JNC 7—It's More Than High Blood Pressure

The World Health Organization has estimated that high blood pressure causes 1 in every 8 deaths worldwide, making hypertension the third leading killer in the world.¹ The JNC 7 report,² published in this issue of THE JOURNAL, summarizes how the burden of hypertension can be decreased. Among the messages emphasized is that systolic blood pressure control should be the focus of treatment. Cardiovascular risk from systolic hypertension begins at 115 mm Hg and risk from diastolic hypertension begins at 75 mm Hg. Individuals who are normotensive at 55 years have a 90% likelihood of developing high blood pressure during the next 25 years, and lowering blood pressure toward the new goal level of 120/80 mm Hg will decrease heart attacks, heart failure, stroke, kidney disease, and will save lives.

In addition, the JNC 7 report reenforces several other messages, including that thiazide diuretics, the least expensive antihypertensive drugs, are also among the most effective for patients who do not have a compelling need for more expensive medications. Moreover, lifestyle interventions are effective for prevention and treatment of hypertension. In addition, practitioner empathy for the patient contributes to trust, motivation, and hypertension control.

However, the JNC 7 report also documents the failure of the health care system to translate current knowledge about hypertension into action. This failure to prevent and treat hypertension is an example of the quality chasm described by the Institute of Medicine.³ Hypertension awareness has not changed in the past decade and treatment rates have increased by less than 10%. Control rates are stagnant at 34%, far short of the Healthy People 2010 goal of 50%.⁴ Failing to take advantage of the knowledge that research has generated represents a wasted opportunity to improve and prolong the lives of individuals everywhere and to avert a looming chronic disease crisis.⁵

The majority of cases of hypertension can be prevented and controlled but this requires commitment to the task. Hypertension control is a problem of technology transfer requiring 3 elements: the technology to be transferred, the system to deliver the technology effectively, and the will to succeed. The JNC 7 report documents that technologies are available to detect, treat, and control hypertension. Technology delivery systems are also available. What is unclear is the degree of the will to succeed, which requires devoting the resources, organizing the treatment systems, and creating the environments that allow patients and clinicians to cross the hypertension quality chasm.

Bodenheimer et al⁶ have described a chronic care delivery model for primary care that can help cross this chasm. The model has 6 interrelated components: self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources. The earliest example of a large-scale delivery system for hypertension treatment based on principles similar to these is the program in North Karelia, Finland.⁷ In 1972, only 2% of all patients with hypertension were treated and controlled (defined as systolic blood pressure <160 mm Hg and diastolic blood pressure <95 mm Hg on a single measurement). Faced with what some considered an overwhelming task, the North Karelia Project organizers redesigned hypertension detection and treatment around a system that included patients, a coordinating center, physicians and public health nurses, the government, and the public. Although improvement has been slow and much work remains, significant improvements in hypertension control were associated with the system. The proportion of hypertensive individuals with a systolic pressure of less than 160 mm Hg and a diastolic pressure of less than 95 mm Hg on a single measurement increased to 23.5% in men and to 36.7% in women by 1997.⁸

Another example of a program based on the principles described by Bodenheimer et al is the primary care hypertension detection and treatment program at Mayo Clinic Rochester. Between 1986 and 1996, hypertension control rates for residents of Olmsted County older than 45 years had decreased to less than 17%,⁹ most likely due to the tyranny of the urgent⁶ and clinical inertia¹⁰ in primary care. In response to these data, a team of physicians developed a blood pressure control program with a core clinical support system that was responsive to the needs of each practice. For example, one clinic adopted a team approach to hypertension management and blood pressure control rates improved from 33% to 49%.¹¹

Several practices have reported similar improvements in outcomes by using similar strategies. A large managed care organization in Florida used one-on-one clinician education and physician-specific reports of at-risk patients to improve blood pressure control rates from 41% to 52%.¹² Two primary care clinics in Minnesota improved blood pressure control rates from 36% to 50% by using computerized recall systems along with a variety of other interventions.¹³ A Veterans Affairs teaching clinic in Ohio improved blood pressure control and increased use of first-line antihypertensive agents through faculty education, consultation by doctorate-level pharmacists, and clinical performance feedback.¹⁴ Although the tactics differed, the fundamental strategy was the same at all sites. Hypertension control rates were continuously monitored and systems were developed to identify, activate, treat, and follow up patients with hypertension. This ensured that blood pressure management would not be overtaken by acute practice.

The JNC 7 report is about more than hypertension. For many, high blood pressure is just one manifestation of what may be termed the lifestyle syndrome,⁵ which is a cluster of conditions and diseases that result from consuming too many calories; ingesting too much saturated fat, sodium, and alcohol; not expending enough calories; and using tobacco or being exposed to tobacco smoke. In addition to hypertension, manifestations of the lifestyle syndrome include the metabolic syndrome, obesity, dyslipidemia, cardiovascular disease, cancer, osteoarthritis, depression, sexual dysfunction, and type 2 diabetes mellitus. To the extent that the stakeholders in hypertension control—clinicians, patients, health services organizations, and the purchasers of health care services—act and are organized to use the tools described in the JNC 7 report to prevent hypertension, the burden from the diseases and conditions of the lifestyle syndrome also will be decreased.

By choosing not to act, the consequences of the lifestyle syndrome epidemic will be dire.⁵ Increasing rates of chronic disease will widen the gap between health care needs and the ability of society or individuals to pay for them. The negative effects will extend to other sectors of the economy as individuals are forced to use disposable income to pay for health care rather than purchase consumer goods and as increasing numbers of individuals with preventable chronic diseases are no longer able to participate in the labor force. Increasing levels of chronic disease can also be expected to fragment families.¹⁵

The JNC 7 report suggests that this scenario is preventable. Successful prevention requires the will to act by clinicians, health care system administrators, purchasers of health care, patients, and communities. This requires a comprehensive program of lifestyle, environmental development, and clinical intervention.^{16 - 19} Hypertension prevention and treatment services will be delivered at rates that approach the goals if supported by systems that ensure that they are delivered.^{7 ,11 - 14 ,20} Techniques used in the North Karelia Project,²¹ refined during the large US community-based heart disease prevention programs²² and now advocated by the American Heart Association,²³ are important components. However, there is no "cookbook" formula for success. As summarized recently by Berwick,²⁰ the social sciences of innovation theory and organizational development have much to offer but do not offer any one-strategy-fits-all solutions.

Action that leads to control of hypertension and reduces the burden of disease must be the criterion for success. The JNC 7 report documents that action can decrease the physical, psychological, and economic burdens that result from hypertension. Clearly, action to control blood pressure is needed now and is a challenge that all must accept.