A New Framework for Treating Hypertension

In this video, Harlan Krumholz, MD, SM, a professor at Yale School of Medicine and director of the Center for Outcomes Research and Evaluation at Yale New Haven Hospital in Connecticut, discusses his new framework for improving hypertension outcomes.

The following is a transcript of his remarks:

We’re not making the progress against hypertension that we need to. Many people are out there with very high levels of blood pressure that are not getting attention, and this has to change.

I want to talk about a paper we’ve just done, but let me lay some background. We’re losing ground on blood pressure. Almost every population-based study is showing that, in fact, blood pressure levels are getting worse around the nation, not better. Moreover, it seems if you look within the electronic health records of most major institutions, there are lots of people who’ve had repetitive elevated blood pressure levels and are not getting the care that they need.

Our group has been focusing on ways in which we can do digital population health surveillance using electronic health records to identify these individuals and to link them with the kind of follow-up and care that they need. The key will be to be able to identify, classify, and then triage appropriately these individuals.

In the course of this, we’ve developed a concept of “persistent hypertension.” Most people know about resistant hypertension. That’s an elevated blood pressure despite the concurrent use of three or more anti-hypertensive medications. But we introduced a construct, a framework, called persistent hypertension: a broader construct for the larger number of people whose blood pressure repetitively remains high despite our interventions.

Resistant hypertension is just one of the causes that leads people to be in that position. People can have high blood pressure, but lack insurance and medication affordability. They can have a hypertension diagnosis, but people can fail to really recognize that and move in and make changes. There can be issues around treatment plans, adherence, or consistent follow-up. There’s all sorts of things that conspire against people being able to achieve blood pressure control that go beyond the fact that their body just doesn’t react in the way we would expect to anti-hypertensive medications.

We tried to identify a group of people within the Yale New Haven Health System who had a blood pressure of 160 systolic or 100 diastolic elevated for five consecutive visits without being able to be under control or getting it below those very elevated levels. We tried to understand what the heck was going on, what it was that was underlying this, and could we group people by the underlying cause?

Now, most doctors who are caring for these patients know that there are multiple reasons why people are unable to achieve their goals, but we’re trying to standardize this in ways that could help us to appropriately triage people to places where we might be able to help them. So, for example, some people might need a health educator, some people might need a social worker, some people might need a pharmacist, some people might need a primary care physician, some people might need a specialist. Could we expedite this and facilitate the connections with people to overcome the main barrier to their ability to get their blood pressure under control?

Now, when we went through this in very systematic ways using qualitative research methods, we were able to identify three content domains, general domains that were related to this persistent hypertension.

One was a non-intensification of pharmacologic treatment. This is the absence of anti-hypertensive treatment intensification in response to this persistently elevated blood pressure. We, healthcare professionals, don’t seem to be reacting to the fact that this person has very elevated blood pressure levels and it’s repetitively so.

Another was non-implementation of prescribed treatment. The healthcare professional actually made the prescription, there’s documentation in the chart, but there are barriers or reasons why people didn’t follow up and weren’t able to complete that task, that prescription.

Then of course there is a third cause, which is non-response to prescribed treatment. The clinician acknowledged persistent hypertension, there was prescription of appropriate pharmacologic agents, it’s reported that people are actually taking these medications, and yet there is inability to get people under control.

Within each of these, there are subcategories and reasons underlying them that could then further refine what we might do about it. In each of these situations, we believe that, based on the medical record evidence, we can begin to determine what might be the proper match for what each person needs to be able to make progress. This isn’t just a matter of what’s on the doctor to do, again this non-intensification [of medication] in a situation where there’s an indication was only one of the many reasons why we weren’t making progress.

I think, as clinicians, we need help, because oftentimes the barrier there is not actually something we can directly control. We need the expertise of other people, other teammates, who can help us make progress. The thought is that this can help us.

So, this study presented a novel pragmatic taxonomy for classifying patients with persistent hypertension by their contributing causes. And importantly, this taxonomy derived directly from real-world data that exists within the EHR [electronic health record]. These could really be ultimately automated and put into tools that can help us be able to make these proper connections.

Look, if we’re going to make progress against hypertension, we need some new ideas, some new approaches. It can’t be just about what happens between the doctor and the patient. It’s about bringing a team to bear, recognizing that there are lots of other causes and that we need to work together across expertise and in partnership with the patients if we’re to make the progress that we need. Otherwise, we will continue to have people walking around with these markedly elevated blood pressure levels, at extreme risk, and inevitably getting into trouble as a result.

Really we can preempt, prevent, and we can help these people live healthier lives if we can all work together and make this go.

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