Hypertension

Organizations Call for More Effective Hypertension Control Approaches Nationwide

High blood pressure affects nearly 78 million Americans and is a major risk factor for heart disease and stroke. Of those who have high blood pressure, also called hypertension, about 80 percent are being treated but only half have it controlled to a healthy level in national surveys.

Today, the American Heart Association, the Centers for Disease Control and Prevention, and the American College of Cardiology issued a joint statement as a call to action for healthcare, industry and communities to prioritize people who are receiving treatment but are not currently at controlled levels. It notes that of those with uncontrolled hypertension, nearly 90 percent see a healthcare provider regularly, and 85 percent have health insurance.

Kaiser Permanente Northern California’s hypertension control program is cited as a model to emulate.  The proportion of the health care system’s hypertensive patients meeting target blood pressure goals improved substantially from 44 percent in 2001 to more than 87 percent in 2011.

Kaiser Permanente’s regional hypertension program, serving more than 3 million members, was implemented using five major components: creation and maintenance of a health system-wide electronic hypertension registry; tracking hypertension control rates with regular feedback to providers at a facility- and provider-level, development and frequent updating of an evidence-based treatment guideline; promotion of single-pill combination therapies; and using medical assistants for follow-up blood pressure checks to facilitate necessary treatment intensification.

The statement says that programs are needed to develop and implement evidence-based treatment algorithms; establish systems that promote teamwork between patient, physician and other health care personnel; provide education and incentives for control; provide regular follow-up and treatment intensification as needed; provide actionable feedback to providers and health systems; maximize the use of technology; and promote a guideline-based simplified medication regimen.

The Kaiser Permanente Northern California hypertension control program was the subject of a study by the Kaiser Permanente Division of Research published in JAMA earlier this year.  Read more about that study here.

Resistant Hypertension: What New Research is Telling Us

If you live in the United States, odds are good that you know someone who struggles with high blood pressure.  Also called hypertension, it is a major health problem in this country, affecting about 70 million adults, according to the American Heart Association. This “silent killer” typically has no warning signs or symptoms, but when left untreated it can lead to heart attacks, heart and kidney failure, stroke, and other health consequences.

John Sim, MD

        John Sim, MD

As the overall awareness and subsequent treatment of this disease improves in the United States, physicians are finding that some patients have difficulty controlling their hypertension even with their prescribed medications. While little is known about those affected by this phenomenon, called “resistant hypertension,” these patients are often at a disproportionately higher risk for organ damage and other cardiovascular problems. John Sim, MD, of the Kaiser Permanente Los Angeles Medical Center, is the lead author of a new study that looked at the characteristics of those affected by resistant hypertension. We talked with him about the findings and what is being done to help patients.

Why are you interested in resistant hypertension?
Hypertension is highly prevalent, affecting 1 billion people worldwide. Historically, our management and control of hypertension has been relatively poor, but the good news is that we have been improving. For instance, the control rate for Kaiser Permanente patients with hypertension is around 85 percent, which is exceptional considering that the national rate is around 50 percent. The result of this success is that we’re gaining a better awareness of hypertension but at the same time, we’re finding a subpopulation of patients who are not responding to our medications despite our best attempts at treating them. With this in mind, it is important that we understand the causes of resistant hypertension and who is most affected by the disease, so that we can intervene with a management strategy and get it under control.

What do we already know about resistant hypertension?
There are many unknowns regarding resistant hypertension. First off, we know that hypertension itself is a risk factor for many different diseases and ultimately, it leads to mortality. When it comes to resistant hypertension, the fact that people cannot control their hypertension with medication suggests an even poorer prognosis. But much of what we know about resistant hypertension is based on assumptions – nobody really knows the prevalence of this disease and its impact on patient outcomes.

Provide us with some background on your study.
To start with, we only have estimates of what proportion of hypertension fits into this “difficult to treat” area.  This leaves us with questions such as, “What types of people are most affected by resistant hypertension?” and “What can we do to treat them?” Our goal with this study was to answer some of these questions and identify those affected by resistant hypertension, which will hopefully lead to different management approaches to help treat this disease. We also wanted to more accurately identify resistant hypertension, gain a better sense of the pervasiveness of the disease, and characterize the population suffering from it. We felt that we could do a more accurate study because of Kaiser Permanente’s excellent work at treating hypertension and our extensive electronic health record database.

