What is the recommended approach to managing a chronic condition, such as diabetes or hypertension, in an adult patient, in line with the Choose Wisely campaign?

Managing Chronic Conditions Aligned with Choose Wisely Principles

Implement team-based care with structured medication titration protocols, target blood pressure <140/90 mmHg using ACE inhibitors or ARBs as first-line agents, target HbA1c 7.5-8.0% using metformin initially, and prioritize lifestyle interventions before medication intensification while avoiding routine unnecessary testing. 1

Core Framework: Team-Based Care Model

The foundation of managing diabetes and hypertension should be team-based care as the primary delivery system, with designated team members implementing medication titration algorithms under physician supervision rather than relying solely on physician-driven care. 1 This approach directly addresses the Choose Wisely principle of efficient resource utilization while maintaining quality outcomes.

• Create protocols for timely patient contact through telephone, secure messaging, or urgent appointments to enable non-physician team members to manage routine adjustments. 1
• Designate specific team members (nurses, pharmacists, care coordinators) to implement pre-approved medication titration algorithms rather than requiring physician involvement for every adjustment. 1

Blood Pressure Management Algorithm

Initiate pharmacologic therapy immediately alongside lifestyle modifications for confirmed office BP ≥140/90 mmHg—do not delay treatment waiting for lifestyle changes alone. 1

First-Line Agent Selection

• Use ACE inhibitors or ARBs as preferred initial agents for all patients with diabetes and hypertension, particularly those with proteinuria, microalbuminuria, or left ventricular hypertrophy. 1
• Target BP <140/90 mmHg for most adults with diabetes. 1
• Avoid lowering systolic BP to <120 mmHg in older diabetics, as this causes harm without cardiovascular benefit and may worsen cerebral perfusion. 2

Monitoring Considerations

• Check standing BP at each visit to monitor for orthostatic hypotension, especially in elderly patients. 3, 2
• Titrate medications gradually to avoid orthostatic hypotension in cognitively impaired or elderly patients. 3

Glycemic Control Algorithm

Target HbA1c <7.5% for most adults with diabetes, relaxing to 7.5-8.0% or even 8.0-8.5% for older adults with multiple comorbidities or limited life expectancy. 1, 3, 2

First-Line Agent Selection

• Use metformin as the first-line agent for type 2 diabetes unless contraindicated by renal function. 1, 3
• Avoid sulfonylureas in elderly or cognitively impaired patients due to prolonged half-life and escalating hypoglycemia risk. 3, 2
• Consider SGLT inhibitors and GLP-1 receptor agonists when initiating treatment, as they reduce BP, enhance kidney function, and lower cardiovascular disease risk. 4

Critical Safety Monitoring

• Assess hypoglycemia risk and awareness at every visit, as cognitive impairment and advanced age increase vulnerability to severe hypoglycemic episodes that can worsen cognition. 3, 2
• Never target HbA1c <7% in older adults with multiple comorbidities—aggressive control increases hypoglycemia risk without proportionate benefit. 2

Lifestyle Interventions (Mandatory for All Patients)

Initiate lifestyle modifications for all patients with BP >120/80 mmHg or diabetes, regardless of medication status—these are not optional or secondary interventions. 1

• Weight loss through caloric restriction 1
• DASH dietary pattern implementation 1
• Regular physical activity (supervised walking programs and aerobic exercise improve vascular function) 1, 2
• Alcohol moderation 1
• Smoking cessation counseling 1
• Ensure optimal protein intake to prevent sarcopenia in older adults with diabetes 2

Cardiovascular Risk Reduction Beyond Glucose and BP

• Target LDL-C <55 mg/dL or ≥50% reduction for patients with diabetes and very high cardiovascular risk using statin therapy. 1, 2
• Initiate aspirin 81-325 mg daily for secondary stroke prevention in older adults with diabetes and established cardiovascular disease. 2

Choose Wisely Principles: What to Avoid

Avoid routine cardiac screening in asymptomatic patients with diabetes—instead perform careful history and assess cardiovascular risk factors rather than ordering unnecessary tests. 1 This directly addresses the Choose Wisely campaign's emphasis on reducing low-value care. 5

Additional Unnecessary Testing to Avoid

• Do not perform routine pre-operative testing without clinical indication—awareness campaigns alone are insufficient; system-level changes in ordering processes are required. 5
• Do not interrupt successful antihypertensive therapy when patients reach 80 years of age. 2

Essential Screening and Monitoring (High-Value Care)

• Screen annually for diabetic kidney disease by assessing eGFR and urinary albumin:creatinine ratio. 1
• Monitor for orthostatic hypotension by measuring BP in erect posture at each visit in elderly patients. 2

Patient-Centered Implementation

• Engage patients in determining individual BP and glycemic targets based on life expectancy, comorbidities, treatment burden, and patient preferences. 1
• Involve caregivers in medication management and safety monitoring for patients with cognitive impairment to address concerns without institutionalization. 3
• Use patient-centered communication incorporating literacy assessment and cultural barriers. 1

Common Pitfalls

• Relying solely on awareness-raising and guideline revision is insufficient—behavior change requires system-level interventions such as electronic order modifications, decision support tools, and performance monitoring. 5
• Failing to relax glycemic targets in elderly or complex patients leads to preventable hypoglycemia. 3, 2
• Aggressive BP lowering in older adults can worsen cerebral perfusion and outcomes. 2