Hypertension: High prevalence signals new adherence challenges

This article is part of the Medical Economics Business of Health: Hypertension resource center.

Although one out of three adults-about 78 million people-has hypertension, only 52.5% of adults have it controlled. With direct medical expenses estimated at $47.5 billion a year and $3.5 billion in lost productivity, why are patients seemingly losing the war against a preventable disease?

It’s a key question healthcare providers need to ask, especially considering the impact of an aging society against an increasingly prevalent disease that places people at greater risk for heart attacks, stroke, and kidney disease.

Since 2007, the 30% prevalence rate of hypertension in the United States has not budged. Data from the National Health and Examination Survey (NHANES) also show little improvement in the management and control of high blood pressure. And by 2030, the prevalence numbers are expected to get worse, not better-increasing another 7.2%.

That means change is needed, physicians say, in the way patients behave, how they monitor their disease and comply with recommendations, and how the healthcare team interacts with them long-term to keep their blood pressure within goal.

The healthcare delivery team’s focus expands from an episode of care to helping patients make necessary behavioral and diet changes, schedule and access care, use better monitoring strategies, improve adherence to pharmacotherapies and other management recommendations, and offer much more healthcare education.

The good news is that when patients with high blood pressure see a physician regularly, 70% have it controlled, says Brent Egan, MD, professor of medicine and pharmacology at the Medical University of South Carolina in Charleston. Egan is president of the American Society of Hypertension’s Specialists Program.

Patients whose blood pressure is not under control are slightly more likely to be uninsured, but a more significant common denominator is that they’re seen zero to one time a year in a healthcare setting, he says.

The adherence challenge

Because hypertension is a silent disease, says Donna K. Arnett, PhD, MSPH, president of the American Heart Association, asymptomatic patients may not fully understand the negative consequences of not adhering to a physician’s treatment recommendations.  And it adds another layer of complexity related to the successful treatment and accurate monitoring, she says.

Another adherence challenge might include discontinuation of medications because of medication side effects. Or patients could just stop treatment or monitoring if they notice initial improvement. 

About 12% of patients won’t fill prescriptions at all, according to Arnett. Some patients won’t refill prescriptions if they don’t perceive a benefit or worry about the cost.

And evidence shows that lowering out-of-pocket expenses for medications works, adds David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnership, Agency for Healthcare Research and Quality (AHRQ). “It might make a lot of economic sense if medication costs weren’t the big drivers of care,” he continues. Patients whose adherence improves because medication is affordable are less likely to develop serious and costly consequences such as stroke or heart attack. At your practice level, one of the ways to address nonadherence is to strengthen patient engagement, Arnett says. Here are three ways to do that:

• Include patients in the treatment plan.

"Patients should be their own advocate in the treatment and management of their hypertension. Understanding what their blood pressure is, by taking home blood pressure measurements, is important,” Arnett says. “Second, I think understanding the lifestyle factors that they can take charge of that can lower blood pressure, including increasing physical activity, limiting the amount of sodium consumption, and increasing potassium intake through lots of fruits and vegetables, is important. And a third thing is limiting alcohol.”

• Help patients overcome medication issues.

Physicians also need to improve their communications strategies to overcome patient reluctance to take medication or increase the number of pills, Egan says. More potent medications and single pill combinations can help.

• Frequently review the management plan.

Aging is an obvious factor that will necessitate modifying medication and other aspects of treatment, Arnett says, but a family crisis, development of another acute or chronic condition, and many other things can cause patients to veer from what had been an effective management plan and have difficulty getting back on track. The approach has to be flexible to provide long-term blood pressure control, and this is more likely to happen when the patient and providers are in regular contact.

Role of PCMH

Many impediments to effectively managing hypertension are built into the prevailing medical practice model in this country, according to Meyers, but the approach taken in a primary care physician office can help.

