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Hypertension, society, and public policy

Heinz Redwood
DOI: http://dx.doi.org/10.1093/eurheartj/sum003 B13-B18 First published online: 11 May 2007

Abstract

There is plentiful evidence of the threat to public health of uncontrolled hypertension, and ample professional knowledge of how to prevent the condition. Yet failure to achieve adequate prevention in practice is widely acknowledged across Europe and North America. The lack of success of well-intentioned public policy initiatives in the past is linked with problems of changing lifestyles, improving patients' adherence, doctor-patient communications, inadequate public sector budgets for prevention as distinct from treatment, and reliance on top-down programmes instead of involving patients or their organizations directly. Current promising methods of tackling these problems are described.

  • Prevention
  • Treatment
  • Lifestyle
  • Medication
  • Adherence
  • Communication
  • Patients organizations
  • Financial incentives

There is an enigma at the core of health policy for hypertension. We know more or less all that we need to know about the causes of hypertension, its risk factors, its progression, and its consequences. We know how to prevent it, manage it, and when necessary treat it with effective medication. If ‘evidence-based’ medicine is to be society's guiding principle for health care, hypertension comes with a surfeit of evidence that is far ahead of the guesswork that is still part of our struggle against viral infections and resistant bacteria, mental and neurological conditions, asthma, and many forms of malignant disease.

Yet expert opinion considers that

  • ‘blood pressure is the most important cause of death and disability in the world—Raised blood pressure is responsible for 62% of all strokes (and) 49% of all heart disease’1

  • ‘hypertension is the most prevalent preventable disease affecting 20–50% of the adult population in developed countries’2

  • according to a recent survey, there are ‘… .alarming gaps between current and recommended hypertension management’3

  • ‘Reflecting on the developments over the past 20 years concerning the awareness of blood pressure in Austria, there was an initial increased awareness following the first campaign, but the effect clearly disappeared as time went on’4

  • ‘…>40 million adults have uncontrolled hypertension in the United States’5

  • By 2025, ‘almost three-quarters of the worldwide population with hypertension will be in developing countries, with this occurrence fuelled by urbanisation.’6

These comments—which could be extended ad nauseam—illustrate the problem of dealing at population level with a medical condition that is dangerous but asymptomatic. Awareness of high blood pressure is a pre-condition for remedial action, but awareness alone is not enough. If it were, then the efforts of public policy and health promotion in the industrialized world where access to knowledge and medication is good (though not perfect) would have been more successful by now in preventing and controlling hypertension than is actually the case.

Awareness, treatment, and control

Wolf-Maier et al. have reviewed surveys of awareness, treatment, and control of hypertension in the population of seven countries during the 1990s, with the following age-adjusted results (rounded to nearest percentage point) for those aged 35–64, where the control threshold is defined as 140/90 mmHg:

The table demonstrates major differences between North America and Europe and a steep gradient between patients' awareness of hypertension and the achievement of control. Bearing in mind that the relevant surveys were conducted in the 1990s when hypertension guidelines between Europe and North America differed more sharply than today, and that control may have advanced since then, the gap between awareness and control nonetheless raises fundamental questions about health policy concepts and their effectiveness in meeting the challenge of hypertension.

Population-based preventive health care and the individual

Public policy for preventive health care has generally sought population-based solutions to perceived threats. National programmes of immunization against infectious diseases have been effective and are widely accepted, especially for children, the elderly, and professionals at high risk of infection. Preparations to combat a presumed bird-flu pandemic demonstrate that the fear of life-threatening infections can be a powerful motive for demanding and paying for population-based preventive measures.

The issue is far less clear cut for a condition like hypertension where there is a strong behavioural element in being or becoming a patient. Human behaviour is erratic, and ‘lifestyle’ problems leading to illness tend to respond unpredictably to official guidance. As a result, uncontrolled hypertension is a well-rehearsed topic of public concern, but one with disturbingly slow progress towards a more effective balance between prevention and treatment. Public policy is less committed to the achievement of prevention of chronic debility than to averting the more direct threat of epidemic infection. It is also less confident about outcomes when allocating preventive expenditure to the behavioural mysteries of changing lifestyles—even when risk factors have been clearly spelled out and the high cost of ignoring them is predictable.

