Team-based approaches needed to fight high blood pressure

Uncontrolled high blood pressure rates continue to grow despite the availability of proven treatments, but collaborative approaches can be effective in fighting this deadly disease, according to a science advisory from the American Heart Association, the American College of Cardiology and the Centers for Disease Control and Prevention.

The advisory is a call to action for healthcare systems and providers to work in closer partnership with patients, and it calls for local, regional and national programs that offer coordinated care using multiple resources to achieve better blood pressure control in all patients.

"Despite access to health care, effective therapies that have been available for 50 years, and various education and quality improvement efforts that have been targeted at patients and healthcare providers, achieving success in hypertension control is still a challenge," said Alan S. Go, M.D., Director of the Comprehensive Clinical Research Unit at Kaiser Permanente Northern California and lead author of the advisory.

High blood pressure – readings at or above 140/90 millimeters of mercury – affects about 1 in 3 Americans and is a major risk factor for heart disease and stroke. Of those who have high blood pressure, also called hypertension, about 75 percent are being treated but only half have it controlled to a healthy level, according to national surveys.

The advisory recommends that healthcare, industry and communities prioritize people with high blood pressure who are receiving treatment but haven't achieved their target blood pressure. The writing group members note that of those with uncontrolled hypertension, nearly 90 percent see a healthcare provider regularly, and 85 percent have health insurance.

"A multi-partner environment may be beneficial to reach people with high blood pressure and ensure that their condition is being treated maximally, and to reduce disparities in high blood pressure control," said Willie Lawrence, M.D., co-author, AHA spokesperson and Chief of Cardiology, Research Medical Center, Kansas City.

According to the advisory, efforts to educate patients and providers have not been sufficient in bringing hypertension under control. Similarly, interventions targeting only physicians have not led to sufficiently consistent and meaningful improvements.

"The tools to control blood pressure have long been available, but hypertension control requires patient and physician involvement within a supportive system," said John G. Harold, M.D., MACC, president of the American College of Cardiology. "We are advocating a team approach that reduces barriers for patients and leverages the power of electronic health records to improve cardiovascular health."

So what works? More recent studies suggest that comprehensive hypertension programs that coordinate care using multiple resources may lead to better overall blood pressure control.

The advisory also provides examples of successful programs that could be emulated. One is a Kaiser Permanente program that increased the proportion of its patients with hypertension with well-controlled blood pressure from 44 percent in 2001 to more than 87 percent in 2011. The program focused on five main elements: creating a system-wide hypertension registry, providing regular feedback on hypertension control rates to providers, implementing and frequently updating an evidence-based treatment algorithm, using single-pill combination therapies and using medical assistants for follow-up blood pressure checks in order to help patients receive necessary treatment adjustments efficiently. Lifestyle changes for patients were strongly recommended as well.

The advisory provides eight principles for developing an effective high blood pressure treatment algorithm (and uses them to provide a usable example of such an algorithm):

• 1. Base the components and processes on the best available science.
• 2. Format the algorithm in a manner that is simple to update as new evidence becomes available.
  
• 3. Use a feasible, simple implementation strategy.
• 4. Include a patient version at appropriate scientific and language literacy level.
  
• 5. Consider costs of diagnosis, monitoring, and treatment.
• 6. Use a format easily incorporated within a team approach to health care.
  
• 7. Use a format able to be incorporated into electronic health records for clinical decision support.
• 8. Include a disclaimer to ensure that the algorithm is not used to counter the treating healthcare provider's best clinical judgment.

"The message for large and small practices and systems is: 'Use an approach that includes an evidence-based treatment algorithm and you can improve blood pressure control for your patients,'" said CDC Director Tom Frieden, M.D., M.P.H. "Pick from any one of a number of available protocols, or develop your own—just use an evidence-based one."

"Arming healthcare providers, health systems, and communities with proven tools, algorithms, strategies, programs, and other best practices, along with expertise and technical assistance for improving blood pressure awareness, treatment and control is essential to reducing the tremendous burden of cardiovascular risk," said the statement authors.