High Rates of Uncontrolled Blood Pressure in the United States: Does This Represent a Missed Opportunity for Healthcare Providers?


Debbie L. Cohen, MD, Renal Division, University of Pennsylvania School of Medicine, 210 White Building, Philadelphia, PA 19104. E-mail:cohendl@mail.med.upenn.edu

Hypertension is extremely common, affecting 1 in 3 adults in the United States. 1 Uncontrolled hypertension contributes significantly to increased risk of cardiovascular disease, stroke, and chronic kidney disease.2–4 A recent morbidity and mortality report by the Centers for Disease Control and Prevention (CDC) highlighted some concerning issues regarding uncontrolled hypertension in the United States. 1

The CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2003 to 2010 to estimate the prevalence of hypertension awareness and treatment among adults with uncontrolled hypertension.5 Hypertension was defined as an average systolic blood pressure (SBP) ≥140 mm Hg or an average diastolic blood pressure (DBP) ≥90 mm Hg or currently using blood pressure (BP)–lowering medication. The sample included 20,811 eligible patients. The overall prevalence of hypertension among US adults 18 years and older was 30.4%, or an estimated 66.9 million adults. Uncontrolled hypertension was present in 53.5% or 35.8 million adults. Among patients with uncontrolled hypertension, almost 40% (14.1 million) were not aware that they had hypertension, 16% (5.7 million) were aware of their hypertension but were not receiving medication, and approximately 45% (16 million) were aware of their hypertension and were receiving treatment.

Interestingly, of the almost 36 million patients with uncontrolled hypertension, 90% reported having a usual source of health care and 85% reported having health insurance. More than half (52%) of Medicare beneficiaries with hypertension had uncontrolled hypertension. Approximately 25% of patients with uncontrolled hypertension had stage 2 hypertension (BP ≥160/100 mm Hg). This brings up a few very important points for physicians, other healthcare providers, and healthcare systems. Since 90% of these patients had a source of usual health care and had health insurance, this represents a huge missed opportunity on the part of the healthcare providers to improve BP control. Healthcare providers need to prioritize BP control in the primary care setting. There are many barriers to improving BP control including patient education, patient compliance with their medications, and the fact that many patients do not feel unwell when their BP is uncontrolled and may not feel motivated to improve BP control. In order to address these issues, healthcare providers and healthcare systems need to actively educate patients about BP risks and emphasize diet, exercise, and lifestyle changes. It would likely be more cost-effective for healthcare systems to fund BP education programs as even small decreases in BP can significantly affect the rate of cardiovascular disease and stroke and hence reduce long-term costs considerably.6 Compliance with medication can also be improved by simplifying medication regimens and using once-daily dosing and combination therapies. With increasing use of electronic medical records, there are opportunities to remind healthcare providers to be more aggressive with BP control.7 Taking ownership of the disease is also important and self-monitoring of BP at home can enhance patient responsibility and improve patient motivation. Most importantly is the need for the healthcare provider to take the active role in making changes to medication regimens when BP is uncontrolled and resist the apathy that arises from the many office pressures, crowded schedules, and patients reporting that they “did not take their medications today” or “BP is better at home.” While it is easier to leave things unchanged than to add additional medication to a patient’s often burdensome list of medications, the data strongly represent an opportunity for healthcare systems and providers to positively impact hypertension control when a patient comes into contact with us, with a potentially huge impact on future BP control.