Hypertension guidelines: doctors, patients, and ‘pre-patients’

Medical guidelines for the management of hypertension have become sophisticated textbooks and essential tools of evidence-based medicine. Refined and updated, the most recent versions are the US ‘Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure’ [JNC 7],7 and the European ‘Guidelines for the management of arterial hypertension’.8 Both provide clear (though in some respects different) guidance and priorities for the medical profession, and neither ignores the individual and social dimensions of prevention and treatment. The analysis of risk factors and the provision of various models of sequential medication are set out in authoritative detail, with special attention also to patients with various co-morbidities. In contrast, the behavioural obstacles to progress are noted as problems and accompanied by tentative exhortation to find solutions—but without many clear indications as to how this might be achieved in practice.

The European guidelines admit that‘The experience accumulated so far suggests that the impact of guidelines in changing clinical practice is rather small. Multifaceted interventions are required to implement guidelines effectively, going from the dissemination of recommendations to educational programmes at the practice site. This requires the participation of all professionals involved in health care, from government level to the individual physician.’ [ibid,8]

The unspoken assumption here is that public policy and professional involvement are The Answer; not part of a range of answers but a ‘top-down’ health care recipe in which patients are recipients, not principals.

The American guidelines go one step further. In their terse abstract of just seven points, two observations introduce the preventive concept of the ‘pre-patient’ and stress the importance of patient motivation:‘Individuals with systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CHD……The most effective therapy prescribed by the most careful physician will control hypertension only if patients are motivated.’ [op.cit. 7].

The doctor–patient relationship

There can be little doubt that, although prevention and treatment of hypertension are multifaceted, the doctor–patient relationship is central to effective implementation.

There happen to be two serious and complementary problems in making it work: doctors generally over-estimate the achievement of blood pressure goals among their patients as well as the effectiveness of getting risk-factor and lifestyle messages across to them. This physician/patient communication gap was described numerately at the St Gallen Special Session ‘Getting into the Healthy CV Success Zone’:‘Physicians believe that 60% of their patients are at BP goal (140/90): only 25% are’ for both systolic and diastolic pressure, or 40% for systolic pressure.9

Patients, on the other hand, find it difficult to change lifestyles radically in response to an asymptomatic condition, and their adherence to prescribed treatment for hypertension (which according to guidelines is ‘for life’) is unpredictable, often inadequate and tends to tail off when blood pressure falls.

In its chapter on hypertension, the World Health Organisation's report on ‘Adherence to Long-Term Therapies: Evidence for Action’10 reviews the many factors involved in patients' failure to adhere, and assigns shared responsibility to each of the health care partners. According to the review, providers lack knowledge, time, incentives, and feedback. Health care systems can be blamed for inadequacies of access, funding, supply, and reimbursement. The tolerability of drugs and complexity of regimens (frequency of dosing, polypharmacy, duration of treatment, and changes in medication) can undermine adherence. And underlying these medical factors are the uncertainties of progress by patients in changing their lifestyle in recognition of known risk factors, and the background of social conditions that reinforce the status quo. Evidently, adherence will not improve by waving a magic wand; but without better adherence, hypertension will continue to defy the weight of evidence showing that control is feasible.

CV Success Zone Programme

The fact that industry, too, can contribute to solutions is illustrated by the Novartis ‘CV Success Zone Programme [op.cit.9], which specifically seeks to ‘advance education and adherence’. It is worth noting that the Programme involves patient support tools on a continuing basis and is designed to optimize doctor/patient communications. It was first launched in the US and has since been introduced in Canada, Latin America, Europe, and Asia-Pacific. An early Consumer Satisfaction survey in December 2005 found that 79% of patients regarded the Programme as ‘Very Important or Important’ while 6% termed it ‘Not Very Important or Not At All Important’.

