Managing hypertension as an optometric physician

ByScott A. Edmonds, OD, FAAO

For many of us who began our optometric careers in the days before therapeutic drug laws, the idea of managing a medical problem without the privileges to write for the actual drugs required to treat the problem is not a new concept. The classic example of this was glaucoma.

We were trained to diagnose, treat and manage glaucoma but we could not prescribe the actual drugs that were required to treat it. When we found a glaucoma suspect, we provided the patient education required for the patient to understand the problem, we ordered visual field tests and carefully examined the optic nerve and then explained the findings to the patient. We saw them multiple times to measure their intraocular pressure, follow their optic nerve and field, and discuss the problem while continuing the patient’s education. Once we decided treatment was required, we referred them to an ophthalmologist to actually prescribe the required drug.

This opened the comanagement door but then we continued to follow, examine, measure and monitor the problem. This was the accepted practice of the day, and all of us that were involved knew that we were providing truly excellent care. As optometrists, we knew our patients, had the time to talk to and educate them, and had convenient locations and short wait times. Busy ophthalmologists did not have the time nor the practice modality to handle this chronic and time-consuming disorder with the threat of serious disability way down the road.

I suggest that today we are in exactly the same situation with the optometric management of hypertension. We understand hypertension and know how to diagnose, treat and manage the problem but cannot, as yet, prescribe the drugs that are required to treat it. With this disease however, we are in an even better role to provide the management.

Unlike glaucoma, hypertension can often be managed by lifestyle changes that improve diet, increase exercise and reduce stress. This level of management does not require drugs and is already within our scope of practice in every state. As we move forward in our quest to use our electronic health records with “meaningful use,” we are now routinely measuring vital signs as part of the optometric examination. Soon we will be sharing these finding with our patients’ primary care physician (PCP0 and getting updates in return.

In the exact parallel of the busy ophthalmologist who did not have the time to provide the education and counseling required to manage glaucoma, a chronic problem with a long time before sight is impaired, hypertension shares the same clinical dynamic. PCPs have been inundated with the newly insured of the Affordable Care Act (ACA) and they too are so busy with acutely sick patients to spend the time to provide education and counseling required to manage hypertension, a chronic problem with a long time before organs are impaired.

According to the U.S. Centers for Disease Control and Prevention, "About one in three U.S. adults — or 67 million people — have high blood pressure. Only about half (47%) of people with high blood pressure have their condition under control. This common condition increases the risk for heart disease and stroke, two leading causes of death for Americans."

Optometrists need to recognize their role in improving these statistics. We have the tools, we have the access to these patients and we are now essential providers under the ACA. The start of legislative efforts to expand our scope have already begun (see California Senate bill 492). Here are a few steps to consider that will increase your role in managing hypertension:

Take some continuing education courses on hypertension to brush up on current medications and management concepts.
Take your patients’ vital signs, including blood pressure, on each visit
For your patients that have hypertension, discuss their hypertension and related medicines during the review of systems and medicine reconciliation.
Carefully evaluate the retinal blood vessels and look for very early signs of hypertensive changes. This is particularly helpful with the use of an Optomap retinal scan or other photo documentation devices. Changes in patients’ own blood vessels can dramatically demonstrate the real physical changes related to uncontrolled blood pressure and can be a powerful motivator for better control.
Spend time at the end of the examination while providing your “doctoring” discussing your patients’ day-to-day management of their hypertension with diet, exercise and stress release. Encourage self-monitoring with inexpensive home-based blood pressure kits. Encourage them to keep a log and to bring it to their doctor visits.
Take advantage of patients that already see you frequently to monitor their glaucoma. Take their blood pressure and their eye pressure and educate them that healthy blood circulation to the optic nerve is as important to their glaucoma control as their eye pressure. Follow this up with good communication with the patient’s PCP.

The optometrist’s role in managing hypertension will not change overnight. Like many issues discussed in this blog and like health care reform in general, it will be a slow evolution. Start today with some of the tips noted above and your patients as well as their comanaging physicians will begin to understand your expanding role in their overall health. You will begin to make your contributions to a healthier America and be on your own road to health care reform.