);

14 Patient Level Strategy A 10mmHg lower systolic blood pressure (SBP) or 5mmHg lower diastolic blood pressure (DBP) is associated with an approximately 20 25% lower risk of coronary heart disease (CHD) and an approximately 40% lower risk of stroke 1. Stamler J, Stamler R, Neaton JD, Blood pressure, systolic and diastolic, and cardiovascular risks. US population data, Arch Intern Med, 1993;153: Asia Pacific Cohort Studies Collaboration, Blood pressure and cardiovascular disease in the Asia Pacific region, J Hypertens, 2003;21: MacMahon S, Peto R, Cutler J, et al., Blood pressure, stroke and coronary heart disease. Part I, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias, Lancet, 1990;335:

15 JNC VII TREATMENT GUIDELINES

16 Assessment Assess for major cardiovascular risk factors Assess for identifiable causes of hypertension Sleep apnea Drug induced/related Renovascular disease Cushing s syndrome or steroid therapy Pheochromocytoma Coarctation of aorta Thyroid/parathyroid disease Chronic kidney disease Primary aldosteronism Greenland P ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: Executive Summary. JACC. Vol. 56, No. 25, 2010.

17 Lifestyle interventions JNC VII recommends therapeutic lifestyle change only for most people with pre-hypertension Weight reduction DASH diet Dietary sodium reduction Physical Activity Moderate alcohol consumption

18 JNC VII Medication Recommendations* Pre-hypertension Lifestyle interventions Stage 1 Hypertension (SBP or DBP mmhg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination Stage 2 Hypertension (SBP 160 or DBP 100 mmhg) 2-drug combination for most (usually thiazide-type diuretic* and ACEI, or ARB, or BB, or CCB) ACEI ARB BB CCB = ace inhibitors = angiotensin receptor blockers = beta blockers = calcium channel blockers *JNC-VII includes chlorthalidone among thiazide-type diuretics.

19 Medication Adherence Clinician empathy increases patient trust and motivation Physicians should consider their patients cultural beliefs and individual attitudes in formulating therapy Team-based care (pharmacy medication therapy management, physician assistants, nurse practitioners, etc.) Consider the Morisky Medication Adherence questionnaire for your hypertensive patients

20 CHALLENGES IN HYPERTENSION CONTROL

21 Special Populations Minorities Blacks have an increased rate of conversion from prehypertension to hypertension Median age-adjusted conversion time when 50% of patients converted from pre-hypertension to hypertension was 2.7 years in whites and 1.7 years in blacks Over age 80 Significant benefits from treatment May be more sensitive to medication side effects or drug interactions due to an increased number of medications taken Selassie A, et al. Progression is accelerated from prehypertension to hypertension in blacks. Hypertension. 2011; 58:

22 Resistant Hypertension Hypertension not controlled using a combination of 3 antihypertensive drug classes, including a diuretic Non-compliance/adherence with medication Fluid imbalance renal failure Hormonal imbalance

23 Incidence of Resistant Hypertension Study from Colorado Kaiser Permanente, found that 1.9% of patients (1 in every 50 patients) with incident hypertension who were begun on treatment developed resistant hypertension within a median of 1.5 years from initial treatment They found 16% of patients on 3 or more drugs continued to have resistant hypertension Daugherty SL, et al. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation. February 29, Epub ahead of print]

24 What Happens if Hypertension isn t Controlled? Left ventricular hypertrophy (LVH) Heart failure Chronic kidney failure Stroke (cerebral hemorrhage) Vascular dementia Retinopathy

25 Incidence of ESRD by Systolic Blood Pressure: Multiple Risk Factor Intervention Trial * Incidence of ESRD per 100,000 Person-Years 5.4 White Men (n = 300,645) Black Men (n = 20,222) < >140 Systolic Blood Pressure (mm Hg) * The original cohort of 332,544 men included 11,677 men in other ethnic groups whose data are excluded from this comparison. ESRD = end-stage renal disease Klag MJ, et al. End-stage renal disease in African-American and white men. 16-year MRFIT findings. JAMA. 1997;277: Slide Source Hypertension Online org

