5
Interventions Directed at Individuals with Hypertension

The previous chapter discusses population-based interventions that can be beneficial irrespective of hypertension status. This chapter focuses more narrowly on interventions directed at individuals who have been diagnosed with hypertension. A wide range of strategies are considered to reduce adverse health consequences associated with hypertension through early detection, treatment, and control. Strategies range from those that offer access to health care providers who screen and treat individuals with high blood pressure, reduce the cost of medications for those in treatment (insurance coverage, benefit design, cost sharing), support hypertension control (e.g., quality control measures), and increase hypertension awareness, treatment, and control (e.g., worksite wellness initiatives). The chapter also considers community health workers as a potential strategy to increase treatment adherence among individuals with hypertension.

ACCESS TO CARE AND CONTROL OF HYPERTENSION

Access to health care, including access to providers, is generally considered important to improved health outcomes (IOM, 2003b,d). Data are somewhat mixed, however, about whether hypertension control is improved if patients have a regular source of care (Ahluwalia et al., 1997; Col et al., 1990; Fihn and Wicher, 1988; He et al., 2002). Studies that have shown improvement in care include data from multiple surveys. For example, national survey data (e.g., the 1987 Medical Expenditure Panel Survey [MEPS]) have shown that having a regular source of care is associated with



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5 Interventions Directed at Individuals  with Hypertension T  he previous chapter discusses population-based interventions that can be beneficial irrespective of hypertension status. This chapter focuses more narrowly on interventions directed at individuals who have been diagnosed with hypertension. A wide range of strategies are considered to reduce adverse health consequences associated with hypertension through early detection, treatment, and control. Strategies range from those that offer access to health care providers who screen and treat individuals with high blood pressure, reduce the cost of medications for those in treatment (insurance coverage, benefit design, cost sharing), support hypertension control (e.g., quality control measures), and increase hypertension aware- ness, treatment, and control (e.g., worksite wellness initiatives). The chapter also considers community health workers as a potential strategy to increase treatment adherence among individuals with hypertension. ACCESS TO CARE AND CONTROL OF HyPERTENSION Access to health care, including access to providers, is generally con- sidered important to improved health outcomes (IOM, 2003b,d). Data are somewhat mixed, however, about whether hypertension control is improved if patients have a regular source of care (Ahluwalia et al., 1997; Col et al., 1990; Fihn and Wicher, 1988; He et al., 2002). Studies that have shown improvement in care include data from multiple surveys. For example, national survey data (e.g., the 1987 Medical Expenditure Panel Survey [MEPS]) have shown that having a regular source of care is associated with 1

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION hypertension screening, follow-up care, and the use of medication (Moy et al., 1995). Data from the 1990 National Health Interview Survey (NHIS) showed a strong association between seeing a physician in the past year and taking action to control hypertension (taking medication, reducing salt, reducing weight) (CDC, 1994). Similarly, in an analysis of the NHANES (National Health and Nutrition Examination Survey) III, He et al. (2002) found that the percentage of persons with controlled hypertension was higher for those who visited the same facility (Odds Ratio [OR] = 2.77 [1.88-4.09]) or saw the same provider (OR = 2.29 [1.74-3.02]) for their health care. Another study reported that severe, uncontrolled hypertension was more common among Medicaid patients who could not identify a source of care (Lurie et al., 1984). A few case control studies have reported similar findings. Shea et al. (1992b) found that severe, uncontrolled hypertension was more common among those who did not have a primary care physician (adjusted OR = 3.5 [1.6-7.7]) and those who did not comply with antihypertensive treatment (adjusted OR = 1.9 [1.4-2.5]). Ahluwalia and colleagues (1997) also found that controlled hypertension was associated with having a regular place of care (OR = 7.93 [3.86-16.29]. In a study of medically stable Department of Veterans Affairs (VA) patients terminated from regular outpatient care, compared with those retained in care, 41 percent of discharged patients had blood pressure that was uncontrolled compared to 5 percent at the time of discharge; blood pressures were taken 13 months after discharge (p < 0.001) (data for the control group were 17 percent at follow-up vs. 9 percent, a nonsignificant difference). Among discharged patients with di- agnosed hypertension, systolic blood pressure rose an average of 11.2 mm Hg; diastolic blood pressure rose an average of 5.6 mm Hg (p < 0.001). Of the discharged group, 47 percent reduced their prescription medica- tions compared with 25 percent in the control group (p = 0.002) (Fihn and Wicher, 1988). Another study found that one of the factors associated with a hospi- talization due to noncompliance with medication (medications included an ACE [angiotensin-converting enzyme] inhibitor) was the number of physicians seen regularly (p = 0.007). The adjusted OR for seeing a greater number of physicians was 2.0 (p < 0.005) (Col et al., 1990). On the other hand, Kotchen and colleagues reported that neither hav- ing seen a provider within the past three months (p > 0.4) nor receiving care from the same provider at each encounter (p > 0.8) was associated with improved hypertension control (Kotchen et al., 1998). Similarly, Stockwell and colleagues found that a greater number of physician visits was not as- sociated with awareness of hypertension, the number of antihypertensive drug days, or blood pressure control (Stockwell et al., 1994). One of the reasons for the lack of a consistent association between

