• Identify appropriate goals for treatment of hypertension, diabetes, and hyperlipidemia.
• Discuss circumstances under which it is appropriate to intensify pharmacological treatment of hypertension, diabetes, and hyperlipidemia.
• List four questions effective in assessing patients' medication adherence.

Amanda H. Salanitro, MD, MS
Division of General Internal Medicine
University of Alabama at Birmingham
Birmingham, Alabama

Monika M. Safford, MD
Division of Preventive Medicine
University of Alabama at Birmingham
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

You are a busy clinician caring for complex patients. Your patients often present with uncontrolled blood pressure, cholesterol, or HbA1c—despite your prescribing appropriate medications and counseling about diet and exercise.

It is often difficult to get patients to recommended treatment goals of:

• Blood pressure < 140/90 mmHg (< 130/80 for diabetes patients)
• HbA1c < 7%
• LDL-cholesterol <130 mg/dL (< 100 for diabetes patients or those with known CAD)

Further, it can be very frustrating to review lack of control visit after visit. Tools to help you get patients to goal are the focus of this module.
 
Your patients may be like many patients with sub-optimally controlled chronic illnesses. A national survey reported only 53% of patients on blood pressure medications had their blood pressure controlled[1]. Similar levels of control are seen in patients taking medications for diabetes and hyperlipidemia[2,3].

Uncontrolled risk factors are associated with worse patient outcomes. Therefore, you would like to optimize your patients’ risk factors. What could you be doing that you may not be doing right now? The following module illustrates common problems leading to uncontrolled risk factor levels, and provides some tools that you may find useful in your practice.

Today you see Mrs. Jones, a 60-year-old grandmother in for a routine visit. She has no acute problems. You have recommended over-the-counter pain relievers for her osteoarthritis pain, but she is on a statin for cholesterol. The nurse recorded her blood pressure (BP) as 145/88. Looking back, Mrs. Jones' blood pressure has been around this same value for most of the last several visits. At her most recent visit several months ago you advised her to limit salt intake and lose weight through diet and exercise, recommending she join Weight Watchers. Today she weighs 1 pound less than at her last visit, and she admits that Weight Watchers was not “her cup of tea.” She finds dieting and exercising very difficult.