Blood pressure management is getting worse, not better
High blood pressure (aka hypertension) has the dubious distinction of being the most powerful risk factor for cardiovascular disease and all-cause death. Data from 51,761 participants with an average age of 48 years in the National Health and Nutrition Examination Survey showed that the proportion of Americans with good blood pressure control increased steadily from 1999-2000 to 2009-2010. Good news! After a slight dip from 2009-2010 to 2011-2012, the prevalence of good blood pressure control increased to 2013-2014. But the prevalence of good blood pressure control declined from 2013-2014 to 2017-2018. Bad news! As you might guess, the prevalence of good blood pressure control was higher for participants with health insurance than for participants without it, for participants with a usual health care facility than for participants without one, and for participants who had a health care visit in the past year than for participants who didn’t.
A black barbershop approach to better blood pressure management
High blood pressure is more common and less well-treated in black men than in other racial groups in America. Researchers at UCLA developed an intervention to recruit black men for intensive blood pressure control based on black barbershops in Los Angeles County, California. The familiarity of regular patrons with other patrons and the barbers at black barbershops might encourage black men to participate in the study. Different black barbershops were randomized to either the intervention or the control. Patrons at intervention barbershops who enrolled in the study received encouragement from barbers to manage their blood pressure. In addition, specialty-trained pharmacists met regularly with study participants to prescribe and monitor a drug-intensification program. Summaries of meetings were sent to the participants’ primary care providers. Pharmacists also delivered prescriptions to participants at the barbershops. Patrons in the control group received instruction about blood pressure and encouragement from their barber to follow up with a health care provider.
After 6 months, participants in the intervention group reduced their systolic blood pressure by 27.0 mm Hg, while participants in the control group reduced their systolic blood pressure by 9.3 mm Hg. Comparable reductions in diastolic blood pressure were 17.5 and 4.3 mm Hg for the intervention and control groups, respectively. Furthermore, at 6 months, participants in the intervention group increased their use of anti-hypertensive medications from 55 to 100 percent, while participants in the control group increased their used of anti-hypertensive medications from 53 to 65 percent. No serious treatment-related adverse events occurred in either group. The intervention produced dramatic, clinically meaningful reductions in both systolic and diastolic blood pressure.
Extension of the black barbershop approach
The black barbershop study in Los Angeles County, California, documented dramatic declines in systolic and diastolic blood pressure in black barbershop patrons over 6 months. The study results were so encouraging that it was extended to 12 months. During the the additional 6 months, pharmacist visits declined by nearly one-half in an effort to reduce their travel time. The dramatic results at 6 months continued to 12 months at which time participants in the intervention group reduced their systolic blood pressure by 28.6 mm Hg compared to 7.2 mm Hg for participants in the control group. Diastolic blood pressure for the intervention and control groups declined by 15.2 mm Hg and 0.4 mm Hg, respectively, from baseline to 12 months. The 12-month systolic and diastolic data at 12 months were statistically indistinguishable from those at 6 months. This means that the success at 6 months continued to 12 months. Follow-up studies will test the efficacy of broad-scale implementation of the study protocol and its benefit/cost ratio.
Blood pressure telemonitoring for rural and low-income persons
Americans who live in rural areas typically have reduced access to health care. This is especially true for black people and Native Americans. Researchers at the University of Mississippi Medical Center developed a telemonitoring program to better serve rural and low-income residents with high blood pressure in Mississippi. Participants with uncontrolled high blood pressure (N=120, average age 59 years) were recruited at the Medical Center. Each participant received a telemonitoring kit with an electronic tablet, a blood pressure monitoring unit with Bluetooth connectivity, and instructions for measuring daily blood pressure. A nurse provided virtual onboarding. A clinical pharmacist reviewed each participant’s blood pressure data every 3 weeks. If a participant’s blood pressure exceeded 130/80 mm Hg, a clinical pharmacist would prescribe better blood pressure medication(s).
Over 6 months, participants lowered their average systolic and diastolic blood pressure by 14.1 and 7.9 mm Hg, respectively. A comparison group of matched patients who received usual care at the Medical Center lowered average systolic and diastolic blood pressure over 6 months by 0.9 and 1.8 mm Hg, respectively. Thus, participants in the telemonitoring group achieved clinically meaningful reductions of systolic and diastolic blood pressure that greatly exceeded those of the comparison group. This and other studies suggest that telemonitoring can help rural and low-income people substantially lower their blood pressure and reduce their risks of cardiovascular disease and premature death.
Scaling up in China
Blood pressure tends to increase with age, with about half of the older global population having high blood pressure. The aging global population portends a major increase in high blood pressure. Researchers in China developed a non-physician, community health care practitioner-led program that enrolled 22,386 participants with high blood pressure in 326 rural villages. The trained practitioners provided coaching to individuals or groups, free blood pressure lowering medication, and showed participants how to measure their blood pressure with a home monitoring device.
Compared to the control group (which received usual care for high blood pressure), persons in the practitioner-led program consistently reduced their systolic and diastolic blood pressure starting about 6 months into the program. After 4 years, persons over age 60 years in the practitioner-led program had an average systolic and diastolic blood pressure levels 21.4 mm Hg and 7.9 mm Hg lower, respectively, than persons in the control group. Results were similar for person younger than age 60. In addition, the incidence of stroke, heart failure, cardiovascular disease, death from cardiovascular disease, and death from any cause declined significantly more for participants in the practitioner-led program compared to the control group. If community health care practitioners can be effective at reducing high blood pressure in rural China, why couldn’t they be similarly effective in the US?.
We can do better
A recent editorial in the Journal of the American Medical Association amplified the findings of the Chinese researchers and others. Donald Jones at the University of Mississippi Medical Center noted that previous impediments to blood pressure control, such as lack of awareness and knowledge among physicians and patients, high cost of medications, and adverse effects of those medications, have disappeared. Why, then, did the prevalence of good blood pressure management in the US decline from 48.5 percent in 2007-2008 to 43.7 percent in 2017-2018? Dr. Jones opined that the US medical care system focuses on managing acute illnesses and injuries to the detriment of preventing and managing chronic conditions, such as hypertension. Recent studies have demonstrated that America has the tools to more effectively manage hypertension. Will we use these tools to benefit our fellow Americans?.
