Barriers to blood pressure control

A new study, published in the October 1999 (Am J Hypertens 1999;12:951–958) issue of the American Journal of Hypertension, documents another disappointing failure to translate available biomedical knowledge into effective antihypertensive care.1 Professor Martha Hill and colleagues at Johns Hopkins have presented important, precise, and detailed information about the health status and life experience of black male residents of inner city Baltimore. Operating in an environment too daunting for most students of cardiovascular disease prevention, Dr Hill and her colleagues have produced excellent data to define the distribution and determinants of participation in treatment, adherence to therapy, and blood pressure control. The authors rightly call attention to the grim context in which these observations have been made. Hypertension is a generally asymptomatic condition, in which the benefit of treatment is the promise of a reduction in the odds of a distant heart attack or stroke. Thus, from a more privileged vantage point, long-term adherence to daily therapy might seem of little moment in a daily life characterized by poverty, unemployment, substance abuse, and frequent incarceration. The striking thing, however, is not the disheartening absence of blood pressure control found in these particular patients, but rather the similarity of their experience to that seen in more favored circumstances. More than half of these 309 inner city residents were in care, and 19% had achieved blood pressure control. These findings almost exactly reproduce the recently reported experience of hypertensive persons drawn from a fully insured multiethnic population of employed health workers.2 In that situation, the 409 hypertensive union members made an average of 9.0 fully ensured physician visits per year and received free medication. Nevertheless, only 14% of these men and women achieved normotension, and exactly the same percentage of treated subjects (33% of New York City workers and 35% of Baltimore inner-city residents) had reached goal pressures. Both in Baltimore and in New York, what seemed to matter was the number of antihypertensive pills taken. Knowledge, race, cost of care, regular physician visitation—all the items to which we so frequently attribute widespread uncontrolled hypertension—did not explain the observed outcomes. Although no one should quibble with the urgent need to alleviate the awesome burdens born by persons like those surveyed by Hill and coworkers, the available evidence suggests that there is no certainty that better blood pressure control will be the result. Ready access to free care does not, in itself, guarantee good outcomes. Not only among employed hospital workers2 but for participants in the VA,3 and wherever else it has been examined,4,5 blood pressure control is poorly achieved. Perhaps, as Hill et al suggest, the flaw may not be in the nature of the patients, the quality of their insurance, or their life circumstances, but rather in the medical care system through which antihypertensive care is delivered. Blood pressure treatment is preventive medicine and it may not mix well with sick care, which is what the American medical care system is about. In fact, there are multiple examples of settings where long term blood pressure control has been, and is being, achieved.6,7 These systems are invariably characterized by being categorical, free of cost to the patient, in which protocol directed care is delivered by a team, with the nurse as primary provider. An information system facilitates two-way communication—directing care through the system and retrieving information to assure adherence to established standards. Clinical trials invariably follow this strategy and routinely produce excellent results.8 It may just be possible that the cataloguing of associations among communal, personal, and professional characteristics, and poor blood pressure control—valuable as this may be theoretically—is not the most fruitful basis for improving the current situation. It may make sense to explore effective programs and to see whether, and how, the components of these systems might be adapted to conventional care. In short, it may be time to move beyond tampering with what doesn’t work and to begin learning how to exploit what does work.