26 Effects of Systolic and Diastolic Blood Pressures on CHD Mortality: MRFIT * CHD Death Rate Per 10,000 Person-Years Diastolic Blood Pressure (mm Hg) * Data shown only for 316,099 white men 35 to 57 years of age who were followed for a mean of 12 years. CHD = coronary heart disease MRFIT = Multiple Risk Factor Intervention Trial 8.8 Neaton JD, et al. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;152: < < Systolic Blood Pressure (mm Hg)

27 Risk of Stroke Death According to Blood Pressure (mm Hg): MRFIT Relative Risk of Stroke Death Systolic Blood Pressure (SBP) Diastolic Blood Pressure (DBP) * * * * * SBP DBP < < Decile (Lowest 10%) (Highest 10%) MRFIT = Multiple Risk Factor Intervention Trial; *P < 0.01; P < Stamler J, et al. Arch Intern Med. 1993;153: ; He J, Whelton PK. Am Heart J. 1999;138(Pt 2): Slide Source Hypertension Online org

28 SYSTEM-BASED INITIATIVES TO IMPROVE CONTROL

29 Meaningful Use and Pay-for-Performance PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure Percentage of patients aged 18 and older who are screened for high blood pressure. PQRS Measure #236 (NQF 0018): Hypertension: Controlling High Blood Pressure Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/<90) during the measurement year.

30 Team-based care the Role of the Pharmacist The Asheville Project is a community-based, pharmacistdirected, medication therapy management (MTM) program provided for several employers in the Asheville, NC area Patients with hypertension receiving education and longterm medication therapy management services achieved significant clinical improvements that were sustained for as long as 6 years cardiovascular events adherence to medications Bunting BA, et al. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:23 31.

31 Quality Improvement and Clinical Decision Support A proven concept that improves care! Alerts Reminders Reports Templates for management Built-in access to guidelines Enhances implementation of quality improvement initiatives

32 Clinical-Community Reporting Efforts RWJF Aligning Forces for Quality Public reporting Wisconsin Collaborative for Healthcare Quality

33 The Connection HYPERTENSION AND SODIUM

34 The Effect of Sodium Intake on Blood Pressure Sodium intake is one of several dietary factors that increases blood pressure Sodium is the principal cation of the extracellular fluid and functions as the osmotic determinant in regulating extracellular fluid volume and plasma volume Sodium is stored in the blood and in the fluid surrounding the cells; kidneys control the body sodium concentration by clearing excess sodium through urine

35 The Effect of Sodium Intake on Blood Pressure Sodium affects blood pressure by changing blood volume Absorbed sodium remains in the extracellular compartments, including plasma (at [140 mmol/l]; interstitial fluid [145 mmol/l]; plasma water [150 mmol/l]; muscle tissue [3 mmol/l]) These levels maintain blood pressure in the normal range Increased sodium intake =increased blood volume = higher blood pressure Sodium reduction = decreased blood volume = lower blood pressure Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: National Academies Press; 2004.

36 Excess Sodium Intake Leads to Hypertension Sodium, through hypertension, is a major contributor to death, disability, disparities, and costs attributable to cardiovascular diseases (CVD) Economic burden Treatment for heart disease, stroke, and other CVD accounts for 1 in 6 U.S. health dollars spent ($273 billion in 2008) Globally, 8.5 million deaths could be averted over 10 years from 2006 to 2015 through a 15% reduction in sodium intake Vital Signs: MMWR 2011; 60(4):1-3 8 Heidenreich PA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123; Asaria P, et al. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:

