Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
In today’s COVID-19 update, a discussion with the U.S. Surgeon General Vice Admiral Jerome Adams, MD, MPH, and experts from the AMA and AHA about the ongoing importance of controlling hypertension during COVID-19.
Resources for physicians to help control hypertension:
- Achieving Accuracy: BP Measurement e-learning module
- US Blood Pressure Validated Device Listing (VDL™)
- 7-Step SMBP quick guide
- Release the Pressure
Learn more at the AMA COVID-19 resource center.
- Vice Adm. Jerome Adams, MD, MPH, Surgeon General of the U.S.
- Kate Kirley, MD, MS, director, Chronic Disease Prevention, AMA
- Eduardo Sanchez, MD, MPH, CMO for Prevention, American Heart Association
Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we're discussing the ongoing importance of controlling hypertension during COVID-19. I'm joined today by Vice Admiral Jerome Adams, Surgeon General of the United States in Washington DC, Dr. Kate Kirley, the AMA's director of Chronic Disease Prevention and a family physician in Chicago, and Dr. Eduardo Sanchez, CMO for Prevention at the American Heart Association in Dallas.
I'm Todd Unger, AMA's chief experience officer in Chicago. Vice Admiral Adams, you released a call to action to prioritize hypertension back in October. Can you tell us a little bit about what that call to action was, and why you felt it was needed, particularly right now during the COVID-19 pandemic?
Vice Admiral Adams: Well, it goes without saying, these are challenging times and people with chronic diseases and conditions may be at increased risk for having severe illness from COVID-19. So, improving overall health in our patients is key to preventing these types of pandemics and health crises in the future and mitigating the current pandemic. It's important for people who have high blood pressure or hypertension to continue to take their medications as prescribed, especially in the midst of the pandemic and to self-monitor their blood pressure at home when and if they can.
This out of office monitoring is strongly recommended in national guidelines and supported by the AMA. No better time than now to equip and empower patients to know their patterns of readings and to share those patterns with their health care team. We're optimistic about an upcoming COVID-19 vaccine. I want to remind people about my three W's, wearing a mask, washing your hands, and watching your distance. But I also want you to know now is not the time to delay care.
If you begin to feel sick, if you have questions, if your body is telling you something is wrong, reach out to your health care team. Because despite what you may hear, the clinic, the hospital, that's going to be one of the safest places you can be at the moment and know the federal government has recognized barriers to health because of COVID-19. We've deregulated telemedicine, making ongoing care from any medical conditions safe and accessible. We want to make sure you can get the care you need, especially to help control your blood pressure.
Unger: Dr. Sanchez, can you start by talking about the AMA and the AHA's reaction to this call to action and how it fits with our ongoing work in this area?
Dr. Sanchez: I think simply put, we would say rah, rah, and look forward to working with the surgeon general and with other collaborators to do everything we can to improve blood pressure control. The thing about high blood pressure is that we know what to do. We're not very good at knowing how to do it. And Target: BP, the program that we've got with that is the American Heart Association has with the American Medical Association is about the how, how do you take the science that says it helps prevent heart attacks, strokes, heart failure, particularly in certain race ethnicity groups.
We want to take that how to every practice in the country, and the call to action gives us license and gives us opportunity to spread Target: BP beyond where we are.
Dr. Kirley: AMA has been prioritizing blood pressure control for nearly a decade now, and we've done so in close partnership with the American Heart Association. And we completely agree with the call to action. It's time to make this a national priority. And clinicians really do have an important role to play here. We have seen in our work with physician practices and health care organizations of really all shapes and sizes that they are enthusiastic about improving their quality of care.
And to get nerdy for a second, there's a really good place to start when you think about improving blood pressure care, and that is with accurate blood pressure measurements. Without accurate blood pressure measurement, whether that's in the clinic or at home, we really don't have a foundation to stand on. It's crucial for diagnosis. It's crucial for ensuring optimal treatment. We really encourage clinical care teams to start with focusing on accurate measurement.
Unger: Now, people have been taking blood pressure for a long time. Don't all health care professionals know how to measure blood pressure accurately at this point?
Vice Admiral Adams: No, they do not. We found that in most cases, if you actually observe a medical professional taking a blood pressure, they are not doing it according to the standards, the guidelines. And in many cases, you're going to get a more accurate blood pressure reading from a patient who's using a home blood pressure monitor and doing it in the comfort of their own home. I want people to know, I actually have high blood pressure myself. One in two American adults do, and I'm one of them.
