Time to Shift Gears and Scale Up National Efforts
Elevated blood pressure is a major modifiable risk for cardiovascular disease (CVD) and the leading cause of preventable death worldwide. Current estimates indicate that ≈7.6 million premature deaths and 92 million disability-adjusted life years are attributable to suboptimal blood pressure.1 Most of the lifestyle causes of hypertension are well known, and clinical trials provide clear evidence that reducing blood pressure with antihypertensive drugs significantly decreases CVD morbidity and mortality. Despite this, the World Health Organization is predicting an epidemic of hypertension and, in clinical practice, most patients with hypertension are undiagnosed, untreated, or suboptimally treated.2 Against the backdrop of increasing CVD burden worldwide, the gap between what we know and do in hypertension prevention and management is a major cause for concern.
Achieving optimum hypertension control to prevent hypertension-associated CVD has been a substantial challenge. There are multiple reasons for lack of blood pressure control, including health care system characteristics, as well as patient and physician characteristics.3 Treatment and control rates of hypertension are particularly low in most developing countries (typically <10%), and even developed countries have far from ideal levels of control.3 However, there is wide variation in national control rates, with some developing countries having higher rates of hypertension control than many developed countries (Table 1). There has been no systematic evaluation of national programs to prevent and control hypertension to aid countries in reducing the disease burden associated with hypertension.
In this issue of Hypertension, Falaschetti et al4 report improvements in hypertension management in England between 2003 and 2006. Using cross-sectional, nationally representative data of adults aged ≥16 years from the Health Survey for England, they found increases in awareness, treatment, and control rates. Overall hypertension prevalence among adults in 2006 was 30%, and of those with hypertension, 66% were aware, 54% were on treatment, and 28% were controlled. Comparative figures in 2003 for awareness, treatment, and controlled were 62%, 48%, and 22%, respectively. Although these findings indicate continued improvements in hypertension management, they are far from the optimum.
Falaschetti et al4 hypothesized the improvements might be, in part, attributed to new payments to general practitioners for attaining hypertension targets implemented in England since 2004. Another recent study also suggested substantial improvements in blood pressure monitoring and control in England after implementation of the “pay-for-performance” (PFP) policy.5 It is critical to try to discern the impact of PFP on hypertension management so that other countries can assess the potential to improve hypertension management using this tactic. In England, awareness of hypertension increased by 3.1% per year in the 5 years before PFP (1998 to 2003) and by 1.4% per year in the 3 years after PFP (2003 to 2006). Similar increases for treatment were 3.2% per year before PFP and 2.1% per year after PFP, whereas for control it was 2.5% per year and 2.1% per year, respectively.6–8 The per annum change in rates of awareness, treatment, and control appeared to be slightly lower after implementation of PFP compared with corresponding rates before PFP (Table 2). Complicating interpreting the impact of PFP, the payments were for achieving blood pressure levels of <150/90 mmHg rather than the more conventional levels of <140/90 mmHg. The basis for improved management of hypertension in England before and after the introduction of for PFP requires more rigorous exploration.
The high use antihypertensive drugs (>60% of treated patients in the England were prescribed ≥2) is also a point to ponder. The very high cost of treating large segments of the population medically strongly supports the need to implement population-based strategies, such as dietary salt reduction. England started a national program to reduce dietary salt in 2003. A population-based approach to dietary salt reduction in Canada is estimated to double the hypertension treatment and control rate, substantially reduce CVD, and save considerable health care costs.9 A recent analysis also indicated that, globally, 8.5 million deaths could be avoided over 10 years (2006 to 2015) by salt-reducing initiatives alone, with a very low estimated cost per person ($0.04 to $0.32).10
Despite the improving trends for hypertension management in England, more intensive efforts are clearly warranted to prevent and control hypertension so that a meaningful impact can be achieved in reducing hypertension-associated CVD. Preventive efforts using population-based strategies need to be the cornerstone of hypertension prevention and control. Meanwhile, the high-risk approach of adequately treating hypertensives with appropriate drugs is important to achieve health gains in the short and immediate term. Both approaches should be complementary and synergistic. This is particularly important for developing countries, which bear a disproportionate burden of hypertension. The World Health Organization has called for improved prevention and control of hypertension. This call needs to be supplemented by a thoughtful and comprehensive evaluation of national programs and recommendations to countries on how this can be best achieved in both developed as well as developing countries.
Sources of Funding
S.M. is supported by the Canadian Institutes of Health Research Canada-HOPE Fellowship, and N.R.C.C. is supported by the Canadian Institutes of Health Research Canada Chair in Hypertension Prevention and Control.
N.R.C.C. has received honoraria for advising and speaking from most major pharmaceutical companies that produce antihypertensive drugs. S.M. reports no conflicts.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
World Health Organization. The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization; 2002.
Bakris G, Hill M, Mancia G, Steyn K, Black HR, Pickering T, De Geest S, Ruilope L, Giles TD, Morgan T, Kjeldsen S, Schiffrin EL, Coenen A, Mulrow P, Loh A, Mensah G. Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action. J Hum Hypertens. 2008; 22: 63–70.
Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: results from the Health Survey for England 2006. Hypertension. 2009; 53: 480–486.
Ashworth M, Medina J, Morgan M. Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework. BMJ. 2008; 28: 337.
Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: results from the health survey for England 1998. Hypertension. 2001; 38: 827–832.