Adapted to local requirements, the Programme has offered discounts to patients in the US; also in Brazil where dietary advice with follow-up is being provided. In Latin America, where 300,000 patients were enrolled in the first 18 months, mean compliance with medication has improved from 3 months to 4.5 months during this period.

These are early results and they are promising, not yet conclusive. They point in the right direction, targeting the key areas of doctor/patient communications, lifestyle education, adherence, with incentives where appropriate. The Programme goes beyond treating patients by involving them. It hopes to provide the missing link—so frequently emphasized in the professional literature of hypertension—between guidelines and the motivation to adhere.

Role of public policy

Public policy is important for both prevention and treatment of hypertension. This applies particularly to Europe where health care is financed predominantly by the public sector; but also in the US where the public sector's share has steadily advanced since the introduction of Medicare and Medicaid in the 1960s to reach 45.6% of total health spending in 2003, with forecasts of 48.1% for 2006 and close to 50% in future years.11

Overall, prevention is not a prominent item in public health expenditure. OECD Health Data shows public expenditure ‘on prevention and public health’ in 2003/2004 as ranging from 7.6 to 8.3% as a percentage of total public spending on health in the US and Canada, respectively, to between 0.8% (Italy) and 4.0% (Germany/Netherlands) in the European Union.12 The difference is partly attributable to the fact that, in North America, the private sector accounts for a much higher proportion of health spending than in Europe. This may have left more scope in North America for the allocation of public expenditure to prevention.

Realistic estimates of European public spending on prevention as a proportion of the public sector's total health expenditure would almost certainly be higher than reported by OECD, because official estimates probably exclude preventive efforts that are classified as health care ‘treatments’ and not as part of official prevention ‘programmes’. A specific study in France, integrating statistics of both types of prevention in 2002, has concluded that, whereas formal expenditure programmes for collective and individual prevention amounted to 2.9% of total current health spending, prevention under the heading of ‘soins et biens médicaux’ [care services and medical goods] added a further 3.5%, bringing the total to 6.4% of current expenditure on health.

The French analysis specifically includes hypertension in the second category when discussing risk factors and the borderline between prevention and care:‘We have in effect considered that uncomplicated forms of diabetes, arterial hypertension and hyperlipidaemia are not treated for themselves but rather in order to avoid the advent of serious cardiovascular illness, which justifies their inclusion in the area of prevention’[author's translation of the French original]13

However, even with this addition to the definition of ‘prevention’, there remains a gross imbalance between expenditure on prevention and treatment, caused by heavy pressure on tight public sector budgets. Evidently, there is imperative demand for medical treatment which has militated against commensurate spending on benefits that would accrue in the longer term from a more determined emphasis on prevention.

Apart from direct spending on prevention, public policy can influence preventive health care by either encouraging or failing to encourage private sector activities and expenditure on both primary and secondary prevention.

Public policy and patients organizations

If ‘pre-hypertension’ is to be recognized as the indicative forerunner of future illness, then patients organizations are suitable and well-motivated vehicles for the involvement of those who stand to benefit most from educational activities on risk-factors, lifestyle changes, and improved adherence to medication in order to meet the difficult individual challenge of behavioural adaptation. Indeed, it was suggested at the Special Session in St Gallen that patient groups for hypertension and cardiovascular diseases might expand their horizon to include ‘pre-patient’ advocacy and education. This requires funding on a modest scale, but patients organizations are rarely self-funding and some are blamed by consumer activists for relying too much on financial support from the pharmaceutical industry. In Europe, a system of public sector accreditation and eligibility for financial contributions (or reimbursement) from public sources for activities designed to accelerate effective prevention of hypertension would help to fill the communications gap between the medical profession and its patients. Supported by contributions from public funds, the motivational impact on patients would be at least as effective as ‘top-down’ public sector programmes, and considerably cheaper.

Public policy and pharmaceutical reimbursement

In Europe, pharmaceutical consumption is strongly influenced by government regulation of pricing and reimbursement which can promote, delay, or ration access to medication, especially for costly, innovative products.