What did you find in this study?
We looked at the ethnically and socioeconomically diverse patient population from Kaiser Permanente Southern California and identified nearly 500,000 patients, or 21 percent, of adults 18 years or older with hypertension, as defined by the American Heart Association and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. We found that of these patients, 12.8 percent met the criteria for resistant hypertension – meaning patients with hypertension that cannot be controlled with three or more medications or those who require four or more medications regardless of blood pressure. Overall, 7.9 percent of the patients had uncontrolled blood pressure despite taking three or more medications.

Which patients were more likely to be impacted by resistant hypertension?
In terms of patient characteristics, we found that patients with resistant hypertension tended to be older, more likely to be obese and were more often black. In addition, people with resistant hypertension had a greater prevalence of comorbid conditions such as diabetes, heart disease, and chronic kidney disease. It is also important to note that people with resistant hypertension appeared to be taking their medications more regularly than those with nonresistant hypertension.

What are the implications of these study findings?
This is what gets me excited. While there are approximately 70 million people in the United States with hypertension, we currently only have one treatment guideline. This is problematic as it assumes that all of these people have the same type of disease which, of course, is not the case. We need to rethink our guidelines for treating hypertension and focus on individualizing care for certain subpopulations.

What are some ways to individualize care for hypertension patients?
The black community is a population that historically has worsened control rates for hypertension. While some hypothesize that this is because of social economics, diet, or access to health care, we believe that a major factor could be that our guidelines are not exactly tailored to this population. For example, black patients tend to be more salt sensitive and thus respond better to general diuretic therapy (water pills). So, perhaps we should be treating certain populations with more efficacious medications in the first place instead of prescribing additional medications when the original therapy is not working. This is just one example of how these study findings could help populations manage their hypertension.

Do you plan on continuing this study in the future?
Yes! This study helped to identify the population and improve awareness of those with resistant hypertension. Now comes the more impactful part of this research, namely, what happens to people with resistant hypertension over a long period of time. As I mentioned before, we assume that this population could be at higher risk of heart disease, stroke and death but there are a lot of factors that go into this risk assessment. The fact that many of these people are likely on a number of medications makes assessing their risk of certain diseases that much more complicated. We are currently working on a comparative effectiveness study that will address this topic as well as others, such as understanding the blood pressure rate associated with the most ideal health outcomes for our patients. This upcoming study will likely be presented later this year. Ultimately, how we use this information to make changes and improve our patients’ health is the goal.

What’s the latest thing affecting how our kids breathe? Their own weight.

While copious evidence exists that should have all of us concerned about the children’s obesity epidemic, there’s now one more reason.

Research conducted by the Kaiser Permanente Department of Research & Evaluation – and published this week in the American Journal of Epidemiology – shows a higher incidence of asthma, as well as more frequent and severe attacks, among obese and overweight children.

What’s not yet clear is the relationship between obesity and asthma, though both have increased substantially over the last 30 years.  More large-scale studies would need to be conducted to explore the link between the two.

Mary Ellen Black, PhD, the lead author of the study, notes that overweight or obese young girls and Asian-Pacific Islander children have a higher likelihood of developing the respiratory condition.  Knowing this, says Black, will allow prevention programs to be developed and shared with these high-risk populations.

This is the second study around the health of kids in the last two weeks to be published by Kaiser Permanente.  Last week, the health organization’s Institute for Health Research found that children with elevated blood pressure do not usually receive the recommended follow up visits and care.  With the challenges around diagnosing hypertension in children (because blood pressure changes as they mature), the National Heart, Lung and Blood Institute recommends following up a child’s high BP reading with another check one to two weeks later.

Matthew F. Daley, MD, a researcher at the Institute for Health Research, Kaiser Permanente Colorado, notes that adult cardiovascular disease – including strokes and coronary artery disease – can start in childhood.  For that reason, proper diagnosis and management of hypertension in kids is vital for their overall, lifelong health.