I've found that my pattern of blood pressure readings is actually different at home when I'm sitting comfortably, when I'm sitting up, when I'm not talking, when I'm taking my blood pressure at the level of my heart than when I'm in the office and they rush you in and throw on the cuff, and they're asking you a thousand questions and taking your blood pressure at the same time. So again, we all need to do a better job in the clinic, but I think we can really augment and supplement in clinic readings by promoting home blood pressure monitoring.
Unger: That's brilliant.
Dr. Kirley: Absolutely.
Unger: Dr. Kirley?
Dr. Kirley: Everything that the surgeon general just highlighted is so important, and there are things that we can do from a system standpoint within the clinic itself to get more accurate measurements there, including retraining our health care professionals. Blood pressure measurement is a really complex skill. We know it decays over time. And so, AMA and AHA, we have worked to really standardize training and offer trainings to health care professionals, really with that goal of making sure that we're all prepared to measure an accurate blood pressure every time.
But that out of office blood pressure measurement piece is absolutely crucial as well. We are really working to support patients in being able to self-measure their blood pressure at home as well.
Vice Admiral Adams: And we don't want to slow you down, but the primary goal of the call to action is really to identify evidence-based interventions that can be implemented, adapted and expanded to improve control over hypertension and home blood pressure monitoring. Again, one of the biggies, mine costs $35 at Walmart. That may be too expensive for a lot of people, and we're working on a federal level and with payers to encourage them to pay for home blood pressure monitors, but it's certainly not the hundred and fifty, 200 dollars that it was several years ago.
We've never had better tools and better resources to get our nation's blood pressure under control.
Unger: Vice Admiral Adams, the pandemic, obviously people have a lot on their mind right now. How has it affected all the efforts to control hypertension?
Vice Admiral Adams: Well, we know that many people have said that they've put off regular checkups. And unfortunately, some people have put off what would otherwise be urgent care during the time of the pandemic. Again, if you have concerns about your numbers, if you don't feel right, you're having a headache, you're having some of the symptoms of a hypertensive crisis, please don't be afraid to go into the hospital.
While hypertension alone hasn't been shown to be a risk factor for worse outcomes from COVID, uncontrolled hypertension causes stroke, causes heart attacks, causes cardiovascular disease and other issues, which are predictors of negative outcomes from COVID-19. I hate when we compare one disease versus another, because to the individual, what is affecting you is affecting you. But I do want to remind people that 266,000 people have died from COVID-19 at the time we're doing this recording.
500,000 people die every single year with uncontrolled blood pressure listed as a primary or secondary cause of death on their death certificates. While we don't want to pit one against the other, we absolutely can't afford to forget hypertension for the sake of COVID, because it's going to hurt our response to COVID and it's going to cause many more people to die unnecessarily.
Dr. Sanchez: It is worth mentioning that with hypertension come other things. Those individuals who have high blood pressure may have other underlying medical conditions, whether that's high cholesterol, type 2 diabetes, full blown, but not yet diagnosed cardiovascular disease, or something that's getting ready to be stroke disease. Having high blood pressure is probably a sign that you should be hyper vigilant around COVID-19.
And just to reiterate, because I think repetition is really important, the three W's, wearing a mask, washing your hands, watching your distance is important every single day with or without hypertension. One more thing, the American Heart Association has had a campaign Don't Die of Doubt. Just to underscore what our surgeon general is saying, if you are having symptoms that you have heard over and over, it might be a heart attack or stroke or somebody is complaining of them, call 911.
The place to be evaluated and taken care of is in an emergency room setting where they've got the equipment to evaluate you, they've got the means to protect you from COVID-19 and they've got the means by which to save your life, if that's what's indicated.
Unger: That's such important advice. Vice Admiral Adams, your call to action also mentioned that barriers exist for certain communities to gain control of hypertension. Can you talk about some of those barriers and what your hope is for addressing them long term?
Vice Admiral Adams: Well, we know hypertension is controllable, and yet control rate are stagnant, especially amongst people of color. Why is that? Well, in many cases, these individuals living in these communities have barriers that are not medical, but they're social. They're what we call the social determinants of health. We know that things like transportation to get back and forth to your appointments, a living wage that helps alleviate stress so that you're not working three, four jobs, and that you're able to get a good night's sleep.
