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Controlling High Blood Pressure

An Evidence-Based Blueprint for Change

Casey, Donald E. Jr MD, MPH, MBA1–3; Daniel, Donna M. PhD4,*; Bhatt, Jay DO, MPH, MPA5; Carey, Robert M. MD6; Commodore-Mensah, Yvonne PhD, MHS, RN7,8; Holmes, Aline DNP9; Smith, Alison P. MPH, RN10,11,*; Wozniak, Gregory PhD11,*; Wright, Jackson T. Jr MD, PhD12

Author Information
American Journal of Medical Quality: January/February 2022 - Volume 37 - Issue 1 - p 22-31
doi: 10.1097/01.JMQ.0000749856.90491.43
  • Open

Abstract

Failing to correctly diagnose and control high blood pressure (HBP) increases cardiovascular disease (CVD), stroke, and renal failure risk. Recent analyses from the 2011 to 2014 National Health and Nutrition Examination Survey estimated that 115 million adults (46%) in the United States have HBP (systolic BP [SBP] ≥130 mm Hg or diastolic BP [DBP] ≥80 mm Hg).1 An additional 12% of US adults have elevated BP (SBP 120–129 mm Hg and DBP <80 mm Hg) and are at high risk of developing HBP; among those taking antihypertensive medication, 53% have uncontrolled HBP.1 Awareness of HBP increased from 69.9% in 1999–2000 to 84.7% in 2013–2014, but then declined to 77.0% in 2017–2018.2 The prevalence of controlled HBP increased between 1999–2000 and 2007–2008, did not change significantly from 2007–2008 to 2013–2014 (53.8%), and subsequently decreased to 43.7% in 2017–2018.3 Disparities in controlled HBP have been reported among persons who are young (ages 18–44 y), non-Hispanic Black, uninsured, and lack access to a usual health care facility.3 In a large cohort study of US adults ages ≥45 years of age, the incidences of atherosclerotic CVD (ASCVD) and all-cause death were 20.5 and 29.6 per 1000 person-years, respectively, among participants with American College of Cardiology/American Heart Association (ACC/AHA) stage 1 HBP who had been recommended to initiate antihypertensive medication, and 22.7 and 32.9 per 1000 person-years, respectively, among participants with ACC/AHA stage 2 HBP.4 This same study also noted that among participants taking antihypertensive medication with above-goal BP (ie, SBP ≥130 mm Hg or DBP ≥80 mm Hg), the incidences of ASCVD and all-cause mortality were 33.6 and 42.5 events per 1000 person-years, respectively. As of 2017, CVD remains the leading cause of death in the United States with 859 125 deaths, which, when combined with 146 383 deaths from stroke, exceeds 1 million deaths annually or 2754 deaths per day.5 It is also recently well documented at the time of this publication that people with hypertension may be at increased risk for severe illness from coronavirus disease 2019 (COVID-19).6 Finally, individuals with HBP face, on average, nearly $2000 more in annual health care expenditures than those who do not have HBP.7

Despite evidence-based recommendations for lower BP goals (<130/80 mm Hg) in the 2017 ACC/AHA BP Clinical Practice Guidelines,8 existing quality measures from the National Committee for Quality Assurance (NCQA) for controlling HBP (for hypertensive adults ages 18–59 y whose BP is <140/90 mm Hg)9 have not changed substantially over the past several years for various insured populations, including commercial, Medicaid, Medicare Fee for Service, and Medicare Advantage (Figure 1).10,11 Reexamining both the targets and processes of managing HBP are thus urgently warranted to help support the use of the latest evidence in optimizing quality of care and outcomes for patients with HBP.

F1-4
Figure 1:
NCQA HEDIS % controlling high blood pressure measure trends 1999–2018.11 Abbreviations: HEDIS, Healthcare Effectiveness Data and Information Set; HMO, health maintenance organization; NCQA, National Committee for Quality Assurance; PPO, preferred provider organization.

