A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension (2010) / Chapter Skim
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5 Interventions Directed at Individuals with Hypertension
5 Interventions Directed at Individuals with Hypertension
Pages 135-174
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. The chapter also considers community health workers as a potential strategy to increase treatment adherence among individuals with hypertension.
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Another study reported that severe, uncontrolled hypertension was more common among Medicaid patients who could not identify a source of care (Lurie et al., 1984)
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were more likely in those ages 65 years or older, a population that has access to health care. In fact, most uncontrolled hypertension was mild systolic hypertension in older adults with access to health care and frequent physician contact (Hyman and Pavlik, 2001)
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(2008) speculated that the much smaller reduction in excess CVD mortality for blacks with controlled hypertension was probably due to several factors, including an earlier onset and greater severity of hypertension, less adequate blood pressure control, and less access to health care services.
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In addition, significant reductions in thickness of the interventricular septum and left ventricular mass, and in the left ventricular index, were observed for men assigned to the exercise arm. Collectively, these findings from well-designed and executed clinical trials of nonpharmacologic interventions for hypertension provide encouraging evidence that carefully supervised nonpharmacologic interventions focused on African Americans will likely reduce their excess risk for serious medical complications known to be caused by uncontrolled hypertension.
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NOTE: Attributable risk is calculated as P(RR – 1)
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. In fact, most uncontrolled hypertension was mild systolic hypertension in older adults with access to health care and frequent physician contact.
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. Oliveria and colleagues also identified patients with uncontrolled hypertension.
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1 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION Patients Aged ≥70 y Patients Aged 40-60 y 57 60 49 50 % of Respondents 35 40 29 30 20 10 11 46 10 0 80-84 85-89 90-94 95-99 100-110 Diastolic BP Ranges, mm Hg Patients Aged ≥70 y Patients Aged 40-60 y 46 50 40 34 31 % of Respondents 30 19 17 17 20 13 11 7 10 5 0 130-139 140-149 150-159 160-169 170-179 180-189 Systolic BP Ranges, mm Hg FIGuRE 5-2 The diastolic and systolic blood pressure ranges at which physicians would start drug treatment in patients with uncomplicated hypertension. SOURCE: Hyman and Pavlik, Archives of Internal Medicine, August 14, 2000, 160: 2283.
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The researchers found that antihypertensive therapy was not intensified in 86.9 percent of visits when blood pressure was ≥140/90. They estimated that improvement of 20 percent in the percentage of visits in which treatment is intensified, blood pressure control could increase from the study's observed 46.2 percent to a projected 65.9 percent in one year.
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Halm and Amoako (2008) , in an analysis of the NHANES III data, found that only one-third of patients with hypertension reported having received a physical activity recommendation from their health care provider.
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. According to the NHANES III data, isolated systolic hypertension in the elderly comprises the majority of uncontrolled hypertension in the United States (Franklin et al., 2001; Hyman and Pavlik, 2001)
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blood pressures of 72 patients with no initiation or change in antihypertensive medication. SOURCE: Oliveria et al., Archives of Internal Medicine, February 25, 2002, 162:417.
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Numbers at top of bars represent overall percentage distribution of all subtypes of inadequately treated hypertension in that age group. n, Isolated Systolic Hypertension (SBP ≥ 140 mm Hg and DBP <90 mm Hg)
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. Furthermore, physicians are not providing treatment consistent with the JNC guidelines, particularly in the treatment of isolated systolic hypertension, yet the largest attributable fraction for lack of awareness and lack of control of hypertension is being age 65 years or older and having isolated systolic hypertension.
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This is due to the large number of people who had diagnosed but uncontrolled hypertension (approximately 14 percent of adults in the preHEDIS population) and the effectiveness of available treatments in preventing CVD events in people who have uncontrolled hypertension." The PCPI is a physician-led initiative to develop tools by physicians for physicians.
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envision that routine measurement of hypertensive care quality among provider groups or plans can lead to improved care processes and blood pressure control (Table 5-2)
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Income and high out-of-pocket costs (OR = 4.6; p < 0.001) were each associated with cost-related underuse of antihypertensive medications (Piette et al., 2004)
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population, the Rand Health Insurance Experiment, hypertensive individuals given free care were more likely to see a physician and to have their hypertension detected and a medication prescribed (Keeler et al., 1985, 1987)
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. Another study of low-income black and Hispanic patients reported that severe, uncontrolled hypertension was more common among persons with no health insurance (adjusted OR = 2.2 [1.0-4.6]
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. Hypertension Control and Cost Sharing Among Those with Insurance Cost sharing is described by AHRQ as the contribution consumers make toward the cost of their health care as defined in their health insurance policy.
