Miracle Behaviours and Hypertension:
A Conversation with Dr. Ellen Burgess

Micheal C. King, Calgary General Hospital

Hypertension affects almost 2 million adults in Canada and is perhaps the most preventable cause of premature death among Canadians. Known as the "silent killer" because it is often asymptomatic until a "morbid event" occurs, hypertension flourishes in the presence of key behavioural risk factors such as smoking, sedentary lifestyle, obesity, and poorly managed stress. 50% of hypertensive patients drop out of therapy within a year. Only two-thirds of those remaining take enough medication to control their hypertension.

Parke-Davis Pharmaceuticals has recently developed an innovative phone counselling service for hypertensive patients taking its antihypertensive medication, Accupril. Dubbed Accu-Assist, the program uses nurse counsellors to provide stage-of-change-linked psychological interventions to help hypertensive patients make necessary changes in their risk behaviours.

Skillful as they may be at providing their clients with creative problem-solving tools, psychologists sometimes balk - when they must actually stop to think about it - at the task of having to come up with their own effective strategies for finding their way out of the woods. Could the reason be fear, lack of information or courage, naiveté, or perhaps all these factors combined? Let's take a look!

Dr. Ellen Burgess is a nephrologist and Director of the Hypertension Clinic at Foothills Hospital in Calgary. She was instrumental in developing the assessment and intervention strategies used by the project and training the nurse-counsellors in their use. Michael King spoke with Dr. Burgess about how Accu-Assist is using miracle behaviours to help patients manage this important health problem.

MK: Ellen, tell me a little bit about the Accu-Assist project.

EB:The Accu-Assist Program was devised by Parke-Davis to offer a support service to patients taking their antihypertensive medication, Accupril. Their initial program was aimed at smoking cessation, diet control, exercise, and stress and stress management. They approached me to see whether our group could develop an educational/intervention package for use by nurse counsellors. The counsellors are part of a company called InfoHealth which is situated just outside Toronto. The Accu-Assist Program has two strata: first, a 1-800 number for patients to call at their convenience to ask questions and get appropriate information and counselling about hypertension and its management. After the phone contact, the patient receives a video and booklet that discusses risk factors for hypertension. The other stratum of the project is a proactive one in which physicians advise their patients that they want them to get counselling on some aspect of lifestyle change related to their hypertension. The physician sends a letter to Info-Health and the nurse counsellor then phones the patient once a month for four months. After each phone call, whether patient-initiated or physician-initiated, a report is sent to the physician outlining which lifestyle behaviours had been discussed and what plan for managing that behaviour had been decided on.

MK: One obvious question: Why is a big drug company with a very profitable antihypertensive medication interested in paying for these kinds of behavioural interventions?

EB: Over the last few years, all drug companies have come under increasing pressure from government and private insurers to do a little more for consumers who are paying so much money for their products. If you buy a computer and have a problem with it, you can phone the company and get some help with that problem. But when it came to pharmaceuticals, the companies didn't provide any service to the patients whatever, beyond printing up some pamphlets once in a while and circulating them to the doctors. More and more, the drug companies are coming to feel they should be seen as health care providers and not just as sellers of pills and potions. We've seen internationally how drug companies are trying to broaden the services they deliver. This project, Accu-Assist, is part of Parke-Davis' move toward that goal. And it's one of the most ambitious projects of its kind in the industry.

MK: The drug companies see benefits in being good corporate citizens. But I gather they also see fundamental problems, for example in the population of hypertensive patients that you work with, in patients' adherence to these treatment regimes. The drugs don't work if the patient doesn't take them. Lifestyle changes don't help if the patient doesn't make them.

EB: Yes. The biggest problem we have in dealing with our patients is that most of them have no symptoms. The idea that they have a condition that requires big changes in their lives and for which they have to take medication is quite abstract to them - until they develop a morbid event secondary to their hypertension. Once they've had a stroke or a heart attack, it's no longer so abstract. Unfortunately, once they've had that morbid event, we really have missed the boat. The interventions may still help then. But it's much better to intervene before they happen. We know from some large scale projects designed to change lifestyle in hypertensive patients that with concerted educational efforts, you can get people to change their risk behaviours. And these changes have an impact on tangible factors like number of days of work lost and incidence of morbid events. So we know the interventions can work, but we've got to deliver them on a large scale and efficiently.

MK: You've made it clear in our talks that you feel it's important to intervene with your hypertensive patients based on where they are in their readiness to make necessary lifestyle changes.

