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Tackling the Challenges to Improve Hypertension Control

Monday, September 16, 2019   (0 Comments)
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Written by: Vincent Salvador

Vincent (Vince) Salvador is a part-time, volunteer intern at Northwest Regional Primary Care Association (NWRPCA) in Seattle, WA. He is involved in a practicum project that aims to formulate evidence-based recommendations and population-wide strategies for improving hypertension control of the patient population in the community health centers. He is a hospital medicine physician in Tacoma and a part-time graduate student of the MPH program at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD.



Despite the advancement in therapeutics and improvement in lifestyle practices supported by scientific evidence, hypertension remains a significant public health issue that has been a challenge to address on a wider scale in the community. From 2006 to 2016, the mortality rate attributed to high blood pressure had increased 18% in the United States (1). Considered as one of the priority health problems in the country, population-level reduction of hypertension burden represents one of the goals envisioned in the Healthy People 2020 (2). It has been previously estimated that 1 in 3 adults in the country have hypertension. Only about half of this patient population have their high blood pressure under control (3). This has important public health implication as having high blood pressure has been linked to significant risk of cardiovascular mortality, morbidity and increased health expenditure (4,5). Among the modifiable metabolic risk factors, hypertension has the strongest association with cardiovascular disease based on a recent international prospective cohort study involving 21 countries of different economic status (6). A small reduction in systolic blood pressure by 10 mmHg could dramatically translate to a decrease in the incidence of stroke by 40% and myocardial infarction by 20% (7).


The prevalence of hypertension in WA state was approximately 28% in 2015 (8). A recent cumulative health outcome data reported to HRSA Health Center Program by 27 health center grantees from the state indicated that the proportion of patients with controlled blood pressure (defined as < 140/90 mmHg) being seen in the community health centers has improved to 68% in 2018 from 65% in 2017 (9). Substantial disparities have been identified in the risk of developing hypertension which has been reported more commonly in males, non-Hispanic blacks, adults more than 65 years old, adults from lower socioeconomic status and those with limited educational attainment (8).


Addressing the burden of hypertension in the community entails an understanding of the key determinants that either improve or worsen the health problem which could be viewed at different dimensions as depicted in Table 1. Having a conceptual framework showing how each factor contributes to the problem, such as illustrated in an ecological model, can facilitate identification of potential interventions that are relevant to the needs of the community. In an ecological model, the health outcome is influenced by the individual, interpersonal, organizational, community and public policy factors that might facilitate the adoption of healthy behaviors (see Figure 1) (10). While health outcome is affected by dynamic interacting factors, it is equally important to be cognizant of the underlying context where interventions will be implemented as opportunities to improve hypertension control could be enhanced or undermined by the existing environmental and cultural factors.


Table 1. Some key determinants of population-level hypertension control taken from the literature 



At the individual level, patient’s compliance to prescribed medication and lifestyle regimen is an important determinant of hypertension control. Aside from contributing to high prevalence of hypertension, lower adherence to prescribed medication/s and lifestyle modifications due to existing health beliefs, lack of knowledge about the disease and side effects of medications could bring about significant racial disparities in the health outcomes (11, 12). Adopting healthy lifestyle and adherence to medical recommendations by patients are influenced by level of educational attainment. A lower level of literacy is associated with less engagement in individual medical decision-making and consequently has worse blood pressure control compared to those with higher level of literacy (13).


Social network in the form of social support from family members, friends and neighbors has a direct impact on influencing patients’ adherence to treatment regimen. The field of social science has offered insights on the importance of peer support to adoption of certain practices. By conforming to social norms and expected roles, individuals may be encouraged to adopt health-promoting behaviors (14). Furthermore, having a greater social support has been linked to less depressive symptoms and improved collaborative communication between the patient and the medical provider (15).



Figure 1. Ecological Model Diagram.

Taken from https://www.acha.org/HealthyCampus/Implement/Ecological_Model/HealthyCampus/Ecological_Model.aspx?hkey=f5defc87-662e-4373-8402-baf78d569c78


The quality of medical care in treating hypertension is highly dependent on the medical team and the resources of the health care organization. An important physician-level barrier that has been recognized is the lack of adherence to treatment guidelines for hypertension (16). While the clinical judgment of the physicians on treatment recommendations is tailored towards their patients’ characteristics, it has been suggested that compliance to clinical guidelines could be related to knowledge gap, disagreement with the guidelines, lack of belief on the effectiveness of the recommended treatment, lack of self-efficacy and motivation to change prescribing patterns (17). Despite the limited resources and other internal barriers in a clinical practice setting, innovative strategy like the adoption of the Patient-Centered Medical Home (PCMH) has facilitated an improved comprehensive care delivery which has led to better clinical outcomes of patients with hypertension (18). Having a specific disease management program as a tool in clinical practice has also led to improved hypertension control among patients (19).


At the community level, the attributes of a neighborhood environment have a wide range of effect on health outcome. High density of fast food establishment in the area and less walkable neighborhood environment are associated with uncontrolled hypertension (20). The built environment affects people’s lifestyle choice which is dependent on whether they have access to healthy food, resources for physical activity and marketing of alcohol and tobacco products (21). The influence of socioeconomic conditions in the community on blood pressure control could not be discounted as well. Highly segregated neighborhoods and lower neighborhood socioeconomic status have been associated with poor hypertension control likely brought about by socioeconomic deprivation, higher crime, less social capital and less appropriate medical care (22).


Both state and national policy health programs geared towards improving hypertension burden have the potential to achieve improved health outcomes if sustained on a wider scale and for an extended time. In WA state, a multiyear, federally-funded innovative plan known as Healthier Washington, was rolled out in 2016 to reform payment system, integrate delivery of health services and promote healthier communities through regional collaboration. Through this statewide health innovation strategy, the local community-based coalitions and the state government had established partnership to align resources and activities in improving health and health equity through formation of Accountable Communities of Health (23). As part of the transition to integrated care and pay-for-value plan, statewide common measures including hypertension control are tied to value-based payment (24). On a national level, reducing population-wide hypertension is one of the targets of Healthy People 2020 which aims to cut down the rate of adults with hypertension and improve control of high blood pressure below the threshold 140/90 mmHg (2).


Addressing the burden of hypertension in the community will likely entail multilevel and multipronged strategies that should take into consideration the local context of the practice setting. There is a need to design context-specific strategies that would allow the health care organizations to deliver high-quality and equitable solutions based on the relevant contributing determinants at the various levels of the ecological framework. Reducing premature cardiovascular disease related to hypertension remains a health priority where opportunities exist for improvement.


For questions on how to get involved with performance improvement on hypertension control in your communities, you can reach Crysta Maniscalco of NWRPCA at cmaniscalco@nwrpca.org.



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