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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION access to health care and hypertension control may be because control of hypertension is inadequate even in those with access to health care. The NHANES III data have shown that 86 percent of individuals with uncon- trolled hypertension have a usual source of care and average 4.3 physician visits per year; 75 percent of those who are unaware of their hypertension had had their blood pressure measured in the previous year. Lack of aware- ness of hypertension (OR = 7.69; p < 0.001) and being aware but uncon- trolled (OR = 2.08; p < 0.001) were more likely in those ages 65 years or older, a population that has access to health care. In fact, most uncontrolled hypertension was mild systolic hypertension in older adults with access to health care and frequent physician contact (Hyman and Pavlik, 2001). In a cohort study of a hypertensive VA population examined over a two-year period, less than 25 percent had adequate blood pressure control (160/90 mm Hg despite having an average of 6.4 (+3.3) hypertension-related physician visits. In addition, the mean systolic blood pressure (SBP) was virtually un- changed at the end of two years (146.2 and 145.4 mm Hg, not significant), while the diastolic blood pressure (DBP) decreased (from 84.3 to 82.6, p < 0.001) (Berlowitz et al., 1998). In the Stockwell et al. (1994) study of a well-insured population, 71 percent of individuals with hypertension were aware of their hypertension, only 49 percent were being treated, and only 12 percent of these were controlled (<140/90 mm Hg), despite frequent utilization of the health care system. Other researchers have also reported poor hypertensive control despite access to health care. Framingham study participants are highly compliant with follow-up exams, and findings on exam are discussed with them and also sent to their primary care providers. Still, in a Framingham cohort followed for four years, only 32 percent of untreated individuals with hypertension were subsequently on treatment, and only 40 percent of those not under control initially (>140 mm Hg SBP or >90 mm Hg DBP) were brought under control. Older age was a strong predictor for lack of control overall and among those under treatment (Lloyd-Jones et al., 2002). In a survey of African Americans, 27 percent were unaware of their hypertension, despite 77 percent of them having had a blood pressure mea- surement by a physician within the previous 2 years; most had mild systolic hypertension. Those unaware of their hypertension were only slightly less likely to have had their blood pressure checked in the past year and were nearly equally likely as those who were aware to have had it checked in the prior 2 years (Pavlik et al., 1997). Kotchen et al. (1998) reported that only 70 percent of inner-city individuals with hypertension were aware of their hypertension, 55 percent were taking medication, and 26 percent were under control despite most having seen a physician within the previ- ous 6 months.