To address these pressing challenges, the American College of Medical Quality (ACMQ) hosted a group of nationally recognized HBP experts, chief quality officers, health system leaders, accountable care organizations (ACOs), government and public health officials, health plan executives and professional societies, and trainees from the ACMQ Student/Resident/Fellow section at their meeting in Bethesda, Maryland, in April 2019.12

This session, titled Blueprint for Change: Defining and Promoting a Single, Effective System of Care for Patients with High Blood Pressure, focused on 2 major objectives:

  • To define key elements of systems design for effective, guideline-based interventions to diagnose and manage HBP.
  • To develop consensus on best ideas for standardization and implementation across the various participant organizations with an overarching goal to construct a model for “The Best HBP Care for the US Health System.”

Participants paid very close attention to a number of specific recommendations from the 2017 ACC/AHA BP Guidelines as well as the (then) recently published 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.13 Each of the specific recommendations has been designated by ACC/AHA Expert Guidelines writing groups as having both a Class I Recommendation (Class of Recommendation [COR]) and either a high (A) or moderate (B) Level of Evidence (LOE) quality.14 COR I recommendations are strong and indicate that the treatment, procedure, or intervention is useful and effective and should be performed or administered for most patients under most circumstances, and also encompass the estimated magnitude and certainty of benefit in proportion to risk. LOE A indicates high-quality, concordant evidence from more than 1 adequately powered randomized controlled trial, meta-analyses of high-quality trials, or randomized controlled trial data corroborated by high-quality registry or practice-based studies. Moderate-quality or less convincing evidence based on 1 or more trials, meta-analyses of moderate-quality studies, or data derived exclusively from registries or other sources that have not been externally validated are assigned LOE B and are now further delineated according to whether the evidence derives from randomized (B-R) or nonrandomized studies (B-NR).

After careful synthesis and summary of input and a transcription of the audio file of the entire session, the following 8 recommendations from Blueprint for Change are presented. The authors strongly believe that these must be combined and implemented together across the health continuum as necessary in order to achieve a single guideline-based effective system of care for adults with HBP:

Recommendations for Accurate BP Measurement

  • 1. Health system and payer leadership should commit appropriate resources, including funds and training, to ensure accurate BP measurement and the appropriate use of validated, calibrated BP monitoring devices consistent with current clinical practice guidelines throughout the entire health care system.8,15

Accurate measurement and recording of BP are essential to categorize the level of BP, ascertain BP-related CVD risk, and guide the management of HBP (ACC COR 1, LOE: Expert Opinion). BP measurements are often unstandardized, despite the well-known consequences of inaccurate measurement.16 The use of nonvalidated and infrequently calibrated BP monitors, inadequate staff training, and/or lack of a standardized measurement protocol can result in a misleading estimation of an individual’s true BP level. Underestimating SBP by 10 mm Hg is estimated to result in a 10%–40% increase in fatal myocardial infarctions and strokes17,18; overestimation by 5 mm Hg would increase treatment intensity unnecessarily in 30 million Americans.19 In addition, during a typical office visit, the workflow may not allow best practices (eg, correct patient positioning, adequate time for rest) for accurate BP measurement. Resources for online training and retraining for both patients and staff are now readily available through sources such as the AHA/American Medical Association (AMA) Target: BP, so that health systems do not need to “reinvent the wheel.”13,20

  • 2. Health system and payer leadership should strongly encourage and support home BP monitoring (HBPM) of all patients with hypertension and should ensure accurate out-of-office measurements and secure data collection (ACC/AHA COR 1, LOE A).8

Out-of-office BP measurements (especially HBPM) are strongly recommended in the 2017 ACC/AHA BP Guidelines to confirm both the diagnosis of hypertension and the achievement of BP targets. HBPM assesses BP control, identifies white coat and masked hypertension phenotypes, and predicts future CVD events more accurately than office BP readings.13 The recent AHA/AMA policy statement on the use of self-measured BP at home emphasized the evidence supporting HBPM, in conjunction with co-interventions such as educational classes, counseling, behavioral change management, telemonitoring, and medication management by clinicians, to improve BP control.21 Infrastructure to directly and securely transfer HBPM measurements to an electronic health record (EHR) is essential but currently limited by universal device capabilities such as nonstandard applications and EHR interfaces. Recording the sources and locations of BP measurements in the patient record is likely necessary to average recordings and fully interpret these data. To best support patient activation and engagement in self-monitoring and verify accuracy of the readings transmitted to providers, patients need to be trained in measurement best practices. Online video instructions promoted through Target: BP coach patients to adhere to standard self-measurement protocols.22 The emergence of innovative digital health tools and resources to promote effective HBPM and lifestyle modifications also is requiring new models of care, such as telehealth and remote monitoring, as well as evidence-based payment models to support these interventions as they rapidly achieve more widespread use.23 To realize the full potential of HBPM and integrate BP readings into clinical decision-making, a robust health information technology structure and workflow adaption is required with appropriate patient insurance coverage for validated BP devices and reimbursement for patient instruction, measurement interpretation, and care management—the challenge and importance of which have been brought into clearer focus during the COVID-19 pandemic.