Because guess what? Lack of sleep leads to high blood pressure. We know that living in an environment where you're constantly threatened either by intimate partner violence or by the surrounding neighborhood that you live in being a high violence neighborhood impacts your risk of high blood pressure.
What we need to do is understand our numbers and make sure we are standardizing the medical remedies, but we also need to take a step back and understand the social risk factors, the social pre-existing conditions that also put people at risk for blood pressure and make it harder for them to control their blood pressure. I think we need to help people understand that there are generic medications out there now. You don't need to be on the $50 or $100 a month pill. My blood pressure medication costs $4 a month.
I don't think enough people out there, and I include practitioners in this, recognize that you can get just as good a control with a $4 medication in most people as you can with a $40 medication. And far too often as clinicians, we don't take the time to ask that question or to inquire, and we become the barrier to someone being compliant with their medications, because we write for a medication that people can't afford. With the knowledge that in many places, people don't have insurance and they are paying for this out of pocket.
Unger: Dr. Sanchez, do you have any additional context?
Dr. Sanchez: Yeah. I'd like to add a couple of things. Surgeon General Adams already spoke to one of them and one of them is we know that not having health insurance increases the likelihood of poor control in persons diagnosed with high blood pressure. The extent to which organizations like the American Heart Association can advocate for expanded health insurance is critically important. In this time of COVID, we should be aware that there are people who have lost their jobs and lost their health insurance.
Organizations like AMA and AHA also need to help direct people to some of our federally funded, federally qualified health centers, which are designed to provide care for people who do not have insurance and who are trying mightily to get blood pressure under control. One other thing to add, a very recent study, a person who has not seen a doctor in a year and has been diagnosed with high blood pressure has the lowest level of control of all the different factors that we've talked about so far.
And it's critically important and part of the call to action that we engage community partners to help identify and help manage high blood pressure. Screening programs are ways for us to find those folks who have been disconnected or were not connected to clinical care and get them connected because blood pressure control is inexpensive. Blood pressure control is relatively simple in the scheme of the things that one has to figure out every single day. And it will save lives, the minute we get someone's blood pressure from too high to just right.
Vice Admiral Adams: Dr. Sanchez, he's a genius. He gets me thinking about all sorts of other things that we should talk about. But I'll be brief. I think it's important to highlight that we've gone from 10,000 telehealth visits per week paid for by CMS to now tens of thousands of telehealth visits paid for on a daily basis here in the United States. There are a few diseases that are as amenable to being treated telephonically as hypertension. We need to challenge ourselves to figure out how can we utilize home blood pressure monitoring.
Mine has Bluetooth. It uploads to my phone. I can shoot it to my doc, and then we check in with people because that's connected with an electronic health record and then we tell them, "Hey, your blood pressure is a little bit out of control. Let's bump up your Norvasc a little bit. Let's make sure you're getting that under control." We have so many tools available to decrease the number of people who are going without care or without seeing a physician, even if they can't have a face-to-face encounter.
And the one other thing I mentioned that Dr. Sanchez got me thinking about in regard to COVID is diet and exercise. In the midst of COVID, we've all been told to sit at home and stay on our couches. Everyone's ordering in, and we're doing that to protect ourselves from COVID. But guess what? That's increasing our risk for high blood pressure. I want to encourage people to try to think about creative ways to be active, even in the midst of a pandemic. You can go out for a walk socially distanced.
Put a timer on your watch or on your phone and just get up and stand up every 30 minutes or so. I actually keep two little weights next to my couch so that whenever I'm watching TV, it immediately goes to my mind that, "Hey, I can get up and do some curls and be active." And you can do that with cans of soup, with buckets of paint. There are ways that you can be active even while you're physically distancing.
But don't let this pandemic put you in a situation where you survive COVID, but you actually end up in the hospital or dying from hypertension that was either caused by or exacerbated by our responses to the pandemic.
Dr. Kirley: And speaking of creativity, if there is one positive to come out of this pandemic, I think it's seeing the innovation that is taking place all around the world right now. I have the really interesting good fortune to work with a lot of federally qualified health centers and community health centers that are working to serve these communities that we were just talking about that are really hurting the most right now.
And it's an inspiration to see how creative they have become with problem-solving, employing telemedicine, employing self-measured blood pressure programs, really doing a lot of outreach to get to those patients that we know are hesitating to seek care right now. It's just really exciting and inspirational to see all of this creativity and innovation right now.