For example, a report on a series of hypertension studies over the period 1982–2002 in Finland has commented on the European shift in emphasis from detection to adequate treatment of high blood pressure. Apart from the doctor-and-patient-related factors discussed earlier, the report refers to reimbursement of medication as a problem:‘In Finland, the strict reimbursement criteria for antihypertensive drug treatment presented by the national social insurance institution may also play some role in unsatisfactory BP control. In these criteria, the BP levels justifying the reimbursement of antihypertensive drug costs are clearly higher than those recommended by the hypertension guidelines’, leading to the conclusion that ‘in particular, effective antihypertensive drug treatment should have been prescribed for individuals with a moderate or high absolute CVD risk more frequently than at present’.14

The phenomenon of prescribing too little, too late, or cheaper but less appropriate medication in order to qualify for reimbursement is by no means peculiar to Finland. It is another aspect of public sector payers putting immediate budgetary control above optimal prevention of CVD over the medium and longer term. Thus public policy is inclined to ‘shoot itself in the heart.’

Prevention and financial incentives for physicians in the US

In the US, the pros and cons of offering financial incentives to physicians and hospitals for greater emphasis on preventive health care have been discussed for many years. The debate has indeed become part of a widely perceived need to strive for major improvements in the quality of US health care.

The scope for financial incentives for physicians and hospitals in the pluralistic framework of health care purchasing in the US is at one and the same time favourable and handicapped in comparison with Europe's more monolithic national health services. Pluralism favours experimentation until a variety of effective mechanisms are found, whereas a ‘Single Payer’ system tends to be slow-moving and resistant to change, although there are exceptions as exemplified by the new incentive system in the UK (see in what follows). However, a Single Payer will tend to commit to a Single Model of financial incentives which may or may not work.

On the other hand, the proliferation of private insurers and health care purchasers in the US makes it difficult to design incentives that will motivate hospitals and group practices of physicians whose patients are insured with many different health plans. Under these conditions, financial incentives tend to be small in relation to administrative costs. To counter this problem, collaborative programmes among major insurers with support from the largest public sector purchaser (CMS—Centers for Medicare and Medicaid Services15) could have considerable impact on physicians and hospitals.

A recent study of 1000 interviews in 12 US metropolitan areas with 35 health plans revealed that 77% of the 35 plans‘…had hospital- or physician-based pay-for-performance strategies that were being actively developed or had pilot or full programmes that had already been implemented. Most of the health plan efforts were new, with about one-third of all reported efforts being in the planning or developmental stages…(They) uniformly reported that their goal is to reduce costs through improved quality and provider efficiency.’16

There are as yet no authoritative reports on patient outcomes as a result of pay-for-performance [P4P] programmes in the US. One risk, implied by the above quotation, is that P4P under US conditions will essentially major on cost containment, with ‘improved quality’ as a subsidiary objective.

That is not a charge that can currently be levelled against the ‘Quality and Outcomes Framework’ (QOF) of the National Health Service (NHS) in the United Kingdom.

Public policy developments in the UK: financial incentives for physicians

The NHS introduced its QOF as a voluntary part of its contract with general practitioners (GPs) in April 2004. Relative to hypertension and cardiovascular diseases, its quality objectives are to a large extent preventive, i.e. QOF strives to secure better health outcomes by early, systematic, and sustained monitoring of blood pressure, cholesterol, other risk factors, and ensuring that patients are on appropriate medication. Financial incentives (which are paid to the practice, not to individual doctors) are based on a ‘points’ system. Points are awarded for keeping the required records, for diagnosis and initial management, as well as for ongoing management. Improved outcomes, such as achievement of clinical guidelines for a high percentage of patients, generally rate the highest number of points.17

The British QOF programme is widely regarded as a dramatic advance in preventive medicine. At its outset, it was described by an American commentator as‘…the boldest such proposal attempted anywhere in the world…With one mighty leap, the NHS has vaulted over anything being attempted in the United States, the previous leader in quality improvement studies’18

QOF differs, in particular, from American initiatives in the following respects:

  • its national scope as a single system;

  • virtual absence of serious controversy over its aims, process and progress;

  • application only to primary care, not hospitals;

  • no mention of cost containment as one of its objectives;

  • very high financial rewards for practices with high point scores;

  • consequently, high additional cost to the NHS;

  • consequently, risk of government decisions to reduce or cease funding in future years.