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION Hyman and Pavlik calculated the attributable risk of lack of awareness of hypertension (Table 5-1): 46 percent of the attributable risk was being age 65 years or older; 22 percent was being male; 5 percent was being Afri- can American; and 9 percent was having no recent visit to a physician. They also calculated the attributable risk of being aware but having uncontrolled hypertension: 32 percent of the attributable risk was being age 65 years or older; 12 percent was being male; and only 8 percent was having had no recent physician visit (Hyman and Pavlik, 2001). Consequences of Racial and Ethic Disparities in Awareness, Treatment, and Control The above demographic differences in awareness, treatment, and con- trol of hypertension directly contribute to the nation’s long-standing racial, ethnic, gender, and age disparities from cardiovascular disease (CVD) and kidney disease. For example, using data from the NHANES III Mortality Follow-up Study (mean duration = 8.5 years; 143,551 person-years), Gu et al. (2008) observed a 3.86 greater risk (hazard ratio = 3.86, 95 percent confi- dence interval [95% CI]: 1.60-9.32) of CVD deaths among individuals with hypertension under age 65 compared to similar-age individuals with normal blood pressure levels. For non-Hispanic whites, the hazard ratio for hyper- tensives vs. normotensives was 1.70 (95% CI: 1.09-2.65); however, when non-Hispanic white hypertensives with controlled blood pressure were com- pared to their normotensive counterparts, the excess CVD mortality risk was no longer statistically significant (hazard ratio = 1.17, 95% CI: 0.72-1.91). For non-Hispanic blacks, a considerably smaller reduction in the hazard ratio was observed—4.65 (95% CI: 2.26-9.57) for controlled hypertensives vs. 3.93 for normotensives (95% CI: 1.78-8.68). The comparable hazard ratios for Mexican Americans were 2.09 (95% CI: 0.93-4.65) vs. 1.27 (95% CI: 0.46-3.52), a reduction slightly greater than that for non-Hispanic whites. Gu et al. (2008) speculated that the much smaller reduction in excess CVD mortality for blacks with controlled hypertension was probably due to several factors, including an earlier onset and greater severity of hyper- tension, less adequate blood pressure control, and less access to health care services. The cumulative effects of these factors probably led to more severe hypertensive target organ damage in blacks, thereby elevating CVD mortal- ity rates even among those whose hypertension was controlled. Lopes et al. (2003) described some of the most promising recent ad- vances in nonpharmacologic (e.g., diet, physical activity) as well as phar- macologic approaches to treating hypertension in African Americans. First, they noted the acceptability (Vollmer et al., 1998) and the effectiveness (Svetkey et al., 1999) of the DASH (Dietary Approaches to Stop Hyperten- sion) diet (low-fat dairy food, fruit or vegetables, and foods low in total and

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19 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION saturated fat) among African Americans who enrolled in the DASH clinical trial. Bray and colleagues, in an analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure, also reported that the lower the sodium level, the greater the mean reduction in blood pressure. The effect was even more pronounced and beneficial for African Americans (Bray et al., 2004). Lopes et al. (2003) also highlighted findings from a randomized con- trolled clinical trial (Kokkinos et al., 1995) wherein African-American men with stage three hypertension were assigned, or not, to a regimen of mod- erately intense, aerobic physical activity for 16 weeks. Engaging in aerobic exercise was associated with a significant decrease in blood pressure among the men randomized to the exercise arm. In addition, significant reductions in thickness of the interventricular septum and left ventricular mass, and in the left ventricular index, were observed for men assigned to the exercise arm. Collectively, these findings from well-designed and executed clinical trials of nonpharmacologic interventions for hypertension provide encour- aging evidence that carefully supervised nonpharmacologic interventions focused on African Americans will likely reduce their excess risk for serious medical complications known to be caused by uncontrolled hypertension. In summarizing advances in pharmacologic approaches to treating hypertension in African Americans, Lopes et al. (2003) concluded that stud- ies continue to support the use of diuretics and beta-blockers as first-line antihypertensive therapy for everyone, regardless of race. However, they noted that findings from the African-American Study of Kidney Disease and Hypertension, or the AASK trial (Wright et al., 2002), also provided some support for the use of ACE inhibitors as first-line antihypertensive drugs in African Americans. An ACE inhibitor-based treatment program, they concluded, was more beneficial than calcium channel blockers and beta-blockers in reducing the progression of renal failure in blacks with hypertensive nephropathy. Thus, recent studies indicate that closely supervised administration of nonpharmacologic as well as pharmacologic antihypertensive interventions by primary care providers could substantially reduce the black-white racial disparities in medical complications due to poorly controlled blood pres- sure. As is true of much of the extant literature on disparities in U.S. health care, the literature on hypertension continues to be disproportionately focused on blacks and whites and there is a lack of evidence-based recom- mendations that address disparities in hypertension awareness, treatment, and control for the nation’s other high-risk populations.

