In the U.S., Why has Blood Pressure Control Declined Nationally, and What Solutions Will Improve Blood Pressure Control?

The National Heart, Lung, and Blood Institute (NHLBI) and Division for the Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention (CDC) convened a multidisciplinary workshop on why blood pressure control recently declined in the United States and what solutions might improve blood pressure control.

Background

Hypertension is the single most important risk factor for cardiovascular disease in the world. In the U.S., it contributes to cardiovascular disease more than any other modifiable risk factor. Hypertension contributes to numerous negative health outcomes, including heart attacks, stroke, kidney disease, heart failure, peripheral arterial disease, and vascular dementia. The proportion of adults with controlled blood pressure is regularly monitored in the U.S. using data from CDC’s National Health and Nutrition Examination Survey (NHANES). NHANES data show that the age-adjusted proportion of U.S. adults with controlled blood pressure improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, was stable through 2013-2014, and then declined to 43.7% in 2017-2018. This workshop was timely, as it immediately preceded the release of the Surgeon General’s Call to Action to Control Hypertension, further demonstrating the national importance of improving hypertension control.

Workshop Purpose and Objectives

The objectives of the workshop were to examine the recent decline in blood pressure control among adults with hypertension, identify possible root causes of the decline and possible research implications, and identify opportunities to reverse and further improve blood pressure control in the US.

Concise Summary of Discussions

Presentations and discussions were centered around the following areas.

• Evaluate recent trends in hypertension control and identify the groups most at risk for having uncontrolled blood pressure.
• Identify potential causes of the lack of progress in hypertension control and possible solutions including identifying the most significant contributors to limiting progress nationally.
• Identify important factors that affect hypertension control efforts within health plans/payers, communities, organizations, and practices/health systems.
• Identify key solutions that could increase the number of health care organizations committed to sustained hypertension control programs.
• Describe barriers to and successes in effectively equipping health care organizations and clinical care teams to provide optimal hypertension care.
• Describe barriers to and successes in patient-level strategies to improve blood pressure control, including populations without regular contact with health care providers.
• Identify key concepts/strategies in need of research or leadership roles by the NHLBI/CDC that will have the broadest impact in health care organizations and communities improving and sustaining blood pressure control for all segments of our health care systems and communities.
• Identify factors, knowledge gaps, research opportunities, solutions, and leadership roles for CDC, NHLBI and other funders that will have the broadest impact in helping to address disparities and support achievement of the national control goal.
• Summarize the most significant opportunities to improve hypertension control.

Multisector approaches were among the many approaches discussed at the workshop to improving hypertension control. The strategy involves patients, community organizations, health care organizations including their staff, employers, payors of health care, and the public sector. Below are some of the potential strategies and research opportunities discussed:

• Additional research to identify and evaluate the most effective multisector approaches;
• Importance of constructive and sustained public health messaging and education programs to heighten patient empowerment and underscore the importance of hypertension detection, control, and the behavioral changes that prevent or slow its development;
• Additional research on hypertension prevention, as a lower rate of development could reduce the demand on detection and control systems;
• The need to strengthen and sustain community-primary care linkages, including the utilization of community health workers;
• The need for novel solutions in primary care and other parts of the health care system such as health information technology, and the challenges of patients with comorbidities requiring complex patient management;
• Additional research to reduce the impact and better understand the influence of social determinants of health on hypertension; These research opportunities might include identifying the most effective community-primary care linkages to mitigate social determinants of health that prevent patients from achieving hypertension control;
• The importance and potential effectiveness of precision (population) public health—which is defined as providing the right intervention, at the right time, and to the right population–in improving blood pressure control;
• Additional research to determine what payment and benefit designs are the most effective in achieving better hypertension control;
• Additional research to further explore the coupling of community needs assessment and nontraditional outreach partners such as community pharmacies into an efficacious control strategy;
• is the need for research into the ongoing challenges of obtaining accurate blood pressure measurements in the large number of health care systems and outside of the traditional health care setting.

In summary, the workshop discussed barriers, possible solutions, and research opportunities ranging from the patient and community, to the health care systems, and to the role of social determinants of health.

Publication Plans

The meeting participants will develop a workshop report for publication in a peer-reviewed journal. The report will highlight discussions that occurred at the workshop and the research and other opportunities explored at the workshop.