This morning, I reposted a piece from 2010 on my Substack, titled Doing Nothing, about an older woman who elected to leave her blood pressure untreated rather than putting up with the side effects she had experienced with every blood pressure medication she had tried.
When it comes to cardiovascular risk, I often use the American heart Association/American College of Cardiology risk calculator. But it doesn’t go beyond age 79. I use it a lot to show patients that statistical impact of quitting smoking, controlling blood pressure or taking cholesterol medication. Just to illustrate, I imagined a 79-year-old woman, non-smoker, who has high blood pressure and let the app tell me how much cardiovascular risk would be reduced if I put her on blood pressure medicine. Untreated her 10 year cardiovascular risk would be 36.3 if she were 79. The optimal risk is 18.4% and the impact of controlling blood pressure would be a reduction down to a 10 year risk of 26.6%. The woman in my story was much older, so her risk would be much higher than 36%.
I find that people have an easier time handling statistical odds if you also give them the probability of nothing bad happening. So, Ms. perfect would have an 81.6% probability nothing would happen. The 79 year old with untreated high blood pressure would still have a 63.7% chance of being okay, but could improve that to 73.4% by taking blood pressure medication.
The woman in my story was 88 years old. According to the Social Security Administration tables, her remaining life expectancy would be just over 5 1/2 years.
Her decision was to stay away from medications because they made her feel bad. It was a quality of life choice she made. I couldn’t blame her. Doctors these days get graded on what numbers our patients achieve. A blood pressure of 140/90 or more is a failing grade and 139/89 is a passing grade. Statistics like that one impact our practices’ bottom line and possibly our own salaries and at least our quality ratings on various websites.
So how bad do doctors feel if their older patients are not “at target“ with blood pressure, cholesterol and other things that we are being graded on? And how good do we feel if we let patients decide for themselves what their priorities are?
You can’t always both ace your quality metrics and also be patient centered at the same time. It’s easier to be hung-ho in getting a 40 year old to quit smoking than it is to make an 88 year old with a remaining life expectancy of less than 6 years to suffer from medication side effects for the rest of her days.
Exactly this, thank you.