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10 TAbLE 5-1 Proportion of Cases of Uncontrolled Hypertension in Each Population Subgroup Attributable to Identified Risk Factors Lack of Awareness of Condition Acknowledged, Uncontrolled Hypertension Relative Attributable Relative Attributable Risk Factor Risk Prevalence Risk Risk Prevalence Risk Age >65 (vs. <65) 7.69 0.13 + 0.0072 0.46 2.08 0.44 + 0.0153 0.32 Male (vs. female) 1.58 0.48 + 0.0046 0.22 1.30 0.43 + 0.0104 0.12 Non-Hispanic black 1.45 0.11 + 0.0063 0.05 — — — (vs. non-Hispanic white) No physician visits in past 1.40 0.25 + 0.0062 0.09 1.89 0.10 + 0.0099 0.08 12 months (vs. >1 visit) NOTE: Attributable risk is calculated as P(RR – 1) ÷ [P(RR – 1) + 1], where P is the prevalence of the risk factor in the population and RR is the relative risk associated with the presence of the factor. Dashes indicated that non-Hispanic black race is not a significant risk factor in the model. SOURCE: Hyman and Pavlik, 2001. Copyright © [2001] Massachusetts Medical Society. All rights reserved.

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11 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION Physician Adherence to Guideline Recommendations and Hypertension Control Although patient compliance with treatment is one reason for lack of hypertension control, it is also clear that lack of physician adherence to hypertensive guidelines is a major problem and a significant reason for the lack of awareness, lack of pharmacologic treatment, and lack of hyper- tension control in the United States (Chiong, 2008; Pavlik et al., 1997). Notably, older age and SBP predicted lack of control, even if the blood pressure was being treated (Lloyd-Jones et al., 2000; Pavlik et al., 1997). The NHANES III data show that lack of awareness of hypertension (OR = 7.69; p < 0.001) and being aware but uncontrolled (OR = 2.08; p < 0.001) were more likely in those ages 65 years or older: persons >65 years of age comprise 45 percent of the unaware, 32 percent of the aware but untreated, and 57 percent of the treated but uncontrolled hypertensives. Lack of hy- pertension control was associated with older age: OR = 2.43 (1.79-3.29) for ages 61-75 years, and OR = 4.34 (3.10-6.09) for those >75 years of age (Lloyd-Jones et al., 2000). In fact, most uncontrolled hypertension was mild systolic hypertension in older adults with access to health care and frequent physician contact. In addition, 75 percent of the unaware, 60 percent of the known but untreated, and 75 percent of the treated but not controlled hypertensives had a DBP <90 mm Hg (Hyman and Pavlik, 2001). A Fram- ingham study found that only 33 percent were controlled to a systolic blood pressure goal, whereas 83 percent were controlled to a diastolic blood pres- sure goal. Of those on medication (61 percent), 49 percent were controlled to a systolic blood pressure goal compared with 90 percent to a diastolic blood pressure goal (Lloyd-Jones et al., 2000). Physician Nonadherence to Recommendations for Treatment of Hypertension Systolic hypertension may be more complex to treat than diastolic pressure (SHEP Cooperative Research Group, 1991), but multiple studies show that physicians are unlikely to treat or intensify treatment for mild to moderate systolic hypertension (<165 mm Hg) if the DBP is <90 mm Hg (Figures 5-1 and 5-2) (Berlowitz et al., 1998; Hyman et al., 2000). Berlowitz and colleagues (in a VA cohort study) found that if SBP was >155 mm Hg and the DBP >90 mm Hg, treatment was intensified 25.6- 35.0 percent of the time (the larger percentage was if the medication had been changed during the previous visit); if the SBP was >165 mm Hg and the DBP was <90 mm Hg, medication was increased 21.6 percent of the time, but if the SBP was <165 mm Hg, medication was increased only 3.2 percent of the time when the DBP was <90 mm Hg. Overall, treatment was

