A MAP toward increased rates of blood pressure control?

Rates of blood pressure (BP) control remain low in adults with hypertension, particularly in medically underserved communities.1 In the United States, the prevalence of BP control is 50% among adults in the general population vs only 30% in uninsured adults.2 Rates of BP control are even lower in many low-income countries where <10% of adults with hypertension have controlled BP.3 Uncontrolled BP is the single greatest risk factor for early mortality worldwide.4 Increasing BP control rates by just 10% could save 14 000 lives per year in the United States alone.5 Why do BP control rates remain low in adults with hypertension who are attending clinics? Research suggests two major factors: therapeutic inertia on the part of healthcare providers and low adherence to therapy on the part of patients. Therapeutic inertia is defined as the providers’ failure to increase medications when treatment goals are not met. Studies have shown that healthcare providers increase BP medications in <25% of study visits when the BP is elevated.6 Uncertainty about the accuracy of clinic BP measurement is a major reason for therapeutic inertia.7 Therapeutic inertia accounts for approximately 20% of uncontrolled BP.6 Low adherence to therapy by patients with hypertension is the other major contributor to low rates of BP control. Forming a therapeutic alliance (ie, partnership) with patients and families has been shown to be critical in increasing adherence to hypertension therapy.8 Although strategies for forming this partnership have been developed and tested,9, 10 these strategies are not consistently implemented in modern health systems. Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is a new strategy for increasing rates of BP control in adults with hypertension.11 This strategy was developed as a collaboration between the American Medical Association and the faculty from Johns Hopkins. The developers sought to coalesce several evidence-based strategies for improving hypertension control including strategies to overcome therapeutic inertia and increase adherence to therapy. The MAP materials are freely available through the American Medical Association website.12 The MAP strategy has three components.11 First, “Measure Accurately” describes a protocol to ensure that patients are correctly classified as having either controlled or uncontrolled BP.13, 14 A single BP is taken by a nurse. If this initial BP is elevated, three unattended BPs are taken using a calibrated, automated device. The average of the second and third measurements is used as the final BP. Second, “Act Rapidly” indicates that healthcare providers should increase medications for any patients with elevated BP. Clinical protocols should be developed and used consistently to guide this decision. Third, “Partner With Patients” describes a portfolio of strategies that can be used to increase adherence to therapy through promoting partnership. The MAP strategy was designed so that all members of the medical team can contribute to increasing hypertension control. In the article entitled “Measure Accurately, Act Rapidly, and Partner With Patients (MAP) Improves Hypertension Control in Medically Underserved Patients,” Hanlin and colleagues present the first study to evaluate the impact of the MAP intervention on rates of hypertension control.15 In this quasi-experimental study with historical controls, the investigators compared BP control rates before and after the MAP intervention was introduced into a single academic health clinic. In total, 715 study patients were included in the main analysis. Of note, several of the investigators were also members of the team that developed the MAP intervention. In this before-after comparison, rates of BP control increased from 61% before the MAP intervention to 90% after the MAP intervention. These higher rates of BP control after the MAP intervention seem to be attributable to two changes. First, the “Measure Accurately” BP protocol led to reclassification of approximately 25% of study patients from uncontrolled BP (based on a nurse measurement) to controlled BP (based on the three unattended, automated BP measurements). Second, for each medication that was increased during the MAP intervention period, the systolic BP decreased much more than for medication increases during the preintervention period (−21.6 mm Hg vs −8.3, P = .0004). This greater impact for each medication increase may have reflected a greater adherence to therapy by study patients. The absolute increase in BP control rates observed in this nonexperimental study compares favorably with improvements seen with team-based care. Team-based care involving pharmacists, nurses, and physicians is a health systems strategy that has consistently been shown to increase BP control rates in adults with hypertension. A recent meta-analysis of randomized clinical trials for team-based care concluded that the median increase in hypertension control rates was 12%.9 Clinical trials and cost-effectiveness studies are needed before MAP can be widely recommended. Clinical trials of the MAP intervention will likely show a lower absolute increase in rates of BP control than the current quasi-experimental study. Studies should compare the MAP intervention with team-based care both for absolute increase in BP control and for cost-effectiveness. In addition, research is needed to test the MAP intervention in low-income countries. Health systems for the management of hypertension are weak in many low-income countries such as those in Africa.3, 16 The MAP intervention might be more appropriate than team-based care in low-income countries since it does not require any additional personnel such as pharmacists, nutritionists, or nurse clinicians. In order to be effective in low-income countries, though, the MAP intervention should be adapted to the unique challenges of African patients with hypertension.17 In conclusion, the MAP intervention is a promising new strategy for increasing rates of BP control in adults with hypertension. The current study by Hanlin and colleagues provides the first evidence for this intervention. Clinical trials and cost-effectiveness analyses are needed before strong recommendations can be made for integrating the MAP intervention into health systems around the world. The authors declare no conflicts of interest or financial disclosures.