Recommendation for Assessment of ASCVD Risk

  • 3. Health system and payer leadership should commit appropriate resources, including funds and training, to ensure that adults ages 40–75 years are evaluated consistently for ASCVD risk estimation and subsequent guideline-based opportunities for prevention (ACC/AHA COR 1, LOE B-NR).8,13

Routine evaluation of ASCVD risk is fundamental to the assessment and treatment of all patients with HBP without preexisting or current CVD. Such assessment helps both the patient and clinician determine the best course of action in terms of promoting lifestyle modification and deciding whether treatment with antihypertensive medication is indicated (eg, especially for ACC/AHA Stage 1 HBP). There are several validated methods to estimate 10-year ASCVD risk, and most are readily available online, including the ACC Risk Estimator Plus based on the Pooled Cohort Equations recommended in the 2017 ACC/AHA BP Guidelines.24

Recommendation for Addressing Social Determinants of Health

  • 4. Health system and payer leadership should strongly encourage and promote adequate resources to assess and address social determinants of health (SDoH) in clinical settings for patients with HBP (ACC/AHA COR 1, LOE B-NR).13

SDoH are defined as the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes.25 AHA has identified key SDoH, including race, ethnicity, racism and discrimination, socioeconomic status, geography, housing, and health care access, that are associated with the prevalence and control of HBP and CVD outcomes.26 To improve control of HBP equitably in all Americans, SDoH must be addressed at a societal level in the form of policy change.27 Additionally, health systems must assess and address individual patient’s social needs related to successful HBP diagnosis, prevention, and control.28 Effectively addressing SDoH will require an investment in infrastructure from health systems that are already under pressure to become more cost-effective and value driven. The US Preventive Services Task Force recently described in-depth recommendations for incorporating SDoH into screening and prevention and an approach to address SDoH more effectively in its future recommendations.29 This infrastructure requires a multimodal approach (Table 1). Achieving high, equitable BP control rates among low-income and/or racially and ethnically diverse populations is possible. The Million Hearts Program publishes success stories of health care settings for underserved populations that have overcome access, economic, and cultural barriers, resulting in major improvements in BP control rates.30

T1-4
Table 1:
Recommendations for Addressing SDoH for Patients With HBP.

Recommendation for Shared Decision-Making

  • 5. Health system and payer leadership should provide adequate resources to implement a standardized process of evidence-based interventions designed to engage patients and their clinicians in shared decision-making (SDM) and tailored to their personal benefits, goals, and values to improve control of HBP (ACC/AHA COR 1, LOE B-NR).13

SDM is defined as “an approach wherein clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options to achieve informed preferences.”31 SDM has been described as a “meeting of two experts” in the clinical encounter where personal experience of the patient and clinical expertise of the clinician complement each other.32 Collaborative decisions between a clinician and a patient require effective SDM with consideration of individual values, cultural and health literacy, preferences, and associated conditions and comorbidities. Decision aids, question prompts, motivational interviewing, visuals, and other communication strategies may be used to facilitate discussions regarding lifestyle habits, ASCVD risk, medication tolerance, barriers to optimal adherence, SDoH, ability to self-manage BP, potential harms for treatment options, and perceived benefits of good control of HBP.33

Recommendation for Team-Based Care

  • 6. Health system and payer leadership should provide adequate resources to implement team-based care (TBC) designed to fully support and achieve successful care for people with HBP in accordance with the aforementioned guideline-based Blueprint for Change recommendations 1–5 (ACC/AHA COR 1, LOE A).8,13

