Treatment expectations in hypertension - Implications for patients enrolled in disease management programs

Hypertension, an insidious condition affecting approximately 50 million US adults, remains a central factor contributing to cardiac and other target o rgan disease. Despite increased detection and numerous therapeutic advances , three out of four people with hypertension in the US have uncontrolled or poorly controlled blood pressure. While hypertension is a leading reason f or primary care office visits and antihypertensive medications are widely p rescribed, most individuals are not achieving goal systolic/diastolic blood pressure of 140/90mm Hg or less. While the definition of adequate blood pr essure control varies in different countries, the problem of inadequate con trol is universal. Numerous barriers contributing to the suboptimal health outcomes have been recognized, including issues related to healthcare provi ders as well as patient compliance with medication and lifestyle changes. Recently, healthcare provider systems and health plans have turned to disea se management strategies to better address quality and outcomes issues in h ypertension management. Disease management, a systematic clinical improveme nt process, encompasses provider and patient education employing national o r locally developed best practice guidelines and behavioral interventions c oupled with close monitoring of clinical processes and outcomes of care. Di sease management programs seek to define a comprehensive and coordinated ap proach to care across multiple providers and patient subgroups. Through ris k assessment and stratification, patients at higher risk of complications c an be identified, and customized intensive care support can be offered. Oth er types of intervention for lower risk individuals include brief visits wi th a cardiovascular educator or care manager, group classes, or self-instru ctional programs. Several successful programs initiated by healthcare syste ms and health plans are described. Adequate blood pressure control is essential to reduce cardiac, renal, and stroke disease later in life. However, large numbers of individuals must be effectively managed for years or decades to achieve reductions in complica tions and cost savings. Unlike more acute conditions that frequently result in hospitalization and loss of function, the immediate cost offsets of hyp ertension disease management efforts are less defined, although the eventua l savings to society could be vast. Less costly methods to promote healthy outcomes across large, relatively stable populations are needed. Automated systems employing clinical decision support at the point of care and intern et-based patient support strategies offer the hope that comprehensive, indi vidualized disease management for hypertension can be affordable as well as effective. In the meantime, the fact that the National Committee on Qualit y Assurance has included blood pressure control as a future measure of heal th plan performance will almost certainly lead to the expanded development of hypertension disease management initiatives.