In its first and second years, the scheme provided for a total of 1050 available points, and average practice achievement was 959 points (91%) in 2004/05 and 1011 points (96%) in 2005/06. For the latter year,‘Each practice will receive on average £125,900 [approx. €176.000 or US$240,000]. Much of this money will be reinvested into NHS GP services, such as extra practice nurses. Practices have also taken on more staff, expanded services, and organised community nurses to visit people in their own homes’19

Hypertension and cardiovascular diseases occupy a prominent position in QOF. For 2006/07, 83 points are available for hypertension alone [six for records of hypertensive patients, 20 for blood pressure measurement in the previous 9 months, and 57 for the percentage of hypertensive patients whose blood pressure at the time of last measurement was 150/90 or less]. In addition, 89 points are available for secondary prevention of coronary heart disease and 24 points for stroke and transient ischaemic attacks. Combined, but excluding a further 68 points for management of smoking, hypertension and consequential diseases account for close to 20% of all available points.

For Year 2 of the scheme, the Health Minister reported that‘75.5% of patients with hypertension who were available and suitable for treatment showed a last blood pressure reading…of 150/90 or less’ (ibid,19)

That is an impressive result but it probably overstates ‘real life’ outcomes for hypertension by some margin. In the first place, 150/90 is somewhat less demanding than the current European and American guideline target of 140/90 or less; and secondly, the number of ‘available’ patients is determined after deducting reported ‘exceptions’ from all hypertensive patients. The QOF scheme allows for nine categories of exceptions on justifiable grounds, for example patients who decline a review or for whom antihypertensive medication is clinically inappropriate. At the time of writing, an analysis of the frequency and type of actual exception reporting has not yet been published. Meanwhile, a recent review has commented that‘…exception reporting also provides an opportunity for family practitioners to increase their income by inappropriately excluding patients for whom they have missed the targets (a practice known as gaming)’20

American reports of P4P initiatives also refer to ‘gaming the system’—a sport in which the administrative bureaucracy even of schemes based on noble concepts and aspirations will often be a loser.

However, although the reported outcomes related to hypertension could in reality be somewhat less striking than implied by ministerial pronouncements, QOF nonetheless represents a remarkable and promising step in the right direction. Its main test will not be clinical but political: will government persist in what is a costly scheme? Or will it eventually fall victim to the budgetary priorities of curtailing current expenditure before its longer-term outcomes have become firmly embedded in clinical practice?

Summary

  1. Society fully recognizes the threat to public health of uncontrolled hypertension but, although it knows how to prevent it, it is generally failing to do so.

  2. Improving outcomes will depend on building an effective balance between

    • reducing risk factors by lifestyle changes;

    • prescribing appropriate medication at the right time;

    • working with patients to improve their adherence to treatment.

  3. Public policy will need to redress today's gross imbalance between inadequate prevention and effective treatment by contributing to the cost of programmes that will reduce the clinical, social, and financial burdens of hypertension and heart disease over the longer term, and by adopting policies that will similarly encourage the private sector to make its contribution.

  4. Public policy also needs to understand and support patients organizations in the necessary effort to bridge a serious communication gap between doctors and patients. It should move from excessive emphasis on ‘top-down’ campaigns towards greater recognition of patients (and ‘pre-patients’) as ‘principals’ in the control of hypertension.

  5. The publicly funded QOF in the UK is an important step in the right direction, with promising initial results in hypertension control. These could form the foundation for long-term success, provided the political will to sustain the Framework does not falter at the first prospective financial hurdle.

Conflict of interest: The author has worked as an independent consultant to Novartis Pharma AG on topics of international public policy in pharmaceuticals and health care.

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References

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