Hypertension Control: Improved, but not enough!

The United States led the world in both recognizing and confronting the problem of high blood pressure. Epidemiological studies in Framingham quantified the burden of blood pressure associated coronary artery and cerebrovascular disease. The US pharmaceutical industry invested heavily and successfully to bring multiple representatives of what have now become 6 major classes of safe and effective antihypertensive agents to market. In little more than 50 years, the burden of disease was appreciated, risk factors identified, tools for intervention produced - and clinical trials provided evidence of their benefit. In short, hypertension presents a dazzling example of how targeted biomedical research can succeed. The trick, however, is to translate what is known into effective disease prevention and health promotion. Here too, America has led the way. Blood pressure “control” rates, now approaching 1/3rd of all “hypertensive” persons, are well ahead of virtually every other nation for which data is available. Still, having two thirds uncontrolled, this can hardly be described as a triumph. Physicians are not the only parties responsible for these unsatisfactory population outcomes. They do bear unique responsibility for the “control” component, however, of the “awareness, treatment, and control” continuum. The most recent report, from NHANES 2003–2004, may indicate a modest improvement to 56%. This falls far short of the 70% control rates reported in clinical trials, special programs, and resource constrained Cuba.2 Thus, physicians might be particularly concerned that in-treatment control rates have long been stuck at just above 50%. Reasons for the shortfall are clearly multiple, and include factors beyond the control of the medical care system. However, public education, vast investment by government, industry, and community organizations have together resulted in treatment of hypertension becoming the most common reason for Americans to visit a physician. Their physicians are now equipped with better understanding of how blood pressure is modulated, a host of medications whose mechanisms of action are known, and vary, several means by which to monitor patient progress, and the results of compliance research. Nevertheless, although awareness and entry into treatment have steadily improved, outcomes in practice have lagged. In this issue of the AJH, Dr. Obidiugwu Duru and colleagues explore the important role of insurance - probably an indicator of socioeconomic status – in determining control rates.3 Not surprisingly, uninsured persons are less likely to have pressure checked, receive treatment, or have pressure monitored. Interestingly, however, uninsured patients who do receive treatment are still less likely to achieve blood pressure control than insured treated patients. Moreover, persons with Medicare alone were just as likely to achieve control as those with supplemental private insurance. The authors conclude that these findings might mean that supplemental drug coverage, under Part D of Medicare, will not influence control rates. I would agree that insurance coverage for drugs, by itself, is not likely to improve outcomes. My guess is that insurance status may be a proxy for more general socioeconomic factors that together impact on success in treatment. The shortfall in control of treated, uninsured patients may, however, suggest that the cost of drugs does matter. Here, physicians can make a difference by choosing drugs that lighten the financial burden. No antihypertensive agent has proved more effective than a low cost diuretic in achieving blood pressure control and in preventing strokes and heart attacks. Other agents either alone or in addition are often needed. But all other drug classes, save for angiotensin ll receptor blockers (ARBs), have relatively inexpensive generic representatives available. Thus, the blood pressure of virtually every hypertensive patient can be successfully treated with low(er) cost drugs. Recognition of these possibilities, coupled with sensitivity to patient needs and preferences, will not solve the whole problem, but is likely to help.1