Hypertension Care in the United States: An embarrassment of riches or just an embarrassment?

Hypertension is one of the most prevalent yet morbid chronic diseases faced in internal medicine, impacting close to half of adults in the United States (US), less than half of whom have their blood pressure at goal.¹ Blood pressure control rates in the US are abysmal and were declining even before COVID-19 upended healthcare delivery in early 2020. As with many conditions, there are stark racial disparities in both the prevalence of hypertension and in the quality of care as demonstrated by inferior control rates in Black and Hispanic adults.² During the COVID-19 pandemic, our nation's collective blood pressure either went unmeasured³ or, if it was measured, it increased⁴ from countless causes including lack of access to healthcare, medications, healthy foods and safe places to exercise.

Our population's poor rate of blood pressure control is not due to lack of knowledge or the availability of effective treatments. Hypertension is not a niche condition with ambiguous or unproven therapies. Lifestyle change works.⁵ Medication works.⁶ Interventional options, such as renal denervation, once less attractive, are evolving and show promise for select patients.⁷ Entering "hypertension" as a search term in Pubmed reveals over 22,000 publications in the past ten years alone. Published in 2017, the comprehensive 103-page Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults⁸ updated definitions and target BP thresholds as well as laid out specific measurement recommendations, treatment strategies, and approaches to hypertension care. This was followed in 2020 by the 50-page Surgeon General's Call to Action to Control Hypertension,⁹ which advocated for better hypertension control as a national imperative. Target BP,¹⁰ which combines the impressive reach of the American Heart Association and the American Medical Association, as well as the Center for Disease Control and Prevention's Million Hearts¹¹ initiative both provide countless tools, resources, educational materials and more for both patients and providers. This is but a fraction of the US-centric resources. In addition, international experts have published similar guidelines, references and toolkits all of which share more similarities than differences. There is no shortage of expertise on this topic, but indeed the opposite. "Information overload" is said to occur when a decision maker is faced with a mass of information of such complexity and level of redundancy that it inhibits their capacity to determine the best possible decision.¹² Surely, this is the situation with hypertension now.

In the late 1960's, psychology researchers John Darley and Bibb Latané described the concept of diffusion of responsibility¹³ also known as the "bystander effect" to explain the sociopsychological phenomenon whereby an individual is less likely to take responsibility when others are present. They applied this theory to explain the tragic stabbing murder of a young woman, witnessed by no less than 38 people, in the middle of a busy residential section of New York City. Applying that concept to hypertension care, consider that due to the diversity of underlying causes of - and complications from - high blood pressure, clinicians in many different specialties including internal medicine, family practice, pediatrics, cardiology, emergency medicine, nephrology, neurology, endocrinology, sleep medicine, geriatrics, obstetrics, and more might manage this condition. Moreover, as the traditional models for medical care have failed to gain traction in controlling hypertension, others have evolved. Novel hypertension care delivery settings now include barbershops,¹⁴ churches,¹⁵ and mobile health vans¹⁶ to mention just a few. Even in more traditional settings such as outpatient doctor's offices, the 2018 National Ambulatory Medical Care Survey estimated that blood pressure is measured over 565 million times annually in US adults.¹⁷ With so many opportunities to impact blood pressure, what could be considered as an embarrassment of riches is actually just an embarrassment.

Although the transition from best evidence to best practice should perhaps be simpler, history has shown that it is not¹⁸. Change is hard. Indeed, effective implementation of change in patient care calls for different strategies targeting barriers to change at myriad levels.¹⁹ In this context, the authors of this AHA Scientific Statement begin by describing the numerous obstacles to achieving success in hypertension control in this country at the individual, organizational, community and policy level. They follow this with nine far-reaching priority strategies aimed to accelerate blood pressure control improvement ranging from accurate blood pressure measurement to anti-racism efforts to large-scale changes in public policy. In their identification of the critical implementation and dissemination gaps, the authors call attention to seventeen different areas for future investigation. These touch upon wide ranging aspects of our country's socio-ecological framework, from school lunches to self-measured blood pressure and from urban planning to protocol-driven medication intensification.

Undoubtedly, we need more rigorous research and advocacy. Nevertheless, without a specific and actionable plan and clear responsible parties, even the best implementation strategies are at risk to fail. Our declining hypertension control rates (and the downstream cardiovascular events that they no doubt herald) should create a true burning platform for change. This AHA statement is a call to action for medical professionals of all types and the community of individuals with hypertension to demand better care. The time to wait is over.