37 Sodium Reduction Benefits All Ranges of Blood Pressure Evidence supports a strong, direct relationship between blood pressure and vascular mortality No evidence of a blood pressure threshold vascular mortality increases throughout the range of blood pressures in both nonhypertensive and hypertensive individuals Average blood pressure was reduced by 22.7/9.1 mm Hg in patients with resistant hypertension when switched from a high to low sodium diet In most individuals blood pressure is reduced within days to weeks of reducing sodium intake Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: National Academies Press; Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia J, Calhoun DA. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension. 2009; 54:

38 DASH and DASH Sodium Trials Dietary Approaches to Stop Hypertension (DASH) Trial Compared the effects of three diets typical American diet, fruits and vegetable diet, and a diet rich in fruits and vegetables and low fat dairy, and reduced in saturated fat, total fat, and cholesterol All diets provided ~ 3,000 mg sodium per day Combination diet (DASH) produced the largest blood pressure reduction after 8 weeks average of 5.5 / 3.0 mm Hg Participants with hypertension experienced an average blood pressure of 11.4 / 5.5 mm Hg DASH Sodium Trial DASH diet and three levels of sodium intake 1,150 mg, 2,300 mg, and 3,450 mg DASH diet and a low level of sodium SBP by 7.1 mg Hg Participants with HTN experienced a BP of 11.5 mm Hg Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336: ; Sacks et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. N Engl J Med 2001; 344:3-10

39 Sodium Intake Levels: Recommended and Actual Recommended levels of sodium intake 2010 Dietary Guidelines for Americans Reduce sodium to < 2300 mg/day For specific populations: 1,500 mg/day 51 years old African Americans Have high blood pressure, diabetes, or chronic kidney disease About half the U.S. population and the majority of adults Actual sodium intake Average daily sodium intake for U.S. adults is >3,300 mg/day USDA and HHS. Dietary Guidelines for Americans, th edition. Washington, DC: Government Printing Office; Vital Signs: MMWR 2012; 61(Early Release);1-7

40 Individual Sodium Reduction Has Population Benefits Reducing the sodium content by 25% of the top 10 food category contributors to sodium intake could result in a 360 mg reduction in average sodium consumption in the United States Reducing average population sodium consumption by 400 mg has been projected to avert up to 28,000 deaths from any cause and save $7 billion in healthcare expenditures annually CDC, MMWR;2012;61:1-7. Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590 9.

41 Reducing Sodium Intake Reduces Blood Pressure Reducing average population sodium intake to 1,500 mg/day may Reduce cases of hypertension by 16 million Save $26 billion health care dollars Gain 459,000 Quality Adjusted Life Years (QALYs) Even reducing sodium intake to 2,300 mg/day could Reduce cases of hypertension by 11 million Save $18 billion health care dollars Gain 312,000 QALYs Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Eng J Med 2001;344:3 10. Palar K, et al. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot 2009;24(1):49 57.

42 Percent of US persons exceeding their 2010 Dietary Guidelines for Americans sodium intake recommendations* % Age Group *All people age 51 and older should reduce sodium intake to 1,500 mg/day. MMWR 2011;60:

43 Most of the sodium we eat comes from processed and restaurant foods Mattes RD, et al. Relative contributions of dietary sodium sources. J AM Coll Nutr 1991;10:

44 44% of US sodium intake comes from ten types of foods Rank Food Types % 1 Bread and rolls Cold cuts and cured meats Pizza Poultry Soups Sandwiches Cheese Pasta mixed dishes Meat mixed dishes Savory snacks 3.1 CDC, MMWR;2012;61:1-7.

