The PEAK - August
The PEAK
August Newsletter
Dr. Matthew Johnson
August 01, 2024
Welcome to The PEAK!
The PEAK, or “Patient Education And Knowledge,” is the monthly newsletter for Free Range Direct Primary Care. This newsletter will hopefully provide you with evidence-based medical knowledge as well as updates regarding the practice.
Practice Updates
School Physicals: If the kids are in need of school physicals prior to starting school. Let me know! I can get them in for a visit.
NEW PATIENTS: My office is accepting new patients! Currently, I can see them in 1-2 days for a new patient appointment. If you know of anyone in need of a primary care doctor, please send them my way!
APPOINTMENTS: If you are in need of an appointment, please schedule here. You may also call or email and I can get you on the schedule.
MEDICATION REFILLS: Please text/call (434-337-5934) or email (drjohnson@frdpc.com) with medication refill requests. I will get them to your pharmacy as soon as possible.
In this issue…
- Standard of Care for Hypertension
- Bioidentical Hormones: What does the evidence say?
- What are the benefits of Direct Primary Care?
What is the current standard of care for hypertension?
The American Academy of Family Physicians (AAFP) recommends treating adults with hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risk of all-cause mortality and cardiovascular mortality. This is a strong recommendation based on high-quality evidence. While a lower blood pressure target of less than 135/85 mm Hg may be considered based on patient preferences and values, it does not provide additional benefit in preventing mortality. The systematic review found no significant differences in total serious adverse events between the lower and standard target groups but noted a significant increase in other adverse events, such as syncope and hypotension, when treating to a lower systolic target.[1]
The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend a blood pressure target of less than 130/80 mm Hg for noninstitutionalized ambulatory community-dwelling adults aged 65 years or older with an average systolic blood pressure of 130 mm Hg or higher. For adults with stage 2 hypertension, a combination of nonpharmacological and antihypertensive drug therapy is initiated, with two agents of different classes, and a repeat blood pressure evaluation in 1 month.[2]
Nonpharmacological therapy is the preferred therapy for adults with elevated blood pressure and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year atherosclerotic cardiovascular disease risk of less than 10%. Adherence to and impact of nonpharmacological therapy should be assessed within 3 to 6 months.[3]
AAFP Issues New Clinical Practice Guideline on Hypertension. Annals of Family Medicine. 2023 Mar-Apr;21(2):190-191. doi:10.1370/afm.2972.
2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Casey DE, Thomas RJ, Bhalla V, et al. Journal of the American College of Cardiology. 2019;74(21):2661-2706. doi:10.1016/j.jacc.2019.10.001.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Whelton PK, Carey RM, Aronow WS, et al. Circulation. 2018;138(17):e484-e594. doi:10.1161/CIR.0000000000000596.
What does the evidence say about the bioidentical hormones?
The evidence regarding the benefits of bioidentical hormones (BHT) is mixed and often lacks robust support. Bioidentical hormones are chemically identical to those produced by the human body and are often marketed as being safer and more effective than conventional hormone therapies. However, the current consensus in the medical literature does not fully support these claims.
A review by Boothby et al. found that while individualized hormonal products may decrease some menopausal symptoms, they have no proven advantage over conventional hormone therapies in terms of pharmacokinetics, safety, and efficacy.[1] Similarly, the American College of Obstetricians and Gynecologists (ACOG) states that compounded bioidentical menopausal hormone therapy should not be prescribed routinely when FDA-approved formulations exist, due to a lack of evidence supporting their safety and effectiveness.[2]
The Cochrane Database of Systematic Reviews evaluated the effectiveness and safety of bioidentical hormones compared to placebo or non-bioidentical hormones for the relief of vasomotor symptoms. The review found that BHT was more effective than placebo for treating moderate to severe hot flushes but was associated with higher rates of adverse effects such as headache, vaginal bleeding, and breast tenderness. The quality of evidence was low to moderate, and no significant difference was found between BHT and conjugated equine estrogens (CEE).[3]
The American College of Clinical Pharmacy also recommends against the consistent use of compounded bioidentical hormones, citing a lack of data supporting their safety and efficacy compared to manufactured hormone therapy.[4]
In summary, while some studies suggest that bioidentical hormones may be effective for symptom relief, there is insufficient evidence to support their routine use over conventional hormone therapies, and they may carry similar risks of adverse effects.
Bioidentical Hormone Therapy: A Review. Boothby LA, Doering PL, Kipersztok S.Menopause (New York, N.Y.). 2004 May-Jun;11(3):356-67. doi:10.1097/01.gme.0000094356.92081.ef.
Compounded Bioidentical Menopausal Hormone Therapy: ACOG Clinical Consensus No. 6. Obstetrics and Gynecology. 2023;142(5):1266-1273. doi:10.1097/AOG.0000000000005395.
Bioidentical Hormones for Women With Vasomotor Symptoms.Gaudard AM, Silva de Souza S, Puga ME, et al.The Cochrane Database of Systematic Reviews. 2016;(8):CD010407. doi:10.1002/14651858.CD010407.pub2.
Use of Compounded Bioidentical Hormone Therapy in Menopausal Women: An Opinion Statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy.McBane SE, Borgelt LM, Barnes KN, et al.Pharmacotherapy. 2014;34(4):410-23. doi:10.1002/phar.1394.
What are the benefits of Direct Primary Care?
Direct Primary Care (DPC) offers several benefits for both physicians and patients, primarily by altering the traditional fee-for-service model to a retainer-based system.
For physicians, DPC can significantly reduce administrative burdens and regulatory requirements, which are major contributors to physician burnout. This model allows for more time with patients, freer communication, and less paperwork, thereby improving job satisfaction and reducing burnout rates.[1]
For patients, DPC can enhance accessibility and continuity of care. By paying a retainer fee, patients often gain same-day or next-day appointments, extended visits, and direct communication with their primary care provider via phone or email. This can lead to improved patient satisfaction and better management of chronic conditions.[2]
Additionally, DPC has the potential to reduce overall healthcare costs. By improving access to primary care, DPC can decrease the need for more expensive urgent care and emergency department visits. For example, a study found that better access to primary care was associated with a significant reduction in urgent care visits.[3]
In summary, DPC can offer benefits such as reduced administrative burdens for physicians, improved patient access and satisfaction, and potential cost savings, although further research is warranted to confirm these advantages comprehensively.
Defining the Place of Direct Primary Care in a Value-Based Care System. Carlasare LE. WMJ : Official Publication of the State Medical Society of Wisconsin. 2018;117(3):106-110.
Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes.Cole ES.Journal of the American Board of Family Medicine : JABFM. 2018 Jul-Aug;31(4):605-611. doi:10.3122/jabfm.2018.04.170214.
The Impact of Improving Access to Primary Care.Glass DP, Kanter MH, Jacobsen SJ, Minardi PM. Journal of Evaluation in Clinical Practice. 2017;23(6):1451-1458. doi:10.1111/jep.12821.