TBC, as it applies to HBP control, is a health systems-level organizational intervention that relies on multidisciplinary teams to improve the quality of HBP care for patients. The Community Preventive Services Task Force, the 2017 ACC/AHA BP Guidelines, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease all highly recommend TBC based on the strong evidence for improving BP control.8,13,34 The most robust evidence for TBC comes from studies that have leveraged the respective strengths of advanced practice providers, nurses, and pharmacists in collaboration with primary care providers, other health care professionals, and patients.35–38 TBC also may include community health workers, and trusted frontline public health workers who can bridge gaps between patients and health care settings and help patients and socially at-risk communities overcome barriers to HBP control.39 Furthermore, other community partners include faith-based organizations, barbershops, retail health clinics, and workplace settings.37,40 Most medical practices have limited clinician time, expertise, and their own on-site resources to support effective TBC. Hence, it will be necessary for health systems and payers to provide infrastructure and capacity for well-coordinated, effective lifestyle counseling, assessments of SDoH, and professional lifestyle coaches to engage in partnership with clinical practices to provide an optimal solution.25

Recommendation for Quality Measurement of Improvement and Accountability

  • 7. The 2019 AHA/ACC Clinical Performance and Quality Measures (CPQMs) for Adults with HBP11 provides an excellent framework for health systems and payers to evaluate and monitor the success of collaborative Blueprint for Change initiatives designed to improve guideline-based care delivery for more than 100 million Americans with HBP.

AHA and ACC published 6 performance, 6 process quality, and a new category of 10 structural CPQMs in November of 2019 with 3 major goals:

  • To develop new performance measures designed to evaluate the control of patients with stage 1 HBP (SBP 130–139 mm Hg) in a manner identical to the current measure commonly used by the NCQA for stage 2 HBP (>140/90 mm Hg).
  • To provide new quality process measures intended to evaluate treatment and monitoring of patients for all stages of HBP, including the assessment of lifestyle modification, medication adherence, and HBPM.
  • To provide a standardized “structural” measurement framework for comprehensive assessment of a “care delivery unit” (rather than at the individual clinician or health plan contract levels) as a guide to designing and implementing an evidence-based system of care for patients with HBP based on the most impactful recommendations outlined in the 2017 ACC/AHA BP and ACC/AHA 2019 Prevention Guidelines.

Given the magnitude and complexity of delivering effective guideline-based medical care to adults with HBP, it is no longer tenable to ignore the widespread inadequacy of current care across the United States as noted in Figure 1. Hence, these CPQMs were developed to facilitate evaluation of the most important aspects of guideline-based care for adults with HBP, including the Blueprint for Change recommendations. The CPQM writing committee created 10 new structural quality measures designed to evaluate the capability and capacity of various levels of the US health care system to implement recommendations from the 2017 ACC/AHA BP and 2019 ACC/AHA Prevention Guidelines (Table 2) (including Recommendations 1–6 of the Blueprint for Change outlined). These new CPQMs also are intended for qualitative evaluation of process and infrastructure implementation of these strategies at the “care delivery unit” level (including solo/small physician offices, group practices, health systems, public health sites, community health centers, ACOs, clinically integrated networks, among others) rather than at an individual clinician or health plan contract level.11 It is no longer tenable for anyone to consider this simply a “primary care” problem.

T2-4
Table 2:
Summary of 2019 ACC/AHA Structural Measures for the Diagnosis and Management of High Blood Pressure.

Recommendation for Care Delivery and Health System Redesign

  • 8. Health system and payer leaders (managerial, clinical, and operational) must actively collaborate at the local, regional, and national levels to create and support a coordinated system of guideline-based care delivery for adults with HBP as outlined in this Blueprint for Change.