45 Other Guidelines and Recommendations Institute of Medicine Reduce the sodium content of the U.S. food supply Health practitioners: commitment to incorporate guidelines on sodium intake into prevention messages and standards of care Million Hearts Reduce population sodium intake by 20% by January 1, 2017 Healthy People 2020 Reduce mean U.S. population sodium intake to 2,300 mg per day by 2020 American Heart Association Reduce population sodium intake to 1500 mg per day

46 Other Guidelines and Recommendations American Medical Association Stepwise, minimum 50% reduction in sodium in processed foods, fast-food products, and restaurant meals over the next decade Physicians and other clinicians should educate patients about the benefits of long-term, moderate reductions in sodium intake Substantial public health benefits accrue from small reductions in population blood pressure distribution, achievable with long-term modest reduction in sodium intake AMA supports the National Salt Reduction Initiative Aim is to lower U.S. population sodium intake by 20% over five years through sodium reduction in packaged, processed and restaurant foods by 25% over that time period Dickinson B, Havas S. Reducing the Population Burden of Cardiovascular Disease by Reducing Sodium Intake A Report of the Council on Science and Public Health. Arch Intern Med. 2007;167(14):

47 Adults with Self-Reported Hypertension Who Received and Acted on Low-Salt Advice Age, years 50% Advice and behavioral change Behavioral Risk Factor Surveillance System, 19 states, 1 territory, and Washington, DC, 2007

48 Role of the Provider AMA recommends that health care providers educate patients on how to reduce sodium intake However, nearly 70% of primary health care providers report advising their patients to remove the salt shaker from the table, and the majority reported advising patients to add less salt during cooking, even though these behaviors are unlikely to result in major sodium reduction Havas S, Dickinson BD, Wilson M. The urgent need to reduce sodium consumption. JAMA. 2007;298: Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1): doi: /archinternmed Image adapted from CDC Vital Signs Fact Sheet, Where s the Sodium

49 Health Care Providers Who Agree with Importance of Sodium Reduction for their Patients Statement: Most of my patients should reduce their sodium intake Health care provider Fang J, Cogswell M, Keenan N, Merritt R. Primary Health Care Providers' Attitudes and Counseling Behaviors Related to Dietary Sodium Reduction. Archives of Internal Medicine 2012;172(1): doi: / archinternmed

50 Role of the Provider Patients may be able to lower the required dose of blood pressure medicines through reduced sodium intake Patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction Referral to a Registered Dietitian for Counseling Education during BP screenings Downloadable CDC resource: Reducing Sodium in Your Diet to Help Control Your Blood Pressure Advise consumption of fresh fruits and vegetables, frozen fruits and vegetables without sauce, and no salt added canned vegetables Advise limiting processed foods high in sodium

51 Role of the Provider Current food environment makes it difficult for consumers who want or need to consumes less sodium to do so Reduction of sodium in the food supply, coupled with consumer education and knowledgeable use of food labels, may provide greater choice and control over sodium intake, a modifiable risk factor for high blood pressure, heart disease, and stroke

52 Patient Education It s Not the Salt Shaker, It s the Food Choices!

53 COMMUNITY AND POPULATION-BASED CHANGES TO PROMOTE PREVENTION

54 Community Partners Community health workers and Promotores de Salud A liaison between health and social services and the community facilitating access to care Provides a trusted liaison through a shared culture with the people they serve Barbershop- and beauty shop-based interventions to improve hypertension control Faith-based support programs Ferdinand KC, et al. Community-based approaches to prevention and management of hypertension and cardiovascular disease. Journal of Clinical Hypertension Online ahead of print. DOI: /j x

55 Population-Based Strategy SBP Distributions After Intervention Before Intervention Reduction in BP Stambler.Hypertension. 1991; Reductions in SBP % Reduction in Mortality Stroke CHD Total

56 CDC Efforts Related to Hypertension Control Community Transformation Grants Sodium Reduction in Communities WISEWOMAN program State Health Departments Million Hearts Initiative

57 Public Health Public health approaches such as increasing physical activity and reducing trans-fats and salt in processed foods can achieve a downward shift in the distribution of a population s blood pressure. In addition to CDC activities on the previous slide, CDC funds many other programs to promote healthy lifestyles.