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, 3 percent of individuals subject to cost sharing discontinued all antihypertensive medications; however, Johnson (1997b) found that the largest price increase led to fewer days of antihypertensive medication use, but not discontinuance of treatment.
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Cost sharing is not always consistent with decrease in utilization. In one study, the intervention group with the change in benefits was less likely than the control group to stop using ACE inhibitors (Huskamp et al., 2003)
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In an older randomized controlled trial that was representative of the U.S. population (the RAND Health Insurance Experiment)
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. EMPLOyER INITIATIVES TO ADDRESS HyPERTENSION Traditional worksite health promotion programs strive to maintain worker health, improve work productivity, lower health care costs, and enhance organizational image and future interests (Goetzel and Ozminkowski, 2008)
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. Healthy People 2010 further describes workplace health promotion to include not only health education that focuses on skill development and lifestyle behavior change but also programs that help employees assess health risks and link to health plan benefits to provide appropriate medical follow-up and treatment.
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. COMMuNITy HEALTH WORKERS AND HyPERTENSION Previous sections have addressed a number of system factors that influence the control of hypertension.
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The roles and duties of CHWs tend to be similar across studies and reflect the common objective of improving blood pressure control through a range of physician- or nurse-supervised behavioral and social support interventions. The latter typically include measuring and monitoring blood pressure; providing health education to patients and families about behavioral risk factors for hypertension; recommending changes in diet and physical activity; explaining treatment protocols, health insurance matters, and the importance of adhering to medication regimens; providing help with obtaining transportation to medical appointments; serving as mediators between patients and health care and social service systems; arranging for translation services; and finally, listening to patients and their family members, motivating them, reducing their isolation, and leading self-help groups.
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as one of 20 priority areas for improvement in health care quality. The committee, in its review of the evidence related to hypertension control and access to care and providers, found that although lack of health insurance is associated with poorer screening rates, poorer compliance with medication, and poorer blood pressure control; the vast majority of individuals with uncontrolled hypertension in the United States are insured.
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Based on the review of the literature, there is strong evidence that physicians are not paying adequate attention to treating and controlling systolic hypertension. The goal of improving the education and training of health care providers in the prevention of cardiovascular disease is central to the Public Health Action Plan to Prevent Heart Disease and Stroke, the DHDSP Strategic Plan, and the National Heart Disease and Stroke Prevention Program (as described in Chapter 3)
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5.2 The committee recommends that the Division for Heart Disease and Stroke Prevention work with the Joint Commission and the health care quality community to improve provider performance on measures focused on assessing adherence to guidelines for screening for hyperten sion, the development of a hypertension disease management plan that is consistent with JNC guidelines, and achievement of blood pressure control. Out-of-pocket cost of medication has been identified in the literature as a significant barrier to patient adherence with hypertension treatment.
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5.4 The committee recommends that the Division for Heart Disease and Stroke Prevention collaborate with leaders in the business com munity to educate them about the impact of reduced patient costs on antihypertensive medication adherence and work with them to encourage employers to leverage their health care purchasing power to advocate for reduced deductibles and copayments for antihypertensive medications in their health insurance benefits packages. The DHDSP might also consider working with the business community to evaluate and disseminate broadly the research on the health impacts of efforts to reduce financial burdens associated with the treatment of hypertension.
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5.5 The committee recommends that the Division for Heart Disease and Stroke Prevention work with state partners to leverage opportuni ties to ensure that existing community health worker programs include a focus on the prevention and control of hypertension. In the absence of such programs, the division should work with state partners to de velop programs of community health workers who would be deployed in high-risk communities to help support healthy living strategies that include a focus on hypertension.
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2008a. The community health worker's sourcebook: A training manual for pre venting heart disease and stroke.
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2001. Predomi nance of isolated systolic hypertension among middle-aged and elderly US hypertensives: Analysis based on National Health and Nutrition Examination Survey (NHANES)
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2007. Community health worker national workforce study: U.S.
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1997b. The impact of increasing patient prescription drug cost sharing on therapeu tic classes of drugs received and on the health status of elderly HMO members.
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2007. With every heartbeat is life: A community health worker's manual for African Americans.
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1991. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension.
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1995. Community health workers: Integral members of the health care work force.
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