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12 APPROACH TO PREVENT AND CONTROL HYPERTENSION FIGuRE 5-1 The proportion of patients over a 24-month period that was not diagnosed with hypertension, separated by average diastolic and systolic blood pressure. Figure 5-1 SOURCE: Physician Role in Lack of Awareness and Control of Hypertension, Hy- man, D.J., V.N. Pavlik, and C. Vallbona, 2000. Copyright © 2000 Journal of Clini- cal Hypertension. Reproduced with permission of Blackwell Publishing Ltd. intensified in only 6.7 percent of visits (Berlowitz et al., 1998). Oliveria and colleagues also identified patients with uncontrolled hypertension. Pharma- cologic therapy was initiated or changed at only 38 percent of the visits, despite documented hypertension for at least 6 months prior to the most recent visit (Oliveria et al., 2002).

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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION Patients Aged ≥70 y Patients Aged 40-60 y 57 60 49 50 % of Respondents 35 40 29 30 20 10 11 46 10 0 80-84 85-89 90-94 95-99 100-110 Diastolic BP Ranges, mm Hg Patients Aged ≥70 y Patients Aged 40-60 y 46 50 40 34 31 % of Respondents 30 19 17 17 20 13 11 7 10 5 0 130-139 140-149 150-159 160-169 170-179 180-189 Systolic BP Ranges, mm Hg FIGuRE 5-2 The diastolic and systolic blood pressure ranges at which physicians would start drug treatment in patients with uncomplicated hypertension. SOURCE: Hyman and Pavlik, Archives of Internal Medicine, August 14, 2000, 160: 2283. Copyright © (2000) American Medical Association. All rights reserved. Figure 5-2

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION In a study that linked adults’ survey responses to their medical re- cords, Hyman and colleagues found that these adults averaged 5.7 physi- cian visits (median 4.0 visits). Of those with a 24-month average blood pressure >140/90, 25 percent were not diagnosed with hypertension. This proportion of “unaware” is comparable to the national rate reported by the NHANES III. Only 5 percent of those with a DBP greater than 90 mm Hg did not have a diagnosis of hypertension, but two-thirds were not diagnosed if the blood pressure was 140-159/<90 mm Hg. Of those on medication, the average blood pressure was 147/86, and only 24 percent had a blood pressure 90 mm Hg, 98 percent had medication prescribed and treatment was intensified 24 percent of the time if the blood pressure remained >90 mm Hg. Treatment was intensified only 4 percent of the time when the SBP was >140 and the DBP <90 mm Hg. There was almost no action taken for persistently high SBP over many consecutive visits (Figure 5-1) (Hyman et al., 2000). A recent study by Okonofua et al. (2006) assessed the extent of ther- apeutic inertia, defined as providers’ failure to increase therapy when treatment goals are unmet, in 62 diverse clinical sites participating in the Hypertension Initiative medical record audit and feedback program con- ducted in the Southeastern part of the United States. The researchers found that antihypertensive therapy was not intensified in 86.9 percent of visits when blood pressure was ≥140/90. They estimated that improvement of 20 percent in the percentage of visits in which treatment is intensified, blood pressure control could increase from the study’s observed 46.2 percent to a projected 65.9 percent in one year. The study did not provide information on the reasons for therapeutic inertia. Physician adherence to guidelines for nonpharmacological strategies to manage hypertension is also problematic. Lifestyle modifications (weight management, healthy diet, exercise) or nonpharmacologic strategies have been found to be effective in managing hypertension as discussed in Chapter 4. Few physicians however, encourage patients to make such modifications. Based on data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1999-2000, only about 35 percent of patients with hypertension received counseling for diet and 26 percent for exercise (Mellen et al., 2004). Asians and Hispanics received the highest levels of counseling and non-Hispanic whites the least. Patients with Medicaid had the highest exercise counseling rates compared to patients with other payment providers. Diet counseling did not differ by payment provider. Diet counseling rates were also higher for patients with co-occurring diabetes, obesity, or dyslipidemia. With respect to exercise counseling, patients with obesity, had significantly higher odds of receiving exercise counseling. Patients with two or more cardiovascular morbidities were also more likely to receive diet and exercise counseling com-

