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How Many Hypertensive Patients Can Be Controlled in Reality

How Many Hypertensive Patients Can Be Controlled in Reality

Background


Hypertension is a leading modifiable risk factor for cardiovascular disease. Worldwide, 7.6 million premature deaths (about 13.5% of the global total) and 92 million DALYs (6.0% of the global total), about 54% of stroke and 47% of ischemic heart disease were attributable to high blood pressure. Hypertension control is therefore a major goal for every National Health Service. In the US, improvement in hypertension detection and control has been observed in the last 30 years: the rate of hypertension increased from 23.9% in 1988–1994 to 28.5% in 1999–2000, but did not change between 1999–2000 and 2007–2008; control increased from 27.3% in 1988–1994 to 50.1% in 2007–2008. Improvement was reported for Canada: control improved from 13.2% in 1992 to 64.6% in 2009. Similar rates of control are also present in the minority of the European countries, such as Denmark, where 57% of treated patients are controlled. In Italy the current control rate is 35%. Despite these improvements, it is clear that hypertension treatment is still far from acceptable, although it is not known how many patients can be controlled in every-day clinical practice. This is an important piece of information, since it may help to work-out a target for quality standards and for improving strategies.

The reasons for low control rate in surveys can be divided into insufficient blood pressure measurement and recording, and insufficient treatment (prescription and adherence).

The great majority of hypertensive patients are cared for in primary care. The analysis of every-day practice shows a problem which cannot be identified by the observation of a randomly selected and carefully evaluated sample of a hypertensive population: many subjects diagnosed with high blood pressure have no up-to-date blood pressure (BP) values in their clinical records. A recent survey in Italian primary care showed that, during the last year, 16% of diagnosed hypertensive subjects didn't visit their GPs: furthermore, of the patients who contacted their GP 16% had no recorded BP value. This problem has been addressed by the British "pay for performance" strategy: in the 2009/2010 report over 90% of the patients had their BP recorded in the previous 9 months. It must be noted that the reported prevalence of hypertension was 13.4%, well below the expected "real" prevalence; therefore the value and the generalizability of such a result is very difficult. Another problem is the method used to measure BP and, consequently, the cut-off value to classify a patient as controlled or not controlled. The importance of this issue is well illustrated by a Danish survey, which showed that 57% of treated patients were controlled according to office BP values, and that the percentage increased to 68% when home BP was used instead. At the moment home BP monitoring? (or 24 h monitoring) isn't recommended for all the patients with hypertension, but up to 50% of the treated population could benefit from this technique, according to the guidelines indicated: evaluation of white coat hypertension, of masked hypertension, and of resistant hypertension.

Other well-known obstacles to getting patients to BP target are drug under-prescription (therapeutic inertia) and poor therapeutic continuity/adherence. In conclusion, it is clear that BP control in real practice cannot improve without 1) using the appropriate measurement technique, 2) knowing/recording the BP values, 3) prescribing the necessary drugs, and 4) obtaining good therapeutic continuity/adherence.

The scientific literature is rich in trials aiming to improve drug prescription, therapeutic adherence, patient involvement, and, finally, BP control. Unfortunately, a definite model is still lacking, and only general suggestions are possible, at least according to Cochrane Collaboration's conclusion, in which he states that: "family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients…. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control, but require further evaluation". It is clear that a multifaceted strategy is needed to further improve hypertension control, and that such a strategy must be simple, cheap, and sustainable in the long run in the actual primary care working framework. A group of GPs volunteered to test such a strategy over an 18-month period, aiming to maximize BP control and to understand how many hypertensive patients can be controlled in usual clinical practice. The main results are reported in this paper.



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