Case 1. Hypertension or Not?
A 52 old man was referred by the practice nurse for initiation of blood pressure medication after having had 3 raised blood pressures recorded, 170/96, 176/100, 178/98.
This gave a conventional diagnosis of mild hypertension. He had a busy job but denied being stressed. Ambulatory blood pressure monitoring was not available in this case. His initial treatment plan:
Lifestyle advice of low salt, losing weight and regular exercise was advised. The patient was keen to avoid medication if possible.
Motivation for the patient came from a desire to avoid medication.
Specific advice on exercise was given for 30 minutes of moderate exercise on 6-7 days a week. He presently did no regular exercise. Different forms of exercise were explored and walking chosen as being the most practical.
A follow up appointment was made for 4/52.
Repeat BP and weight recordings were made at monthly follow up appointments.
The following recordings were made. 164/92, 162/90, 156/86, 154/86, 146/ 82, 144/ 82.
He noted he was sleeping better, felt much better and hadn’t realised he had been stressed with his job. He lost 2kg.
NICE recommends ambulatory 24hr monitoring before a diagnosis of hypertension. This may have picked up a white coat hypertension diagnosis. Lifestyle intervention would still be indicated.
“Discharged” with a normal BP profile but follow up check at 6/12.
Potential cost savings:
Cost of drug prescription for hypertension treatment for 12/12 each year until maybe he becomes hypertensive in the future.
Blood test monitoring of electrolytes if he had ACE or diuretics per year.
Clinical time for future monitoring 2 x BP checks and problems or side effects.
Appointments x 6 to initially monitor, but if initially he was treated, then follow up and stabilisation after initiating anti-hypertensive’s may have cancelled these out.
Case 2. Depression
A 46 year old man presented with mild depression. His PHQ9 score for depression was 9/30. One normal mode of practice would have been to start an antidepressant and follow up monthly.
Instead, an alternative behaviour lifestyle approach was chosen with an emphasis on exercise which the patient previously enjoyed but had allowed to relapse. His initial treatment plan:
Exercise discussed with motivational interviewing and 7/7 of 30 minutes moderate exercise was ‘prescribed’ with cycling being the chosen exercise in the form of commuting to and from work.
Follow up monthly was undertaken with the addition of the Welsh bibliography prescribing scheme (self help books from the local library).
Slow resolution of depression occurred and the patient episode resolved after 12/12.
Antidepressant medication for 12 months or more.
Appointments cost neutral, same number of patient follow up appointments used as this doctor’s normal practice.
Case 3. Obesity
A - 38 old female type 2 new diabetic presented following a diagnosis of diabetes and being overweight. Wt 154kg, BMI= 51.6
For the first 2 years despite advice on diet and exercise, her weight fluctuated with crash diets and intermittent exercise between 154kg and 137kg, but after 2 years it was back to 151kg and with ever rising Hba1c she had progressed onto metformin with increasing doses. One year ago with metformin at 1gm bd and an abnormal hba1c yet again she was given motivational interviewing guidance on activity.
Prior to this she;
“Used to dread getting out of bed in the morning. I wish I wouldn’t wake up.”
Now for the first time she has exercised regularly and consistently.
“I look forward to the day. I have lost inches from my waist and my back pain has gone.”
Her Hba1c has dropped for the first time and is now normal on metformin 1gm bd. Her weight is 141 kg. She has decided to increase her activity time with a target of 300 minutes a week.