Hypertension Management: Ripe for Disruption

I n 1994, Jeff Bezos began to sell books online. With the virtual bookstore that would eventually become Amazon.com, he engaged customers more often than brick-and-mortar bookstores and delivered books to the customers’ destinations of choice, commonly the customers’ homes. Books were chosen as the initial offering in the delivery of this virtual service in part because of the large number of book titles available. By bringing the store virtually to the customers wherever they were, Amazon.com both disrupted and revolutionized the retail industry. Hypertension is similarly common and is present in 1 in 3 US adults. Treatment reduces the risk of cardiovascular sequelae, including stroke, myocardial infarction, and kidney disease. Unfortunately, satisfactory blood pressure control is achieved for only half of US adult hypertensive patients. This gap in care persists despite the availability of effective and lowcost therapeutic options. Underlying reasons include inadequate rates of antihypertensive medication initiation and intensification and inconsistent patient adherence to recommended lifestyle changes and antihypertensive medications. The current analysis by Mr. Lin Mu and Dr. Kenneth Mukamal explored medication initiation and intensification. Using a combination of 2 nationally representative databases capturing ambulatory care visits spanning 2005 to 2012, the authors sought to characterize current US practice patterns in hypertension management. They found that antihypertensive medication initiation and medication addition occurred during only 7 million of 42 million (16.8%) primary care clinical encounters with patients with documented systolic/diastolic blood pressure ≥140/90 mm Hg. The proportion decreased over time from 19.3% in 2007 to 12.3% in 2012 and was driven principally by a fall in antihypertensive medication initiation among patients not on prior hypertensive medication. The authors queried whether the observed low and declining rates were consequences of limited in-office time for primary care providers and patients who may have a myriad of other medical issues to address. The current analysis has several strengths and limitations. On the one hand, the databases used are nationally representative, richly detailed, and yielded a robust sample size. The authors performed appropriately nuanced analyses of the available data by exploring treatment intensification patterns according to several clinical and demographic subgroups and blood pressure levels. On the other hand, data on dose adjustments of existing medications were lacking, and only a single blood pressure measurement from each office visit was recorded. The former shortcoming allowed for the possibility of underestimation of treatment intensification, whereas the latter introduced an element of greater uncertainty to blood pressure measurement, which is already inherently variable over time. Limitations notwithstanding, the overall message is clear: Low rates of in-office antihypertensive medication initiation and intensification constitute an important opportunity to improve the quality of care and outcomes for US hypertensive outpatients. How can we achieve better population-level hypertension control? As the findings of the current analysis suggest, greater attention to in-office treatment is needed. Nevertheless, optimizing clinic visits is but one piece of the puzzle. Change is needed not only in clinics but also in health care systems. Integrated health care systems such as the US Department of Veterans Affairs and Kaiser Permanente Northern California have reported hypertension control rates >80%. These results have been achieved through a variety of programs and include the use of monitoring and feedback, pay-for-performance incentives, and team-based approaches emphasizing the roles of nurses and pharmacists. Broader dissemination of such strategies will require tailoring to local environments. Engaging patients where they are most of the time—out of the office—is also required. Several public health initiatives have made demonstrable progress in this regard. Broad-based The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Cardiology Section, VA Eastern Colorado Health Care System, Denver, CO (P.L.H., P.M.H.); Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (P.L.H., P.M.H.). Correspondence to: Paul L. Hess, MD, MHS, Cardiology Section (111B), Denver VA Medical Center, 1055 Clermont St, Denver, CO 80220. E-mail: [email protected] J Am Heart Assoc. 2016;5:e004681 doi: 10.1161/JAHA.116.004681. a 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. 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