A National Commitment to Improve the Care of Patients With Hypertension in the US | Hypertension | JAMA | JAMA Network
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October 7, 2020

A National Commitment to Improve the Care of Patients With Hypertension in the US

Author Affiliations
  • 1Office of the Surgeon General, Department of Health and Human Services, Washington, DC
JAMA. Published online October 7, 2020. doi:10.1001/jama.2020.20356

Hypertension is common, costly, and controllable. Almost 1 in 2 US adults has hypertension, and among those, the estimated rate of controlled blood pressure was only 43.7% in 2017-2018 a decline from 53.8% in 2013-2014.1 Uncontrolled blood pressure can lead to largely preventable events such as myocardial infarction, stroke, and maternal mortality, as well as debilitating and expensive conditions such as kidney disease, heart failure, and cognitive decline. Hypertensive disorders of pregnancy, which have increased in the US, contribute to adverse maternal and child health outcomes and can increase a woman’s lifetime risk of cardiovascular disease. Disparities in blood pressure control and, consequently, in these health outcomes, persist by race and ethnicity, age, and geography. Yet broad and equitable hypertension control is possible, and some health care practices and systems have achieved rates of 80% or higher across a wide spectrum of sites and populations served.2-5

These facts about hypertension—a highly prevalent, poorly managed, inequitably experienced, and highly controllable condition—are more than sufficient to merit the Surgeon General’s Call to Action to Control Hypertension.6 Some may question the release of this report now, when the challenge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become the most pressing health priority in the US. However, it is precisely the effects of the pandemic, and the painful lessons that are being learned, that add even greater urgency to improving hypertension control rates for all US adults.7 The coronavirus disease 2019 (COVID-19) pandemic has revealed substantial differences in exposure to the SARS-CoV-2 virus and severe outcomes from COVID-19. The higher rates of infection, severe complications, and death among people of color, in particular, are at least in part due to social determinants of health: housing, transportation, education, access to health care, availability of healthy food options, a secure income, and freedom from structural and institutional barriers related to race and bias. These same determinants either support or impede success in controlling high blood pressure. When coupled with widespread implementation of best practices in clinical settings and empowering individuals to actively manage their blood pressure, acknowledging and addressing a community’s social conditions may generate sustained improvements in control of both hypertension and COVID-19.

Now is the time to draw attention and drive action to proven strategies that improve blood pressure control. Controlling hypertension requires sustained and specific actions by individuals with and at risk for high blood pressure; health care and public health professionals and the systems in which they operate; and communities. Smart, substantive, and ongoing investments by each of these sectors are needed to achieve better health outcomes in the near term, but also a more resilient, equitable, and prosperous nation in the future.

The goals and strategies presented in the Surgeon General’s Call to Action provide a national roadmap to drive change (eFigure in the Supplement). The 3 goals are: (1) make hypertension control a national priority; (2) ensure that communities support hypertension control; and (3) optimize patient care for hypertension control. The goals and strategies are grounded in the evidence, informed by experiences of high-performing systems and communities, and adaptable to match the resources available and the populations served.

The first major goal is to declare hypertension control a national priority; this is justified by the costs in lives, health, and dollars lost to a largely controllable condition. Generating widespread awareness of the effect of uncontrolled blood pressure on health and the economy is the first step in galvanizing action by the diverse set of sectors outlined in the document. Among the partners essential to achieving a national aim of hypertension control are payers and employers, who, by prioritizing blood pressure control in value-based contracting and incentive programs, could enable practices to invest in the teams and processes proven to achieve high performance over time. Payers and employers also could help individuals manage their hypertension by eliminating cost-sharing for blood pressure monitors and medications. Setting blood pressure control as a population health priority also draws attention to the profound disparities associated with hypertension, with racial and ethnic minority groups experiencing higher rates of hypertension, lower levels of blood pressure control, and greater risk of direct or indirect (eg, COVID-19–related) complications. The reason to establish this goal is not merely to describe these health inequities, but to do so as a catalyzing step toward their elimination.