Findings for both studies are part of Kaiser Permanente’s ongoing child health research.  You can read more about its work in research here.

Hypertension and Heart Health: A Q&A with Joseph Young, MD

Joseph Young, MD

               Joseph Young, MD

As American Heart Month comes to a close, it’s important to acknowledge that heart health should be a priority year-round.  One of the key risk factors of heart attack and stroke is hypertension, and according to the CDC, 1 in 3 U.S. adults has high blood pressure.  The good news?  It’s controllable.  Kaiser Permanente recently published a Q&A with Joseph Young, MD, internal medicine physician and clinical hypertension lead for The Permanente Medical Group – and we’ve included excerpts from that conversation below.

KP:
Can you give us a quick ‘Blood Pressure 101’?

Joseph Young, MD:
Blood pressure is just the pressure of blood flowing inside the body’s blood vessels. The top number is the pressure when the heart pumps at its peak. The bottom number is the pressure when the heart is relaxing and filling back up with blood. An ideal blood pressure is 119/79 or lower. A top number between 120 and 139 or a bottom number between 80 and 89 is called ‘prehypertension.’

KP:
What is high blood pressure?

Young:
If your blood pressure is 140/90 or higher, you have high blood pressure, also known as hypertension. As an aside, in a healthy, active person, what might seem like low blood pressure is often normal. In the United States, 29 percent of the adult population, or roughly 70 million people, has high blood pressure. Being overweight, lack of physical activity, too much salt or alcohol, stress, older age, genetics and family history, and various diseases all can contribute to high blood pressure. The good news is that it is easy to treat high blood pressure with a healthy lifestyle and a number of well-tolerated, once-daily medications.

KP:
What are the main guidelines for healthy practices that can reduce risk?

Young:
Regular physical activity is very important and helps to lower blood pressure. Pick something you enjoy — that will make it easier to stick with it. And it doesn’t have to be fancy. You could just walk briskly at least 150 minutes a week, for example. Limit salt intake, too, because salt causes fluid retention, which increases blood pressure. Many people don’t realize that most salt doesn’t come out of a salt shaker; it’s from processed and restaurant food. So, cook with unprocessed fresh fruits, vegetables and lean sources of protein at home, and limit how often you eat out to no more than one to two times a week. Don’t drink too much alcohol. If you smoke, quitting is the most important thing above anything else that you could do for your overall health. Smoking does not increase blood pressure, but smoking combined with high blood pressure or with any other risk factor is especially dangerous.

For more information, check out the full article available at Kaiser Permanente’s News Center.

HHS Announces 2012 Hypertension Control Champions

One year ago, the Department of Health and Human Services, with several key partners, launched the Million Hearts™ national public-private initiative.  Million Hearts aims to prevent 1 million heart attacks and strokes over five years through behavioral changes and clinical interventions.  One of the most significant contributing factors to cardiovascular disease is hypertension, or high blood pressure.  According to the CDC, nearly one in three American adults (67 million) has high blood pressure, and more than half (36 million) don’t have it under control. Additionally, high blood pressure contributes to nearly 1,000 deaths per day and accounts for nearly $131 billion in direct health care costs a year.

Today, the U.S. DHHS Secretary Kathleen Sebelius recognized two health care providers in the United States as 2012 Hypertension Control ChampionsEllsworth (Wis.) Medical Clinic and Kaiser Permanente’s Colorado region.  The designation signifies these two health care providers have had remarkable success controlling hypertension across their patient populations, supported by verifiable data documenting the improvement.  Watch a video of the announcement here.

Since 2008, Kaiser Permanente Colorado’s focus on managing hypertension has resulted in an improvement from an initial member control rate of 61 percent to its current control rate of 82.6 percent.  The average hypertension control rate nationally is around 50 percent.

