May 31, 2011

USA: A Long-Awaited Advance in the War on Blood Pressure .

NEW YORK, NY / Wall Street Journal / Heart Beat / May 31, 2011

By Ron Winslow

 Americans are finally making headway in the battle against high blood pressure, one of the biggest contributors to cardiovascular disease.

At Kaiser Permanente's big northern California health plan, 80% of more than 600,000 patients diagnosed with hypertension, or high blood pressure, have the condition under control, up from 44% a decade ago. In the Southeast, 70% of nearly a half-million patients whose doctors participate in a South Carolina-based quality-improvement network had reduced their high blood pressure to medically recommended levels. That's compared with 49% in 2000.

These achievements, reported last week at a meeting of the American Society for Hypertension, reflect broader gains against the problem nationwide. A major study published last year in the Journal of the American Medical Association that was based on national health surveys found that half of Americans with high blood pressure had it under control in 2008 compared with 31% at the beginning of the last decade and 27% in the early 1990s.

"The progress that's been made nationally is really striking," says Brent M. Egan, a blood-pressure expert at Medical University of South Carolina, in Charleston, and senior medical director of the multi-state quality-improvement network that is attacking the problem. "It has exceeded what I thought was possible."

A recent push by her health-care provider has helped Marjorie Bushman control her blood pressure. Lori Eanes for The Wall Street Journal

What's changing the tide isn't a major research breakthrough, new medicine or fresh insight into the nature of the problem. Rather it is a deliberate, intense focus on tweaking and executing nuts-and-bolts strategies. Some of these strategies have proven effective in clinical studies but are only recently beginning to take hold in medical practices.

Kaiser Permanente's initiative is based partly on established clinical guidelines for diet, exercise and medical treatment. In addition, Kaiser solicited ideas from its individual clinics with a high percentage of patients whose blood pressure was under control, and used the most effective strategies.

Among the changes: Kaiser began encouraging its doctors who prescribed hypertension medication to start patients on a single pill that combines two blood-pressure drugs. The institution made the change after seeing positive results from the approach in clinical trials. Previous guidelines called for treating patients initially with a single medication.

Kaiser started a registry to track patients with hypertension. To gather names, one medical group at Kaiser culled patient lists to find members who hadn't had a recent checkup and ask them to come in for a blood-pressure test. Another group looked at prescription records to help identify patients who might benefit from a more effective treatment. Such efforts helped expand Kaiser's hypertension-patient registry to 660,000 people in 2009, up from 394,000 in 2001.

Marjorie Bushman working in her garden.

Marjorie Bushman, 62 years old, is in generally good health but had high blood pressure. Here's how the Brisbane, Calif., resident got it under control.

* January 2007: Ms. Bushman learns at a regular checkup with her Kaiser Permanente doctor that her blood pressure is 145/74.
* The doctor starts her on two hypertension drugs: an ACE-inhibitor and a diuretic. Getting below 140/90 is the goal; the ideal is below 120/80.
* At follow-up visits over several months, doses of the drugs are adjusted to find the most effective treatment for her. Her blood pressure initially drops to 140/70.
* By July 2007, it falls further to 135/76. For convenience and better adherence, her doctor switches her to one pill that combines both drugs.
* Ms. Bushman keeps active, walking three miles three mornings a week and attending strength-training classes at a gym once a week. She makes sure fruits and vegetables are a staple of her diet.
* In March 2009, her blood pressure stabilizes at about 120/70.
* About every two months, Ms. Bushman has her blood pressure checked by a medical assistant at a Kaiser clinic.
* Early 2011: Ms. Bushman's most recent blood-pressure: 117/74.

"We can't just rely on patients showing up on our doorsteps," says Marc Jaffe, a Kaiser doctor who is clinical leader of the health plan's northern California cardiovascular-risk-reduction program. "That won't result in extremely high blood-pressure control rates."

When Marjorie Bushman, a 62-year-old printing-services broker from Brisbane, Calif., came in to her Kaiser clinic for a regular checkup in early 2007, she was told she had high blood pressure. Her reading: 145/74. Her doctors prescribed two pills, Ms. Bushman says, a diuretic and an ACE-inhibitor, both commonly used to treat hypertension. (Before 2005, Kaiser's policy was to start hypertension patients on a diuretic alone and add an ACE-inhibitor to the drug regimen if the initial treatment wasn't enough to get blood pressure below 140/90.)

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Ron Winslow

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