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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION pared to those with less than one co-occurring morbidity. In NAMCS office- based practices, 36 percent of hypertension patients received diet counseling and 27 percent received exercise counseling. In NHAMCS hospital-based clinics, 25 percent received diet counseling and 14 percent counseling for exercise. A more recent study found that health care providers fail to counsel pa- tients with hypertension to increase physical activity as a measure to lower blood pressure. Halm and Amoako (2008), in an analysis of the NHANES III data, found that only one-third of patients with hypertension reported having received a physical activity recommendation from their health care provider. However, 70 percent of those counseled followed the recommen- dation and had on average a systolic blood pressure that was 3 to 4 mm Hg lower than those who did not follow the recommendation. Given the potential impact of nonpharmacologic strategies on hypertension manage- ment, this is an area that deserves greater attention. Reasons for Poor Physician Adherence with Guidelines Survey data shows that U.S. physicians are more likely to report that they adhere to diastolic threshold recommendations for initiating or inten- sifying treatment than for systolic thresholds (Chiong, 2008). In a national survey of primary care physicians, Hyman found that 33 percent would not start treatment for middle-aged patients with uncomplicated hypertension unless the DBP was >95 mm Hg; 52 percent of physicians would not start treatment for an SBP of 140-160, and 43 percent would not start treat- ment unless the SBP was greater than 160 mm Hg. For patients ages 40-60 years without complications who were on drug treatment, 25 percent of physicians would not intensify drug therapy for a persistent DBP of 94 mm Hg; 33 percent would not intensify drug treatment for an SBP of 158 mm Hg. Providers were even less aggressive in older patients: 48 percent would not take action for an elevated DBP of 94 mm Hg, and 67 percent would not take action for those ages 70 years or older with an SBP <160 mm Hg (Hyman and Pavlik, 2000). Similarly, in a survey of primary care clinicians at three VA medical centers compared with the clinical database of patients cared for by these providers, clinicians overestimated the proportion of patients who were prescribed guideline-concordant medications (75 percent perceived vs. 67 percent actual, p < 0.001) and the proportion of patients who had blood pressures levels <140/90 at their last visit (68 percent perceived vs. 43 per- cent actual, p < 0.001). Physicians with lowest actual performance were the most likely to overestimate their adherence and rates of control (Steinman et al., 2004). Oliveria and colleagues (2002) identified patients with uncontrolled

