Among clinicians who treat hypertension — which is almost everyone — the 2017 U.S. hypertension guidelines kicked off a frenzy because of the new definition of high blood pressure; but that narrow focus distracts from the global goal. Attention was focused almost exclusively on how a reading of 130/80 had replaced 140/90 as the new standard. But another number should be consuming our attention and arousing our jealousy: 90%. That’s the proportion of patients with hypertension at a few well-organized systems whose blood pressures are controlled, versus 50% to 60% in most of the country. The most pressing question in hypertension is not how we define it in individuals, but how to manage it at the population level.
Hypertension is not the only chronic condition for which classification criteria are useful but can be distracting, as well. The same can be said for body mass index criteria to define obesity and hemoglobin A1c levels to define diabetes mellitus. Cutoffs play important roles in other parts of daily life — speed limits, for example, are routinely ignored by drivers, yet every 5 mph increase is associated with an 8% increase in highway fatality rates.
Think of the new definition of hypertension as a reduction in the speed limit. The real impact of the 2017 hypertension guidelines should be a directive to mobilize organizational change. The 130/80 target will not serve well if it diverts attention from the big picture. It should nudge us to do better, to move the bell-shaped curve to the left, which will take adoption of systems that are not present in most of U.S. health care. Prior performance proves control cannot be achieved solely by individual clinicians treating individual patients through traditional office visits. Innovation is required.
Why Is This So Hard?
Clinicians who treat hypertension are used to failure; the reasons are summarized in the 2017 hypertension guidelines. Typically, patients have possession of their antihypertensive medications only 50% of the time, and only 1 in 5 patients has adherence rates needed to achieve the benefits observed in clinical trials, as seen in Section 12.1.1 of the report. Lifestyle changes can lower blood pressure, but getting patients to eat healthy diets, lose weight, exercise, and reduce their alcohol consumption are beyond what most clinicians believe they can do.
Add to these challenges the fact that hypertension is asymptomatic, medications have side effects, and physicians are too busy to provide ready access or do education — and we understand the conclusion of many clinicians that doing better is not possible.
How Are Some Organizations Doing Well?
The problem with that conclusion, however, is that some organizations are, in fact, doing better — much better. Kaiser Permanente North California has paved the way with control rates at 90%. This control uses the “old” definition of 140/90, but the results are enough to pose an obvious question — what are they doing right?
The answer seems to be tied to unwavering dedication. Kaiser committed itself to hypertension control and to applying all available resources to make it happen. Their large size and integrated care delivery model enabled them to invest in systems that address barriers to blood pressure control. Critical to their success were: formation of an electronic registry to identify and track hypertensive patients; system-wide adoption of a treatment algorithm for providers; frequent follow-up with medical assistants for blood pressure checks, with no copay required; and use of combination pill therapy.
Progress is not limited to staff model health maintenance organizations like Kaiser Permanente. Government agencies have joined the effort. Veterans Health Administration hospitals also deploy a systematic approach to the management of hypertension in primary care that raised control rates to 76.3% in 2010 from just 45.7% in 2000.
Future Care Innovations Needed
Applying lessons learned from successful organizations with the goal of attaining the new blood pressure targets helps define a clear path forward for the rest of health care — even academic medical centers. Beyond key features already recognized — a robust electronic patient registry, an evidence-based algorithm, and combination therapy — several additional innovations are fundamental to the success of future programs. Economic forces and clinical evidence dictate that home blood pressure measures replace traditional office measurements for the titration of therapy. Further, especially with the prevalence of hypertension now reaching nearly half of Americans, any workable solution must minimize both office visits and the involvement of high-level professional providers.
Cardiovascular Innovation at the Brigham and Women’s Hospital (BWH), where we both practice, is an example of a program designed to change the game. It is developed as a scalable, efficient solution that can work in different systems of health care, not just within one particular integrated model. For hypertension control, blood pressures are measured remotely (at home) and systematically by patients, and transmitted seamlessly into the electronic medical record. Patient navigators are responsible for applying an iterative clinical algorithm and communicating recommendations with patients. Advanced information technology solutions and rapid titration cycles facilitate reaching blood pressure goals quickly.
Modeled in parallel with an innovative lipid-lowering platform and one for heart failure, the BWH Hypertension program showed dramatic success in a small pilot of 130 patients: Of the 116 who were engaged in the program and measured their blood pressure at home, 91% of hypertensive patients were controlled in an average of 7 weeks. We often say our patients are more complex and sicker at academic medical centers, and that may be true — but it looks like they respond similarly to other hypertensive patients to system interventions.
The key to any successful program will be demonstration of scalability, widespread applicability, and sustainable reductions in blood pressure. Challenges threaten progress at all levels, from refining electronic medical records and registries, to subsidizing patient cuffs, to developing and coordinating software required for transmission and analysis of blood pressures. Payment and cost-containment have to make sense, including global payment rather than fee-for-service programs. And solutions have to overcome therapeutic inertia, fear, and ignorance in all stakeholders.
Among other important initiatives is the Million Hearts Initiative, launched in 2012 by the Department of Health and Human Services to prevent 1 million strokes and heart attacks within 5 years. Blood pressure control is an essential part of its agenda, encouraged by The Hypertension Control Challenge, a competition to identify practices achieving benchmark hypertension control rates through innovations in health care approaches. Professional societies are joining these efforts: The American Heart Association is disseminating its Heart360 Innovation, a pharmacist-led program where patients report their home blood pressures online.
Stay Focused on the Right Goal
Hypertension is a global clinical problem of immense magnitude. Release of the new hypertension guidelines should not precipitate wasted attention on squabbles over the individual target. Instead, it heralds a call for focusing on control of the population. The current 50% control rate for America is embarrassing. A target of 80% control could be met easily with focused attention. Greater effort will yield 85% control, and multiple systems have proven that 90% is reachable, if we make it a priority.
The tough new hypertension guidelines should make all of us think differently and universally, and force new opportunities wide open. Organizations can and should accept the protocols, develop and adopt new technologies, innovate, and mobilize to create sustainable solutions for controlling hypertension. This is our moment to control hypertension on an organizational, national, even international level. Health care providers must invest up front for societal dividends that will pay off without measure.