Simple Treatments, Ignored

A new federal health analysis has found that 36 million adults in the United States have high blood pressure that is not being controlled even though 32 million of them get regular medical care and 30 million of them have health insurance.

This is not primarily a case of poor, uninsured people unable to get the care they need. It is shocking evidence of how our complicated, dysfunctional health care system can’t deliver recommended care to many patients who could benefit, because their doctors are asleep at the switch. As a result, patients go on to suffer medical harm and their care inflicts big costs on the health care system.

Health authorities recommend that people whose blood pressure reaches 140/90, a condition known as hypertension, take steps to bring it down by dietary changes, exercise or medications. The reasons are compelling. People with high blood pressure are four times as likely to die of stroke and three times as likely to die of heart disease as people with normal blood pressure. They are also prone to kidney failure. Their health care costs related to high blood pressure exceed $130 billion year.

The new analysis, issued last Tuesday by the Centers for Disease Control and Prevention, found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people who were aware but were not taking medication, and those who were aware and were treated with medication but still had hypertension.

This is an abysmal record for a condition that is easy to detect and treat. In some cases, patients had multiple high blood pressure readings entered into their electronic medical records but nobody told them about their condition or put their names on a list to be contacted for treatment. They fell between the cracks, even in some of the nation’s most respected health care systems, mostly because overburdened doctors did not give hypertension high priority.

Dr. Thomas Frieden, director of the C.D.C., said health care providers who make reducing high blood pressure among patients a top priority can quickly bring it under control. He pointed to Kaiser Permanente, a multistate managed care consortium, as one that has had real success on this front.

Kaiser Permanente says that in Northern California it increased the percentage of patients whose hypertension was under control from 44 percent in 2001 to 87 percent in 2010. Over approximately the same period, stroke mortality declined by 42 percent, heart attacks by 24 percent and the most serious type of heart attack by 62 percent. The organization created a hypertension registry to track patients and the care they were getting; eased the burden on doctors by using pharmacists to initiate drug therapy and medical assistants to monitor patients’ progress; made it easy for patients to get free blood pressure checks; and showed doctors how their record on controlling blood pressure compared with others in the system.

Federal health officials have set an ambitious goal to reduce the population with uncontrolled high blood pressure by 10 million within five years. In most cases, they believe, medication will need to be part of the treatment. There is little doubt that drugs are beneficial in treating patients who have severe cases of hypertension (a systolic blood pressure of 160 or more). But for some patients who have milder hypertension (systolic blood pressure from 140 to 159), the benefits may not be as obvious or may be outweighed by drug side effects.

The United States Preventive Services Task Force, a group of independent health experts that advises the Department of Health and Human Services, has found good evidence that treating high blood pressure with medication would decrease cardiovascular problems while causing few major problems. It also supports other approaches, like weight loss, increased physical activity, lower sodium and alcohol consumption, and stress management. The benefits of reducing high blood pressure — not to mention the cost savings — are obvious. The wonder is that the health care system has done such a bad job of delivering those benefits.