Unveiling the Gaps: Hypertension Control Beyond the Cascade of Care Framework

Objective: While the cascade of care framework established a typical “aware-treated-controlled” path to hypertension control, less is known about alternative paths to hypertension control. This study aimed to: (i) Identify untypical paths to hypertension control; (ii) Assess social factors associated with untypical hypertension control scenarios. Design and method: This analysis included 170,263 French adults aged 25-69 in CONSTANCES population-based epidemiological cohort between 2012 and 2020. Blood pressure (BP) measurements following a standardized protocol during clinical examinations and hypertension history were obtained at inclusion. Pharmacological treatment data were collected from the Système National des Données de Santé (SNDS) database. Hypertension was defined by systolic BP>140/90 mmHg and/or antihypertensive treatment. Awareness, treatment, and control were assessed through participant declarations, reimbursement for antihypertensive drugs, and BP measurements, respectively. Social factors and cardiovascular morbidities associated with untypical control paths were examined using logistic regressions. Results: In our study, 30.8% (n=52,434) of respondents had hypertension. While the care cascade identified 13% of hypertensive respondents achieving control, this percentage rose to 19% when considering the alternative “unaware-treated-controlled” path (n=9,980). Consequently, one-third of hypertension control was not captured by the typical cascade framework. The untypical path to control was associated with female gender (adjusted odds ratio [aOR], 1.68 [95% confidence interval (CI), 1.52-1.86]), younger age (aOR1-unit decrease, 1.08 [95% IC, 1.08-1.09]), higher education level (aORmost educated 1/4 vs less educated 1/4, 1.43 [95% IC, 1.25-1.64]), and comorbidity with another cardiovascular disease (aOR, 6.47 [95% IC, 5.79-7.23]). Northern African origin (aORvs Majority population, 1.32 [95% IC, 1.05-1.66]) was also positively associated with untypical control path, while Sub-Sahara African origin was negatively associated with untypical control path (aORvs Majority population, 0.46 [95% IC, 0.29-0.71]). Conclusions: This study underscores that adhering strictly to a sequential cascade of care approach may exclude socially characterized groups not fitting into defined categories. Revision of the cascade of care framework, incorporating diverse treatment modalities and recognizing potential patient reentries, is suggested to accurately assess hypertension control.