Vice Admiral Adams: And Todd, you're never going to let me back because we're not letting you talk. But again, I want to follow up and point people to the Million Hearts Champions. These are a group of individuals that have achieved greater than 80% blood pressure control amongst their populations. There are federally qualified health centers. There are VA clinics. There are people who are working for Indian Health Services. They're treating the most vulnerable, the most disadvantaged.
And the point being, if they can do it in those populations through innovation, through hard work, through standardization of protocols, anyone can do it. There's never been a better time to get your blood pressure, because half of you all out there have it by definition, or to get the nation's blood pressure under control.
Unger: You're absolutely right. I'm like you, working on mine. So that's exciting news. And I have one final question for all of you. Thinking beyond this pandemic that we're in right now, what does success look like? When and how are we going to know that we have made progress in controlling hypertension? Why don't you start Dr. Kirley?
Dr. Kirley: Well, success from the AMA standpoint really looks like seeing improvement in the national blood pressure control rates. That's something we're tracking very closely. We will really continue our commitment to support physicians and care teams in caring for patients with hypertension. We offer a lot of resources here. We have the AMA and AHA's Achieving Accuracy: BP Measurement module, which is an e-learning module to get back to that blood pressure measurement retraining that I was talking about before.
We support the US validated device list, which is a list of blood pressure devices that have been validated for clinical accuracy, so clinicians can guide patients to find monitors that they can use at home for self-measured blood pressure, as well as monitors for their clinic. And we have our 7-steps guide to help practices set up SMBP programs quickly. We'll continue supporting practices, offering these resources for as long as we can, and we really appreciate this call to action really drawing attention to this important issue.
Unger: Dr. Sanchez, what does success look like to you?
Dr. Sanchez: I'll just add. I agree with Dr. Kirley. We got to set the things in place that are going to help us achieve success, the structure and process elements, if you will. But to me, success looks like blood pressure control across all groups having achieved that 80+%. And I say, let's go for 90%. And having done so, seeing a decline, that is a new decline, in cardiovascular deaths and in stroke deaths in this country. We've kind of plateaued. We need to start heading down again.
Dr. Sanchez: And that's what true success will look like, because that will be the sign that more Americans in an equitable way are leading long healthy lives, the ultimate goal of all of this. Blood pressure control is not the end game. It's a means to an end, a longer healthier life.
Unger: Vice Admiral Adams?
Vice Admiral Adams: All right. You want me to bring it home?
Unger: Bring it home.
Vice Admiral Adams: Well, earlier I spoke to the goals outlined in the call to action, and I want to stress one goal in particular in the effort to address hypertension in this country and that is simply to make hypertension control a national priority. There've been so many other epidemics that we've talked about in the past several years. We need to start talking about uncontrolled hypertension as an epidemic and making it a national priority.
And this can be done by increasing awareness of potential health risks associated with hypertension by recognizing the financial costs of uncontrolled hypertension and engaging new stakeholders, like employers, and by eliminating disparities in treatment and control of high blood pressure. Success to me is seeing the national control rate begin to improve again, because you all know, we saw it declining and then we saw it level off and start to go back up.
That's going to take likely a few years, but shorter-term successes include more people adopting best practices within health systems across the country. Treatment protocols, med adherence strategies, out of office monitoring, things that are best practices, seeing lower sodium food options available everywhere at an affordable price, not just available, but available at an affordable price, and communities filled with safe and easily accessible places to be physically active.
And we're seeing expansions of that with blue zones in purpose-built communities. Controlling hypertension if achievable, but not without collaboration. We need broad scale, multi-sector, culturally sensitive and diverse interventions. And progress will only be seen when we begin to implement these strategies for hypertension control and rates of uncontrolled hypertension go down. But the good news is, again, many people are doing it and we lay out these best practices in the call to action.
And I want to thank the AMA, I want to thank the AHA for helping us put together this call to action. We just want to encourage you all to read it and to help us make hypertension control a priority, and then everything else will flow from there.
Unger: And I want to thank the three of you for this amazing discussion. Vice Admiral Adams, Dr. Kirley, Dr. Sanchez, thanks so much for being here and sharing your perspectives. We'll be back soon with another COVID-19 update. For resources on COVID-19, visit the AMA site, ama-assn.org/covid-19. Thanks for joining us. Please take care.
Vice Admiral Adams: Thank you.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA