Hypertension control is falling, and the cause may surprise you


Timothy M. Smith

Contributing News Writer

After decades of progress on hypertension control, the disease took a startling turn for the worse in the U.S. in the middle of the last decade. A recent study found hypertension awareness, treatment and treatment effectiveness had all declined while access to care went unchanged. The upshot: Quality of care fell too.

SMBP quick guide

AMA's self-measured blood pressure quick guide offers an easy reference for physicians and care teams to help train patients to perform SMBP monitoring.

The study, “Hypertension Control in the U.S. 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age and Race-Ethnicity Groups,” published in Hypertension, sought to both assess changes in variables known to impact hypertension control and determine if the recent decline in hypertension control was broad-based or if it magnified pre-existing disparities.

Using data from National Health and Nutrition Examination Surveys, which assess national health status through representative samples of the U.S. civilian, non-institutionalized population, the study included adults 18 and older in consecutive two-year, cross-sectional cycles from 2009 through 2018.

Key variables included blood pressure, hypertension, hypertension awareness, treatment effectiveness, hypertension control, diabetes mellitus, chronic kidney disease, cardiovascular disease, body mass index, education, income, health insurance status, visit frequency and access to care.

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The study found that hypertension control—to a target of <140/<90 mmHg—had plateaued in the U.S. in 2009–2014, at 53.8%. But by 2017–2018, it had declined more than 10 percentage points, to 43.7%.

“The sequential cascade of hypertension awareness, treatment, and treatment effectiveness is the principal pathway to hypertension control,” wrote the authors, who include Brent M. Egan, MD, vice president of cardiovascular health at the AMA. “Unfortunately, awareness, treatment and treatment effectiveness fell in all adults with hypertension and in the age and race-ethnicity groups evaluated,” although it was not statistically significant in all subgroups.

“These observations suggest that attention to all three variables in the cascade is required to reverse broad-based, population-wide decline in hypertension control,” they added.

Learn about four reasons why BP control has dropped among American adults.

At first glance, access to care—defined in the study as health insurance, a regular source of health care and one or more visits in the past year—might seem a logical culprit, but that was unchanged in all ages combined and all demographic groups evaluated, except adults 18–39, who saw a decline in having a usual source of care.

“Since access to care was unchanged and hypertension awareness, treatment and treatment effectiveness declined, the quality of care in diagnosing and managing hypertension fell,” the authors wrote.

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As a case in point, the percentage of adults taking a single antihypertensive medication increased, despite rises in obesity and diabetes, both of which require combination pharmacotherapy.

The “growing monotherapy trend,” the authors wrote, “is unacceptable.”

In addition, hypertension control and treatment effectiveness fell in all three race-ethnicity groups—non-Hispanic White, Non-Hispanic Black and Hispanic.

This decline “magnifies concerns of clinician reluctance to intensify pharmacotherapy for uncontrolled hypertension,” the authors wrote.

The study had several limitations, including that some details of antihypertensive pharmacotherapy, such as medication adherence and dose intensity, were unavailable.

Read what doctors wish patients knew about home BP measurement.

Programs like the American Heart Association’s Life’s Simple 7, which gives special attention to structural inequities, “are a logical approach to addressing the broad-based decline in hypertension control and related health disparities,” the authors wrote.

The AMA too has developed online tools and resources using the latest evidence-based information to support physicians to help manage their patients’ high blood pressure. These resources are available to all physicians and health systems as part of AMA MAP BP™, an evidence-based quality improvement program, providing a clear path to significant, sustained improvements in BP control.

Additionally, the AMA recently launched “BP Measurement Essentials: Student Edition,” an e-learning series designed to teach all health care students the fundamentals of blood pressure measurement.