Protocol-Based Treatment of Hypertension

Improved treatment of hypertension is among the most important-and quite possibly also the single most neglected-area of clinical medicine.Only half of Americans with hypertension have blood pressure less than 140/90 mm Hg, and more than 13%-an estimated 9 million people-have a systolic blood pressure of 160 mm Hg or higher and/or diastolic pressure of 100 mm Hg or higher. 1 Much better control is possible: Canada has a rate of blood pressure control of more than 65%, 2 and the Minneapolis-St Paul region has a level of blood pressure control more than 20 percentage points higher than the United States as a whole. 3The United States is making progress, but this progress is painfully slow-the rate of control is increasing only 1% per year. 4 simple numbers, it is estimated that nearly 36 million US adults have uncontrolled blood pressure, with 2 major subgroups that would benefit from protocol-based care. 1 The first is the large number of people-14 million-who are unaware of their hypertension. 1Most of these people are hiding in plain sight: they are in clinical treatment with elevated blood pressure documented, but hypertension neither diagnosed nor treated.High-performing systems can reduce by half the proportion of hypertensive patients unaware of their blood pressure and not being treated. 5The second group is the estimated 16 million people who know they have hypertension and are taking medication for it, but do not yet have it under control. 1 Thirty-two million of the 36 million whose blood pressure is uncontrolled have a usual source of care and 30 million are insured, including 14 million Medicare beneficiaries.But the most compelling statistic-and the one that makes the case for more focused clinical attention-is that nearly 3 of 4 people with uncontrolled hypertension (an estimated 26 million people) visited a health care professional at least twice in the prior year. 1 Opportunities are being missed to initiate and improve care of patients with hypertension, and as a result they are experiencing preventable myocardial infarctions, strokes, and kidney