The second major goal is ensuring, encouraging, and utilizing community-level supports for hypertension control. Communities are the primary level at which the social determinants of health operate. While foundational in their role as root causes of health disparities, these determinants can be changed for the better. For example, communities could invest in safe, affordable places to be physically active, improving walkability and promoting the use of bicycles. Ensuring access to nutritious, affordable, and high-quality food options for all residents should be a priority for communities. As members and leaders of their communities, physicians, nurses, pharmacists, and other health care professionals could support and advocate for community-based programs that facilitate healthy lifestyles. Making strong recommendations to and systematic referrals of patients to these key community resources could help clinicians reinforce key messages and equip patients to gain control of their blood pressure.

The third major goal is focused on achieving optimal clinical care for patients with hypertension. Lessons from high-performing systems are similar across practice sizes and settings. Achieving hypertension control rates of 70% and greater requires a team; a standardized treatment approach or protocol; a data system that provides accurate and timely insights into performance; and a set of strategies to support patients in self-monitoring their blood pressure and in adhering to medications and lifestyle recommendations.3,4,8

A recent policy statement from the American Heart Association and the American Medical Association,9 as well as current clinical practice guidelines,10 recommend out-of-office or self-measured blood pressure monitoring (SMBP) along with support from the clinical team to help individuals achieve and maintain control, and to avoid the traps of “white coat” or “masked” hypertension. The rapid adoption and expansion of telehealth during the pandemic may accelerate the implementation of SMBP programs by practices and health systems across the country. Improving access to validated devices, training patients in their use, setting up systems to receive and analyze patient-generated data, and returning timely treatment advice back to patients are steps that could generate rapid returns in patient engagement and subsequently in hypertension control.9

Rewarding clinical teams and health systems for excellence in hypertension control can take many forms. Whether through value-based insurance design, quality awards, financial bonuses, or local or national recognition, these returns are essential in creating deep and enduring investments in hypertension control.

Integrating hypertension guidelines and blood pressure targets into electronic health records could also help practices and systems improve blood pressure control. By participating in financial arrangements that reward high performance on hypertension control, practices could expand their teams to include effective but underutilized members, such as pharmacists and community health workers. Clinicians could develop protocols that use generic medications to reduce patient cost. Prescribing fixed-dose combination medications, synchronizing medication refills, and encouraging mail order delivery of prescriptions could also help improve patient adherence. Both communities and clinical systems have demonstrated improvements in hypertension control through the collective implementation of such community and clinical interventions.

The Surgeon General’s Call to Action to Control Hypertension6 charts a clear path to hypertension control for the US. Raising the rate of blood pressure control to a level that protects and preserves health will require commitments from nontraditional sectors such as business, education, and faith-based institutions, as well as continued or heightened focus by those organizations and institutions that already prioritize hypertension control. Individuals can start by checking their blood pressures regularly, practicing healthy habits including taking medications if and as prescribed, and seeking community improvements and clinical support as necessary. The involvement of policy makers, payers and employers, health care and public health professionals, researchers, and community leaders is critical in addressing the underlying contributing factors for hypertension and the gaps in blood pressure control and in realizing the opportunities to improve the nation’s health, resilience, and prosperity. The time for action is now. Implementing the goals and strategies in the Call to Action, together as a nation, could help patients, clinicians, and communities achieve the health, wealth, and equity benefits that national hypertension control can bring.

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Article Information

Corresponding Author: Janet S. Wright, MD, Office of the Surgeon General, Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201 (janet.wright@hhs.gov).

Published Online: October 7, 2020. doi:10.1001/jama.2020.20356

Conflict of Interest Disclosures: None reported.

References
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    1 Comment for this article
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    The More Things Change
    Michael Mundorff, MBA, MHSA | integrated healthcare system
    I believe part of the confusion among patients, which may drive reluctance about treatment, is the many guidelines which are sometimes conflicting and always changing over time. The lay press' breathless and often uncritical coverage of them is not helpful. For example, the USA’s ACP states that a systolic blood pressure (SBP) above 130 requires (not necessarily pharmacologic) treatment, while the EU puts that bar at an SBP of 140. Then a recent large study demonstrated there is a sliding-scale risk of adverse events for an SBP higher than 90, which would include most adults. So part of the Surgeon General’s task should be to clarify all of these conflicts and advocate what that department believes to be the best course for patients, supported by current evidence.
    CONFLICT OF INTEREST: None Reported
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