Introduction
In the 1990s, child and maternal malnutrition was the leading cause of death worldwide, whereas today hypertension (HTN) is the single largest risk factor for global disease burden, accounting for 9.4 million deaths annually and 7% of disability-adjusted life years [1]. Despite a large variety of effective and safe drugs, HTN control rates, defined as the proportion of treated patients achieving the recommended blood pressure (BP) threshold, have remained at an alarmingly low level for decades in many European countries [2]. The cross-sectional EURIKA study, conducted simultaneously in 12 European countries, showed that only 39% of 7,641 treated patients had their BP controlled in 2010 [3]. At the same time, Canada was able to increase BP control from 13% in the 1990s to 65% today, mostly due to the implementation of the Canadian Hypertension Education Program (CHEP), resulting in a remarkable reduction of myocardial infarctions, strokes and stroke-related deaths [4,5].
Improvement in BP control rates is probably one of the most beneficial steps that can improve life expectancy and the quality of life for millions of people with immediate and measurable results. Over the last few years, developments in hypertension management have included new interventions (e.g., renal denervation and carotid baroreceptor stimulation), novel treatments such as direct renin inhibitors, new treatment modalities such as fixed-dose combinations, and increasing use of out-of-office BP measurement. Despite these developments, the lifetime burden of hypertension remains substantial and highlights the need for new strategies [6]. In terms of the number needed to treat, the five-year rate to prevent one death is 125 in hypertension [7]. In 2016, BP control was still suboptimal with only 39% of hypertensive patients achieving a BP target of less than 140/90 mmHg. Hence, a call to action was published by a group of European physicians. One of the key actions identified to improve the management of hypertension was a stronger commitment from healthcare systems [8].
Current situation
In 2010, the European Study on Cardiovascular Risk Prevention and Management in Usual Daily Practice (EURIKA), a cross-sectional study of the status of primary cardiovascular disease prevention, identified that only 39% of patients achieved a target BP.
Initiatives to improve blood pressure control
Experiences in different countries have demonstrated that large improvements can be achieved by applying adequate actions. Before considering European hypertension management initiatives to improve BP control, it is important to consider the Canadian initiative CHEP, launched in 1999, to improve hypertension control rates.
Canada
Canada has one of the highest rates of awareness, treatment, and control of BP in the world [9]. CHEP is a professional education programme which provides annually updated simple recommendations and clinical practice guidelines for the detection, treatment, and control of hypertension. Dramatic increases have been observed in the diagnosis and treatment of hypertension. It has been estimated that there was a 77% increase in the number of individuals diagnosed with hypertension in Canada from 1996 to 2003 [9]. An increase of 106.8% was observed for antihypertensive prescriptions between 1996 and 2006. These improvements in hypertension management have been associated with major benefits in terms of reduction in cardiovascular deaths and hospitalisation rates [9]. Recently, there have been a number of initiatives launched in Europe to improve hypertension management. Some examples for Austria, France, Sweden and Switzerland are summarised here.
Collaboration among doctors, authorities and pharmacists (Austria)
In order to increase the awareness and consequently the control of hypertension in Austria, two recent initiatives will be briefly introduced to exemplify actions that might be undertaken.
APOTHECARE I: low control rates of 17% were observed in the first large-scale studies conducted in Austria in the late 1990s [3]. In October 2015, 4,303 patients with HTN who approached one of 158 participating pharmacies with a prescription completed for antihypertensive medication were included. A total of 93% were aware of their disease, 90% claimed to have taken their medication prior to the survey, and 41% had their blood pressure (BP) controlled at a threshold of 140/90 mmHg [10]. Despite a high degree of awareness and frequent use of fixed-dose combination drugs, only 41% of diagnosed, treated, and adherent HTN patients had their BP controlled. As a consequence, the APOTHECARE II trial was designed and is currently recruiting. Patients with medically treated arterial hypertension, who attend a pharmacy in order to obtain their antihypertensive medication, are invited to participate in the trial. The main inclusion criterion is uncontrolled hypertension, as determined by an automated office blood pressure measurement at a threshold of 135/85 mmHg. The main exclusion criteria include a first-ever prescription of an antihypertensive agent, resistant hypertension, systolic blood pressure ≥180 mmHg and dialysis. Randomisation occurs on the level of pharmacies (cluster randomisation). Patients in the interventional arm are immediately referred to their treating physician for up-titration of antihypertensive therapy. Re-examination of automated office blood pressure occurs in the respective pharmacy, and patients are referred to their treating physician again if required. A structured and educational BP record card accompanies these measures.
Patients in the observational arm undergo periodic automated office blood pressure measurements and are referred to their treating physician at the end of the trial in case of persistently uncontrolled blood pressure.
This study is designed to overcome physician inertia and to strengthen the role of pharmacies as stakeholders in hypertension care. In these trials, pharmacies have been reimbursed for the first time for a therapeutic interaction with a patient, which led to an emotional discussion at the board of family physicians. It is important to shed light on the different obstacles interfering with optimal medical care; sometimes they are within the very same ranks.
Simple algorithms supported by the health authorities (France)
In 2012, the French League against Hypertension and the French Society of Hypertension, with the support of the French Ministry of Health, made BP control a priority with the goal of achieving 70% of treated and controlled hypertensive patients by 2015 [11]. A simplified algorithm was proposed with seven key points dedicated to general practice: confirmation of high BP outside the office; screening for poor adherence; switching from monotherapy to fixed combination therapy in case of lack of control after initial treatment; proposing a prescription of three-drug therapy of hypertension in patients not controlled by a two-drug therapy; screening for signs in support of a cause of uncontrolled hypertension; organising a healthcare course for hypertensive study participants and access to specialists; evaluating the performance of management [11].
Although these guidelines have been well received and facilitate the progressive implementation of the national recommendations, there are still a number of barriers to improving BP control. For example, fixed triple therapies are not reimbursed and there is no further discussion for full coverage of patients with severe (resistant) hypertension. Also, industrial promotion is rare and there are recurrent negative messages in the media concerning the overtreatment of hypertension. Results from the PASSAGE registry, conducted using 1,000 French general practitioners in 2014, demonstrated that only 54.4% of patients met the BP control criteria of 140/90 mmHg in those less than 80 years old and SBP less than 150 mmHg in those more than 80 years old [8].
A national salt strategy (Switzerland)
In Switzerland, the Federal Office of Public Health has elaborated a national strategy to reduce salt intake, called Salt Strategy 2008-12, later extended to 2016. The short-term goal of this programme was to reduce the salt intake of the Swiss population initially to less than 8 g/day and in the long term to the recommended target of <5 g/day. The first step of this national programme was to assess salt intake in the population in the context of the Swiss Salt Study [12].
After finding the evidence for high salt intake in Switzerland, the Swiss Salt Strategy has come to the following conclusions and formulated the following steps of action. Authorities should intensify their efforts to commit to the Salt Strategy and to mobilise necessary resources for this purpose. Scientific societies should collaborate with the authorities to obtain sufficient financial support to favour research and to establish an efficient monitoring of salt consumption in Switzerland. Societies will increase their engagements in the information for physicians and patients on the risks of a high salt diet, on the means to promote a reduction of salt intake and on the potential clinical benefits of lowering salt intake. They will support all the efforts made to improve the information for consumers with the development of better labelling of food products as far as the salt content is concerned. Scientific societies will also support the authorities in their efforts to convince the food industry to progressively lower the salt content of their products in order to achieve the goals of the Salt Strategy [12].
P4P – Pay for performance schemes (UK)
Numerous studies have examined the impact of pay-for-performance (P4P) programmes. However, only a few studies have looked at a possible effect on continuity of care (COC) and the role of chronic conditions. A study from Taiwan, set in a compulsory universal health insurance programme, has shown clear benefits in a four-year follow-up. Significant impacts were observed after the implementation of the P4P programme for chronically ill patients. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of hospital admissions and emergency department visits. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. The authors conclude that health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in healthcare outcomes [13].
There are extensive data from the UK regarding pay-for-performance schemes and how these relate to quality of care; however, few to date have addressed patients with hypertension. Findings from the UK P4P scheme suggest that generous financial incentives are associated with high levels of achievement for aspects of care for hypertensive patients, but much of this achievement may be attributable to other quality improvement initiatives [14,15].
Whether or not P4P is a feasible option to improve hypertension care remains controversial to some extent. Practices participating in a socio-economically deprived area might have a significant disadvantage in such performance-orientated schemes.
PAP – Physical Activity on Prescription (Sweden)
Despite exemplary public schemes for health awareness, about 40% of the population is insufficiently physically active in Sweden, representing a substantial societal health burden. The estimated costs of this inactivity were 66 million euros in Sweden, including costs for production loss and health care. Scientific evidence supports physical activity as a preventive and therapeutic measure of inactivity-related chronic conditions. The “Physical Activity on Prescription” (PAP) programme aimed to increase the physical activity level among sedentary adults [16,17]. The physical activity behaviour was significantly improved. Extrapolating this finding, physical activity on prescription could be a sound alternative target for authorities to subsidise, rather than solely pharmaceutical products, as physical exercise has been shown to have a positive effect on haemodynamic and inflammatory processes affecting vascular remodelling, eventually leading to hypertension [18,19]. Aerobic exercise reduces blood pressure in both hypertensive and normotensive persons. An increase in aerobic physical activity should be considered an important, if not the most important, component of lifestyle modification for prevention and treatment of high blood pressure [18].
Conclusion
Several national, international and regional strategies have been demonstrated to be successful in the prevention and treatment of arterial hypertension. Despite the availability of this impressive armamentarium for healthcare providers and health authorities, the burden of uncontrolled hypertension is still present in Europe, costing lives, causing individual tragedies through one of the secondary effects of hypertension, namely disabling stroke, and finally costing billions of euros to the taxpayer. There have been many calls for action regarding hypertension control to address the responsibility of authorities, there will have to be many more until they shall be heard. To not let these calls be silenced in the overwhelming storm of information lies within the duty of national and international societies. It their duty, as well, to continue to encourage authorities to join the task of preventing and controlling hypertension.
Our mission: To reduce the burden of cardiovascular disease.