Participants at the 2019 ACMQ Meeting in Bethesda, Maryland, expressed strong consensus that a significant number of health system and payer leaders have not prioritized or made formal and visible strategic commitments of direct resources necessary to improve care for the more than 100 million Americans with HBP. Although excellent national, high-quality clinical practice guidelines and resources are promoted widely through the Health and Human Services Million Hearts initiative,41 the AHA/AMA Target: BP Improvement Program22 and the AMA M.A.P. (Measure accurately, Act rapidly, Partner with patients) BP Program,42 many health care system and health insurer executives (including Medicare Advantage and Medicaid) and their clinical leaders are largely unaware of these readily accessible nationwide opportunities. Recently released, “The Surgeon General’s Call to Action to Control Hypertension”6 seeks to avert the negative health effects of HBP by identifying evidence-based interventions that can be implemented, adapted, and expanded in diverse settings across the United States by making HBP control a national priority. However, the specific evidence-based improvements in the health care system required to achieve HBP control remain lacking, especially those outlined in Table 3.

T3-4
Table 3:
Opportunities and Actions for Health Systems to Improve on Guideline-Based Care Delivery for Adults With HBP.

The Blueprint for Change for Controlling HBP: Conclusions

The 8 Blueprint for Change for Adults with HBP recommendations presented in this article provide a comprehensive evidence-based road map for senior leaders from health systems, payers, clinicians, public health practitioners, and government to work collaboratively to improve guideline-based care delivery for more than 100 million Americans with HBP. Figure 2 presents a solid starting point for visualizing and formulating an effective, comprehensive conceptual model for this proposed health system and payer-driven redesign. To achieve a cohesive system of guideline-based care delivery improvements for adults with HBP, leaders from federal and state governments, major integrated health systems, and payers must collaborate to provide proper financial, managerial, clinical, and operational expertise, as well as visible leadership support at the local, regional, and national levels. To catalyze this process, the authors propose a national, multisector conference—including health system and managed care leaders, the medical device and pharmaceutical industry, major payer leadership (Centers for Medicare & Medicaid Services, private insurers, and large employers), national and state professional health care provider societies and associations (and other relevant stakeholders)—to foster collaboration, consensus, focus, and urgency for next steps. Without active collaboration, current unrealistic expectations that primary care physicians and other such providers will be able to achieve population levels of BP control will continue to be unmet. A new and integrated Blueprint for Change-style organizational structure and process designed to confront the number one public health problem in America is a necessity, not an option. Organizational leadership at the highest levels of management and governance must now step up to develop and implement the cohesive, comprehensive, and integrated delivery system, payer- and government-based model of care for adults with HBP that is delineated in this report. Failing to do so will only result in continuation of the same unfortunate gaps in care, persistent inequities, and disturbing trends of inadequate BP control that exist today. HBP remains the single most prevalent and impactful chronic health challenge facing the United States that the authors strongly believe is eminently solvable. Implementing the Blueprint for Change outlined here will take the many millions of people with HBP and the teams who care for them a long way toward achieving impact on this critically urgent national imperative.

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Figure 2:
A comprehensive, guideline-based system of care for people with high blood pressure.

Conflicts of Interest

Dr Casey is with Writing Committees for the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults and 2019 ACC/AHA Clinical Performance and Quality Measures for Adults With High Blood Pressure; and is the Immediate Past President of American College of Medical Quality. Dr Daniel is an employee of Booz Allen Hamilton. Dr Bhatt is ABC News Contributor; Board Member of National Forum on Heart Disease and Stroke Prevention. Dr Carey is the Vice Chair, Writing Committee, 2017 ACC/AHA Blood Pressure Guideline; and the Chair, Writing Committee, 2018 AHA Scientific Statement on Resistant Hypertension. He is the Principal Investigator, National Institutes of Health (NIH) Grant R01-HL-128189 and Project Director, NIH Grant P01-HL-074940. Ms Smith is an employee of the American Medical Association and a consultant to the American Heart Association. Dr Wozniak is with Writing Committee, 2019 ACC/AHA Performance Measures for High Blood Pressure. He is an employee of the American Medical Association. Dr Wright is supported by a grant from the Ohio Department of Medicaid and Agency for Health Care Research & Quality (1U18HS027944-01); was a member of the 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Writing Committee; and the 2019 AHA Scientific Statement on Measurement of Blood Pressure in Humans. All the other authors have no conflicts of interest to disclose.

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Keywords:

hypertension; performance measurement; clinical practice guidelines; quality improvement; social determinants of health

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.