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION health care accounts for a relatively low proportion of poor awareness or poor control of hypertension. Within the context of the current health care reform debate, the committee supports the recommendations by a former IOM committee for “comprehensive and affordable health care to every person residing in the United States” and that “all public and privately funded insurance include appropriate preventive services as recommended by the U.S. Preventive Services Task Force” (IOM, 2003a). The commit- tee encourages the Division for Heart Disease and Stroke Prevention to be supportive of such efforts but directs the division’s attention to addressing the quality of care for hypertension, especially as it relates to health care providers’ capacity to deliver quality hypertensive care. Based on the review of the literature, there is strong evidence that physicians are not paying adequate attention to treating and controlling systolic hypertension. The goal of improving the education and training of health care providers in the prevention of cardiovascular disease is central to the Public Health Action Plan to Prevent Heart Disease and Stroke, the DHDSP Strategic Plan, and the National Heart Disease and Stroke Preven- tion Program (as described in Chapter 3). For example, under the National Heart Disease and Stroke Prevention Program, Virginia, Georgia, and South Carolina have programs to support professional education and training to promote quality health care.1 The committee believes that understand- ing the reasons behind nonadherence and increasing physician awareness, understanding, and implementation of JNC treatment guidelines are essen- tial to increasing the number of individuals with controlled hypertension, especially systolic hypertension. This is especially salient among the elderly, given the aging of the U.S. population. The committee is concerned that undiagnosed hypertension and treated but uncontrolled hypertension are occurring under “the watchful eye of the health care system” and that physicians are not adhering to JNC guidelines. While a number of studies have documented the problem, little information is available to understand clearly why providers do not adhere to JNC guidelines related to screening and treating or intensifying treatment for mild to moderate systolic hyper- tension. As one study reported, some physicians were satisfied with blood pressure levels above 140 mm Hg and 90 mm Hg, and some physicians attributed higher risk to elevated diastolic pressure than to elevated systolic pressure, especially in the elderly (Oliveria et al., 2002). Numerous ques- 1 Virginia’s program primarily focuses on educating, training, and certifying health care pro - fessionals in the proper procedures in measuring blood pressure. The Georgia Cardiovascular Health Initiative, along with its partner, the International Society on Hypertension in Blacks, conducts a series of continuing medical education for community-based health center staff and other providers. Similarly, South Carolina and its partner, the American Society of Hyperten- sion, Inc., provide continuing medical education to health professionals on evidence-based treatment of hypertension. The training leads to certification as a “hypertension expert.”

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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION tions remain regarding whether the lack of adherence is related to a lack of physician agreement with the new treatment guidelines, physician lack of knowledge regarding the guidelines, inertia due to treating at the previous guideline of 160/95 mm Hg, or other barriers. 5.1 The committee recommends that the Division for Heart Disease and Stroke Prevention give high priority to conducting research to bet- ter understand the reasons behind poor physician adherence to current JNC guidelines. Once these factors are better understood, strategies should be developed to increase the likelihood that primary provid- ers will screen for and treat hypertension appropriately, especially in elderly patients. Educating clinicians about the importance of treating and controlling systolic hypertension may be one important strategy but is not expected to be the only one. Furthermore, high levels of uncontrolled hypertension are indicative of poor-quality care. The committee agrees with the IOM recommendation that identified hypertension (with a special focus on appropriate manage- ment of early disease) as one of the top 20 priorities for improvement in health care quality (IOM, 2003c). The evidence reviewed indicates that although physicians screen for blood pressure, screening does not always lead to treatment or to intensified treatment when appropriate. 5.2 The committee recommends that the Division for Heart Disease and Stroke Prevention work with the Joint Commission and the health care quality community to improve provider performance on measures focused on assessing adherence to guidelines for screening for hyperten- sion, the development of a hypertension disease management plan that is consistent with JNC guidelines, and achievement of blood pressure control. Out-of-pocket cost of medication has been identified in the literature as a significant barrier to patient adherence with hypertension treatment. It is estimated that for every 10 percent increase in cost sharing, overall prescription drug spending decreases by 2-6 percent (Goldman et al., 2007). Goldman and colleagues compared the impact of reducing cost barriers with other interventions designed to improve adherence with medications for chronic conditions and noted that even the most successful interventions designed to increase patient adherence to medication did not result in larger improvements in adherence than reducing the costs, and generally relied on complicated, labor-intensive regimens (Goldman et al., 2007). The committee finds the evidence convincing that reducing costs of

