Before we begin, we had a big announcement on the live show a couple days ago: Healthcare Triage is now on Patreon. Patreon, of course, is a subscription platform where you can help support Healthcare Triage and help make it even better than it is today.

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And now, for the content. I read a study a few weeks ago on blood pressure treatment for nursing home residents, and I gotta admit I almost ignored it. There are just so many like it. But it's just ridiculous that the kind of stuff in that study continues, and that we can't seem to do anything about it. We're still doing stuff that harms patients. This is Healthcare Triage News.

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We know that in many people, high blood pressure is bad. We therefore try to do things to lower it. But then we go ahead and decide that if lowering blood pressure is good for some people, it must be good for everyone.

In frail, elderly people, however, there's no evidence that this is true. And there may be evidence that lowering blood pressure is a bad idea. But that runs counter to what we've always been told about the general public, so many people ignore it.

"Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents: The PARTAGE Study," was published in JAMA Internal Medicine. It was a longitudinal study of elderly people living in nursing homes, meaning that the authors recruited people there and then followed them for about two years.

They were interested in seeing how different aspects of care were related to the subjects' chance of dying. Almost 80% of them were being treated for high blood pressure, in spite of the fact that we know that's likely not a good idea.

Previous analysis of this study had shown that blood pressure was inversely related to all-cause mortality, even after adjusting for a gazillion confounders such as age, sex, history of previous cardiovascular disease, Charlson Comorbidity Index score, cognitive function, and autonomy status, or activities of daily living.

This study went further, to look at whether being on lots of drugs for high blood pressure was bad, even after controlling for the blood pressure relationship. Patients in this study were on an average of seven drugs, and were on at least two drugs for high blood pressure.

What the study found, to no one's real surprise, is that people on two or more blood pressure medications who had a systolic blood pressure of less than 130 millimeters of mercury had a significantly higher all-cause mortality. This held true even after additionally adjusting for propensity score matched subsets, other cardiovascular issues, and the exclusion of patients without a history of hypertension who were nonetheless receiving blood pressure-lowering agents.

Even though there's evidence that keeping blood pressure lower in this population is likely bad, many of them were on multiple medications to do just that. Those on more medications, or getting more treatment, were more likely to die.

Here's the kicker: this wasn't a study done in the United States. It was done in France and Italy. So this isn't me bashing on the United States healthcare system. This is a problem writ large.

We find something that is bad. We find that lessening it is better. We then start to lessen it even more. Soon, we're trying to lessen it for everyone. We're saying it's too high in all populations, even when we don't have evidence that's true. We say it even as evidence builds that less is bad for some people.

Better clinical decision support might help, but we can't seem to get that in electronic health records, and doctors hate those anyway. Many are still unaware that guidelines even exist. And then when things get really bad, we act as if we aren't to blame.

From an editorial in JAMA, and I'm quoting, "It is surprising that among frail elderly patients with a systolic blood pressure of less than 130 millimeters mercury, or 20% of the study group, the use of multiple antihypertensive drugs was continued, because few evidence-based data support this approach."

Really? It's surprising? Getting doctors to change their behavior is hard. And as we've covered in previous episodes, getting them to stop doing something may be even harder. But all of this is important. And it's part of why health services research is so critical.

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