According to their press release, Kaiser Permanente’s hypertension control strategy has five central components:

  1. Registries: Through data housed within the Kaiser Permanente HealthConnect® electronic medical record, registries are created to identify members with hypertension.
  2. Actionable lists: Kaiser Permanente staff then draft lists to help identify which members did not have their blood pressure under control.
  3. Patient outreach: To reach those newly identified members, Kaiser Permanente nurses and other care team representatives work collaboratively to contact members and encourage them to come into local medical offices for blood pressure checks at least once a year.
  4. Managing blood pressure in the office: Kaiser Permanente primary care teams and clinical pharmacy staff develop long-term medication management programs for members with hypertension.
  5. Eliminating barriers: Members with hypertension are able to receive free blood pressure checks on a walk-in or appointment basis.

In September 2011, shortly after Million Hearts officially launched, Janet Wright, MD, executive director of Million Hearts, joined several other leaders in the heart health space at the Center for Total Health in Washington, D.C., for a summit to address hypertension.  You can see our coverage of that event at these links.

2011 in Review: One-on-One Interviews on Hypertension & Heart Health

Continuing our “year in review” highlights of programs and content since this blog’s launch earlier this fall, today we have brief one-on-one interviews with three of the expert panelists from the Hypertension & Heart Health Summit held at the Center for Total Health in September. In the first video, you’ll hear thoughts from Janet Wright, who is now executive director of the Million Hearts Initiative — a joint effort co-led by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, and sponsored by other federal agencies and private-sector partners.

The next video features Elijah Saunders, MD, with the Association of Black Cardiologists.

Today’s final video is a moment with Ralph Brindis, MD, with Kaiser Permanente.

2011 in Review: Murray Ross on Non-Communicable Diseases

As 2011 comes to a close, we are revisiting some of the events, programs and topics we’ve highlighted since launching the Center for Total Health blog in September — and bringing new content to you in the process. In today’s post, we have a conversation with Murray Ross, PhD, vice president and director of the Kaiser Permanente Institute for Health Policy. We sat down with Murray in September, shortly before the U.N. High-Level Meeting on Non-Communicable Diseases (and the Hypertension and Heart Health Summit held at the Center for Total Health during Be Well Week). In this interview, Murray shares his thoughts about NCDs and their growing effect — in the United States and globally — on health care costs.

Walking and Chronic Conditions: More from the Walking Summit

For more highlights from the September 20 Walking Summit that was held at the Center for Total Health in Washington, D.C., check out the video below.  Moderated by Jack Cochran, MD, with The Permanente Federation, this panel focused on walking and chronic conditions.  In the video, the panelists – Harold Silverman with the American Diabetes Association; John Arden, PhD, with Kaiser Permanente; and Roquell Wyche, MD, with Washington Hospital Center – address the effects walking can have on chronic conditions like diabetes, depression, cardiovascular disease and hypertension.
 

Hypertension and Heart Health: Experts Discuss Prevention, Diagnosis and Management

September 19 and 20, the United Nations is holding its High-Level Meeting on Non-Communicable Diseases – one of which is cardiovascular disease.  In support of the U.N.’s meeting, the Center for Total Health hosted a summit to address one of the most significant contributing factors to cardiovascular disease: Hypertension.  Held on September 15, the Hypertension and Heart Health Conference featured a panel of experts discussing the challenges of preventing, diagnosing and controlling high blood pressure.
 

Moderating the conference was Susan Dentzer, editor-in-chief for Health Affairs.  Speaking at the event were Richard McCarthy, MD, Kaiser Permanente’s physician-in-chief for District of Columbia and suburban Maryland, and Nils Daulaire, MD, director of global affairs for the U.S. Department of Health and Human Services.  Panelists included Elijah Saunders, MD, a founding member of the Association of Black Cardiologists; Ralph Brindis, MD, senior advisor for cardiovascular disease at Kaiser Permanente Northern California; and Janet Wright, MD, senior vice president for science and quality at the American College of Cardiology.  Wright was recently named the director of the Million Hearts Initiative – a plan from the DHHS to prevent 1 million heart attacks and strokes over the next five years through behavioral changes and clinical interventions.
 

Check out highlights of the event in the video below.  And stay tuned for more excerpts  from our conversations with the panelists.

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