“Most patient visits are at the primary care level, and if primary care practices were set up in a way that it could really help people prevent disease, and when they have health conditions manage them effectively, then that is really empowering people to manage their own health care,” he suggests. “By giving them the extra support they need for behavior change and the right information about the right medications, helping them make good healthcare decisions, the whole system benefits, the whole country benefits.”

The PCMH model is an important consideration, Meyers says, because in PCMHs, primary care is responsible for helping patients meet their healthcare goals, and the model uses the skills and experience of a team of people to manage not just individuals and families but whole populations. Also, both providers and patients have the right health information technology (HIT) tools for clinical decision support and a back-and-forth flow of information, and providers are paid in a way that rewards quality and patient-centered care.

“The relationship between the healthcare system and people has to change,” he adds. “We have to understand patients’ goals, values, what they’re trying to do, and work with them to come up with a plan that makes sense for them.

“We’re at a very interesting time right now in healthcare systems thinking,” Meyers adds. “Things are starting to change. People are exploring the idea of, ‘Can we pay for this better? Can we pay doctors for outcomes and value and patient-centeredness?’ We’re experimenting with payment models. At the same time, HIT is really starting to make some of our visions possible, like patient portals and clinical decision information at your fingertips.”

The Centers for Medicare and Medicaid Services (CMS) is one of the biggest players, evaluating several payment and service delivery models through the CMS Innovation Center, including a comprehensive primary care initiative. “If that model works and we can show that the quality of care went up and the cost went down, then Medicare has the power to roll that out and make that a national system,” Meyers says.

Additional data on hypertension control also might improve hypertension management, Egan suggests. If data from a large study such as NHANES are based on a single exam, doctors don’t know how reliable they are, and because many patients in the study whose pressure is uncontrolled are in the 140- to 150-mm Hg range, it’s unclear how many are truly hypertensive. Similarly, an occasional office blood pressure measurement may not be a reliable indicator, due to white coat syndrome and blood pressure variability.

“In some ways, we may be overestimating the number of people who have high blood pressure and underestimating control just by the nature of the way it’s being defined, in large part by a national survey that relies on just one examination,” Egan explains.

Therapeutic inertia

He also attributes some cases of uncontrolled hypertension to therapeutic inertia. Often, he says, physicians are reluctant to intensify therapy when blood pressure nears 140 mm Hg.

Through his involvement in the National Heart, Lung, and Blood Institute’s Hypertension Initiative and Stroke Belt Elimination Initiative, Egan has observed a decline in therapeutic inertia in a network of about 400 clinics from seven out of eight visits to two out of three, which should improve hypertension control by 17%. This estimation was arrived at by calculating a therapeutic initiative score for each physician in the program, education, regular feedback, and leadership from influential physicians in the practice and community.

Egan adds that because therapeutic inertia is partly due to concern over the reliability of the measurement at any given office visit, the concern can be addressed through greater use of home and ambulatory monitoring and repeated automated measurements in the office without any observation.

Improving population behavior

But more effective hypertension management cannot be achieved solely through doctor-patient encounters. The public health sector also needs to be involved. Egan believes that effective public health messaging has been “lost” despite considerable success several decades ago in reducing smoking and lowering the intake of sodium and saturated fats.

“Our ability to create messaging for groups is better than it’s ever been, but we haven’t been using those advances in tailoring messages to affect population health behavior. I think we desperately need to reactivate those strategies,” he says. “What happens is that we spend a lot of time in the primary care physician’s office trying to change patients’ behavior, but then we send them back out trying to swim upstream against population behavior. We’re very much social creatures, and if we can begin creating healthier population behaviors, that will become the norm. Right now, healthier behaviors are not the norm, and we’re paying the price for that.”

Public health messaging would be helpful in motivating patients to make lifestyle changes-sooner rather than later-as well as helping them understand the risks of hypertension and encouraging adherence to medication use.

“We believe that getting 85% of treated patients under control is certainly possible, and most of the rest who are not controlled to less than 10 mm Hg from goal. A lot of the rest of this will require a partnership of public health and primary care. It will require reengineering reimbursement so physicians are paid for things that lead to results,” Egan says.