58 Quick Facts about Hypertension and Sodium 9 in 10 people eat too much sodium 44% of the sodium we eat comes from 10 types of foods Reducing sodium by 1,200 mg/day can save $20 B Image adapted from CDC Vital Signs Fact Sheet, Where s the Sodium Image adapted from CDC Vital Signs Fact Sheet, High Blood Pressure and Cholesterol Every 39 seconds an adult dies of heart attack, stroke, or other cardiovascular disease Nearly 1 in 2 people with hypertension doesn't have it under control

59 Hypertension Control and Sodium Reduction EDUCATOR TOOLKIT

60 Resources CDC Vital Signs: Hypertension and Cholesterol ndex.html CDC Vital Signs: Where s the Sodium? CDC Vital Signs: Prevalence, Treatment, and Control of Hypertension 04a4.htm?s_cid=mm6004a4_w

61 Resources CDC Grand Rounds: Sodium Reduction: Time for Choice CDC Blood Pressure Information DASH Diet h/new_dash.pdf

62 Resources JNC VII The Asheville Project Morisky Medication Adherence Questionnaire %2C%20Ang%20A%2C%20Krousel- Wood%20M%2C%20Ward%20H.%20Predictive%20Validity% 20of%20a%20Medication%20Adherence

63 Important Hypertension Trials SHEP (Systolic Hypertension in the Elderly Program) In persons aged 60 years and over with isolated systolic hypertension, antihypertensive stepped-care drug treatment with low-dose chlorthalidone as step 1 medication reduced the incidence of total stroke by 36% ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) The mean systolic blood pressure was 4mm Hg higher in blacks and 2 mm Hg higher in non-blacks in the lisinopril group than in the chlorthalidone group. Blood pressure control was 8-13% better in the chlorthalidone group than in the lisinopril group for blacks. Although in the trial overall the chlorthalidone group was better controlled than the lisinopril group, this difference between the two groups among blacks is quite striking. MRFIT (Multiple Risk Factor Intervention Trial) Changed protocol in clinics using primarily HCTZ to chlorthalidone due in part to an a higher trend in mortality in clinics using predominantly hydrochlorothiazide. Changing to chlorthalidone was associated with a trend toward better outcomes. TROPHY (Trial of Preventing Hypertension) Found that it is possible to prevent or delay the onset of clinical hypertension in people with blood pressure that falls within the "prehypertension" category

64 Important Hypertension Trials TOHP (Trials of Hypertension Prevention) Sodium reduction, previously shown to lower blood pressure, may also reduce long term risk of cardiovascular events. TONE (Trial of Nonpharmacologic Interventions in the Elderly) Reduced sodium intake and weight loss constitute a feasible, effective, and safe nonpharmacologic therapy of hypertension in older persons. HYVET (Hypertension in the Very Elderly Trial) According to Timothy Gardner, M.D., President of the American Heart Association: The results of HYVET demonstrate that effective antihypertensive treatment with indapamide (Natrilix SR) in persons aged 80 years old or older, is beneficial in reducing the risk of cardiovascular events, and thus extends the patient group in whom prevention must be pursued.

65 From Medscape Education Case Studies Timing is Everything: 24-Hour Control of Blood Pressure William C. Cushman, MD

66 How well prepared are your residents for managing hypertension? Study from Johns Hopkins of baseline knowledge of PGY3 internal medicine residents Hypertension 62-66% Lipid Management 31-36% Diabetes 35-40% Smoking 53-54% Obesity 44-47% Total of 15 Chronic Diseases 48-50% Baseline knowledge of PGY3 did not differ from PGY1 and PGY2 Sisson SD, Dalal D. Internal Medicine residency training on topics in ambulatory care: A status report. Am Jour of Medicine. 2011;124(1):86-90.

67 Discussion Questions (could be used before delivering the module or after) You have a busy Family Medicine Practice 1. At what point would you consider referring a patient for hypertension control? 2. How does team-based care delivery for hypertension control work in your clinic? 3. Can you think of ways to improve your health information technology to improve hypertension control? 4. How do you guide your patients to reduce sodium in their diet?