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION antihypertensive medication is an important and efficient way to increase medication adherence. 5.3 The committee recommends that the Division for Heart Disease and Stroke Prevention should encourage the Centers for Medicare & Medicaid Services to recommend the elimination or reduction of de- ductibles for antihypertensive medications among plans participating under Medicare Part D, and work with state Medicaid programs and encourage them to eliminate deductibles and copayment for antihyper- tensive medications. The committee also recommends that the DHDSP work with the pharmaceutical industry and its trade organizations to standardize and simplify applications for patient assistance programs that provide reduced-cost or free antihypertensive medications for low- income, underinsured, or uninsured individuals. The committee notes that the DHDSP is also well positioned to educate the private sector that eliminating or reducing the costs of antihypertensive medications is an important and efficient way to increase medication adher- ence. Through collaborations with the National Forum for Heart Disease and Stroke Prevention (Chapter 3) and cooperative agreements and partner- ships with the private sector, the division provides support and guidance to the employer community on hypertension and cardiovascular disease pre- vention and control. The division’s product, The Business of Heart Disease and Stroke Prevention Toolkit, for example, although extremely informative and useful, does not address benefit or value-based benefit purchasing that can help reduce costs of essential antihypertensive medications. The private sector is already experimenting with reducing the copayments associated with drugs commonly prescribed for diabetes, asthma, and hypertension (Pitney Bowes, Marriott, others). The results of these experiments should be shared broadly with the business community. 5.4 The committee recommends that the Division for Heart Disease and Stroke Prevention collaborate with leaders in the business com- munity to educate them about the impact of reduced patient costs on antihypertensive medication adherence and work with them to encourage employers to leverage their health care purchasing power to advocate for reduced deductibles and copayments for antihypertensive medications in their health insurance benefits packages. The DHDSP might also consider working with the business community to evaluate and disseminate broadly the research on the health impacts of efforts to reduce financial burdens associated with the treatment of hypertension.

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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION The use of community health workers to support the care of individuals with hypertension has been identified as a promising strategy. Community health workers have contributed to greater medication adherence among individuals with hypertension and have been shown to play an important role in linking diverse communities to the health care system and navigat- ing that system. 5.5 The committee recommends that the Division for Heart Disease and Stroke Prevention work with state partners to leverage opportuni- ties to ensure that existing community health worker programs include a focus on the prevention and control of hypertension. In the absence of such programs, the division should work with state partners to de- velop programs of community health workers who would be deployed in high-risk communities to help support healthy living strategies that include a focus on hypertension. REFERENCES Adams, A. S., S. B. Soumerai, and D. Ross-Degnan. 2001a. The case for a Medicare drug coverage benefit: A critical review of the empirical evidence. Annual Review of Public Health 22:49-61. ———. 2001b. Use of antihypertensive drugs by Medicare enrollees: Does type of drug cover- age matter? Health Affairs 20(1):276-286. Ahluwalia, J. S., S. E. McNagny, and K. J. Rask. 1997. Correlates of controlled hyperten- sion in indigent, inner-city hypertensive patients. Journal of General Internal Medicine 12(1):7-14. AHRQ (Agency for Healthcare Research and Quality). 2004. Closing the quality gap: A criti- cal analysis of hypertension care strategies. http://www.ahrq.gov/qual/hypertengap.htm (accessed October 28, 2009). Aldana, S. G. 2001. Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion 15(5):296-320. AMA (American Medical Association). 2006. Hypertension (HTN): Algorithm for measures calculation—EHRS. http://www.ama-assn.org/ama1/pub/upload/mm/370/htnanalyticnarr 307_7.pdf (accessed February 5, 2010). American College of Sports Medicine. 2009. ACSM’s worksite health handbook-2nd edition: A guide to building healthy and productive companies. Edited by N. P. Pronk. Cham- paign, IL: American College of Sports Medicine. Anis, A. H., D. P. Guh, D. Lacaille, C. A. Marra, A. A. Rashidi, x. Li, and J. M. Esdaile. 2005. When patients have to pay a share of drug costs: Effects on frequency of physician visits, hospital admissions and filling of prescriptions. Canadian Medical Association Journal 173(11):1335-1340. Artz, M. B., R. S. Hadsall, and S. W. Schondelmeyer. 2002. Impact of generosity level of out- patient prescription drug coverage on prescription drug events and expenditure among older persons. American Journal of Public Health 92(8):1257-1263. Austvoll-Dahlgren, A., M. Aaserud, G. Vist, C. Ramsay, A. D. Oxman, H. Sturm, J. P. Kosters, and A. Vernby. 2008. Pharmaceutical policies: Effects of cap and co-payment on rational drug use. Cochrane Database of Systematic Reviews (1).

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