CardioExchange Archive

A large percentage of the 65 million people with high blood pressure in the United States do not know they have hypertension or have not succeeded in controlling their hypertension. Although many programs have been proposed, there is little evidence that any method can produce long-term improvement in hypertension control.

Now, in a paper published in JAMA, researchers at Kaiser Permanente report the outcomes achieved with a large-scale multipronged approach to hypertension control. The program included a comprehensive hypertension registry and the development and sharing of performance metrics. Electronic medical records were used to encourage optimal treatment, while patients were offered free follow-up visits with medical assistants and simplified medication regimens, including the use of single-pill combination therapy. Physicians were encouraged to use algorithms derived from evolving evidence.

The Kaiser Permanente Northern California (KPNC) hypertension program started with 349,937 patients  in 2001 and increased to 652,763 patients in 2009. The rate of hypertension control increased from 43.6% to 80.4% over that period. By contrast, the overall national control rate increased much less dramatically, from 55.4% to 64.1%. The authors acknowledge the limitations of an observational study and point out that at the beginning of the study, the rate of control was lower than the national level. The growth in size of their patient population may have resulted in the inclusion of more patients who were easier to control.

In an accompanying editorial, Abhinav Goyal and William Bornstein write that despite the enormous amount of research and literature on hypertension, current guidelines “offer little guidance to health systems on how to improve hypertension control in the populations they serve. This deficiency in the guidelines is largely attributable to the lack of science behind health system approaches to blood pressure control.” One significant factor in the success of the Kaiser program is is the reduction of “practice variability by standardizing the approach to care.”

“Although often perceived as undermining individual physician judgment, standardization of care has several advantages when applied across an entire health system, including ease of adoption of best practices across multiple centers, lower likelihood for protocol deviations, lower costs of care, and better outcomes.”