Clinic-Based Strategies to Reach United States Million Hearts 2022 Blood Pressure Control Goals

Abstract

Background: The Centers for Disease Control and Prevention's Million Hearts initiative includes an ambitious ≥80% blood pressure control goal in US adults with hypertension by 2022. We used the validated Blood Pressure Control Model to quantify changes in clinic-based hypertension management processes needed to attain ≥80% blood pressure control.

Methods and results: The Blood Pressure Control Model simulates patient blood pressures weekly using 3 key modifiable hypertension management processes: office visit frequency, clinician treatment intensification given uncontrolled blood pressure, and continued antihypertensive medication use (medication adherence rate). We compared blood pressure control rates (using the Seventh Joint National Committee on hypertension targets) achieved over 4 years between usual care and the best-observed values for management processes identified from the literature (1-week return visit interval, 20%-44% intensification rate, and 76% adherence rate). We determined the management process values needed to achieve ≥80% blood pressure control in US adults. In adults with uncontrolled blood pressure, usual care achieved 45.6% control (95% uncertainty interval, 39.6%-52.5%) and literature-based best-observed values achieved 79.7% control (95% uncertainty interval, 79.3%-80.1%) over 4 years. Increasing treatment intensification rates to 62% of office visits with an uncontrolled blood pressure resulted in ≥80% blood pressure control, even when the return visit interval and adherence remained at usual care values. Improving to best-observed values for all 3 management processes would achieve 78.1% blood pressure control in the overall US population with hypertension, approaching the ≥80% Million Hearts 2022 goal.

Conclusions: Achieving the Million Hearts blood pressure control goal by 2022 will require simultaneously increasing visit frequency, overcoming therapeutic inertia, and improving patient medication adherence. As the relative importance of each of these 3 processes will depend on local characteristics, simulation models like the Blood Pressure Control Model can help local healthcare systems tailor strategies to reach local and national benchmarks.

Keywords: adults; blood pressure; cardiovascular disease; hypertension; medication adherence.

Figures

Figure 1.. Structure of the Blood Pressure Control Model.

The figure shows the structure of the Blood Pressure Control Model and how blood pressures are estimated. Each week, the model determines if the: (1) patient had an office visit with a provider, (2) patient’s measured office blood pressure was controlled, (3) provider intensified antihypertensive medication, and (4) patient was adherent to antihypertensive medication. The model assumed that blood pressure was taken at all office visits and adherence was defined as patients continuing to take the last added antihypertensive medication (i.e., did not permanently discontinue use).

Figure 2.. Predicted Percent Achieving Controlled Blood Pressure According to National Guidelines.

The figure shows the predicted percent of the population with controlled blood pressure under usual care, best observed values for hypertension process management variables obtained from the literature, and “perfect care.” Blood pressure control was defined according to the JNC 7 guidelines as

Figure 3.. Return Visit Interval Needed to Achieve Million Hearts 2022 Goal of 80% Blood Pressure Control at Different Antihypertensive Intensification and Adherence Rates.

The figure shows the 4-year results when varying key hypertension management process parameters and the combination needed to achieve ≥80% blood pressure control. The columns are the average antihypertensive adherence rate (i.e., proportion of patients continuing antihypertensive medication for at least one year). The rows are the average antihypertensive intensification rate (i.e., proportion of clinic visits with an uncontrolled blood pressure where antihypertensive medication was intensified). The boxes, are the maximum average return visit interval (in weeks) after an uncontrolled blood pressure. *Usual care input for adherence was 57.0%, return visit interval was ~13.8 weeks, and mean simulated usual care intensification rate over 4 years was 18.7%.

Figure 4.. Hypertension Awareness, Treatment, and Control Status Among U.S. Adults with Hypertension in 2022 After Simulating Best Observed Values and Perfect Care.

The figure shows the percentage of U.S. adults with hypertension in 2014 and the estimated impact on blood pressure control rates when improving clinic-based hypertension management to the best observed values obtained from the literature and “perfect care.”