EB: In our hypertension clinic, we've had a multi disciplinary approach for over 15 years. We have a nurse-educator, a dietitian, a psychologist, and a physician. The physician can give pills but the pills may have little effect unless the patient makes some basic and specific behavioural changes. If patients reduce the amount of salt in their diet, they get better effect. If they increase their activity, they get better effect. If they quit smoking, they get better effect. If they reduce their drinking, they get better effect. And we've been impressed with the data from Prochaska's group that we may be more time-efficient and effective in our counselling of patients if we have a better idea of where they are in regard to the process of change. For example, if a patient hasn't yet realized that their alcohol intake is driving their blood pressure up, there's not much point in trying to talk with them about ways of reducing their drinking. We need to work instead on getting across to them the impact of their behaviour.

MK: I understand you were involved in training nurse-counsellors in how to assess patients for stage of change and then how to use stage-linked interventions with them. Can you give me an example of a script that might be followed for a patient who called in on the 1-800 number?

EB: When the patient calls in, the nurse goes through an initial questionnaire with them to find out which risk factors they have. We also need to find out if they have already had an event. If a patient has already had a stroke, discussing activity with them has to be considered from a different perspective. If smoking is the focus, for example, the nurse asks the two questions that tell us what stage of change that particular patient is in: "Do you intend to quit smoking in the next six months?" and, if yes, "Do you intend to quit smoking in the next 30 days?". With that information, we can sort out whether they're precontemplators, contemplators, in preparation, and so forth. If they say they've already quit, we find out if its been for less than or more than six months. That way, we can see whether they're in the action phase or whether they've crossed over into maintenance. With the information about what stage of change the patient is in, the counsellor moves into a stage-specific interview on each of the risk behaviours. If the patient turns out to be a precontemplator, the script moves to specific questions such as "have you tried to quit smoking in the past" and focusses on reframing previous failures for the patient. The script goes into reasons why the patient may not have quit. Common answers are available to the counsellor so that he or she has the appropriate encouraging response. For example, if the patient says smoking is a habit that he or she just can't change, the counsellor shares with them that most persons who quit do so on their own and often describe it afterward as the greatest success of their lives and one that gives them a great sense of satisfaction.

MK: So in Prochaska's terms, what the counsellor is trying to do is to start setting up a "pro/con" balance that can gradually be moved in favour of change.

EB: Exactly. In each of the precontemplation scripts, we ask the patients to sit down right after the phone call and make a list of the pros and cons of making these lifestyle changes. With contemplators, the script goes further, offering patients common reasons why people don't change and asking whether those reasons sound familiar to them. What we want them to do is to revoice some of the cons and some of the pros and see how the balance moves between them over time. We try to get them to think about it rather than just listening passively to a taped message. That's why the scripts have questions in them at regular intervals to make sure there is a two-way interaction happening.

MK: How is Parke-Davis planning on evaluating this project?

EB: We explained to them that if they were going to evaluate this program simply by looking at how many people quit smoking, or lost weight, or whatever, they could save their money right there. This was not going to be that kind of miracle cure. If we assess whether patients exposed to this program move from one stage of change to the next, we've got a more sensitive way of judging the real impact of the program. In the proactive arm of the program, patients are getting a phone call a month for four months. With follow-up questions in those later interviews, we can see very clearly whether people have moved along at all. We're also discussing the possibility of a follow-up telephone interview with the patient or maybe a questionnaire to the patient or the patient's physician asking about physical and psychological changes from the interventions.

MK: This is a pretty sophisticated approach to outcome since you're looking at the way in which people move from stage to stage toward the ultimate target rather than just at whether they achieve the final outcome or not. How many people is this project going to reach?

EB: 17,500 people in one year.

MK: That's amazing. And how many people would you be able to see in your consulting practice in that time?

EB: Less than a thousand. This project is much larger than what any clinic could do. Plus, people from anywhere in Canada can access this program. So even if you're in Tuktoyaktuk, you can speak to a counsellor anytime that is convenient to you and get appropriate, consistent information and counselling. Services are available in French and English, in Mandarin and Cantonese, and in Italian.

MK: So you're really spreading your influence as a health care provider way beyond what you could do from your office with people who can come in to see you.

EB: Yes. A major problem for physicians in Canada is that we don't have time to give adequate training to our patients. Counselling is not a fee item. And to be very truthful, doctors are not trained in how to counsel patients around these health care issues and may not be up on the latest information from the literature even if they had the time and the training to provide it. Obviously, patients without symptoms are not going to pay their own money for counselling to help them deal with a condition that doesn't seem to intrude into their lives.

MK: It sounds like we're coming more and more to the realization that most of these large-impact illnesses are behaviour disorders and that they need behavioural solutions.

EB: Absolutely. People have control to a large extent over their health, whether it's through smoking, diet, activity, whatever. For whatever reason, they aren't exercising that control.

MK: Dr. Ellen Burgess. Thank you.

EB: You're welcome.