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Abstract

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Hypertension is an important public health problem both in the United States and worldwide, contributing to many forms of cardiovascular and renal diseases. Although great strides have been made in the proportion of the US population that achieves recommended blood pressure targets, many Americans still have undertreated and uncontrolled blood pressure that increases the risk of expensive strokes, heart attacks, heart failure, and dialysis. Because hypertension is a common but heterogeneous and sometimes complex condition, the American Society of Hypertension (ASH) has, since 1999, designated physicians as “ASH Hypertension Specialists.” Such Hypertension Specialists (as defined by ASH's Specialist Program) are fully licensed physicians with a primary board certification who are competent in all aspects of the diagnosis and treatment of hypertension, as evidenced by passing a specific examination on these topics offered by ASH's Specialist Program. These physicians have a proven track record of controlling blood pressure in “resistant hypertensive” patients, the general population whom they serve, and educating other physicians to help them achieve higher blood pressure control rates among their patient populations. This report sets out a rationale for increased reimbursement for care of hypertensive patients by ASH-Designated Hypertension Specialists.

In the most recent National Health and Nutrition Examination Survey (NHANES 2007–2008), approximately 29% of American adults had hypertension.[1] Although the prevalence of hypertension has remained stable since 2000,[1] the age-associated increase in hypertension prevalence, and the increase in the absolute numbers of older Americans[2] leads to the conclusion that, in 2010, approximately 77.8 million American adults were affected, making this the most common form of cardiovascular disease in the United States.[3] Nationwide data indicate that hypertension has the highest population-attributable risk for stroke (the fourth leading cause of death in 2010, the most recent data currently available,[4] and the leading cause of permanent disability since 1928), is one of the three most important risk factors for heart disease (which has been the leading cause of death in the United States from 1917 to 2010[4]), is a major predisposing risk factor for heart failure (the number one cause of hospitalization in Medicare beneficiaries since 1990), and a major cause of end-stage renal disease (the most expensive item, on a per-person-year basis, in the Federal budget).[3] In addition, hypertension is the third most significant risk factor for peripheral vascular disease (the most common cause of lower-limb amputations), and the number one risk factor for vascular dementia (the number 8 cause of death in 2010, and the second-most common cause of nursing home placement). Perhaps because hypertension is the most common reason for an adult to consult a physician for treatment of a chronic condition,[3, 5] the cost of hypertension in 2009 in the United States was estimated at $50.1 billion.[3] More importantly, the National Committee on Quality Assurance (NCQA) has calculated, nearly identically for the past 8 years (2002–2010), that better control of hypertension nationwide would be the medical intervention that is likely to save the most lives (5217–61,490), and the second most hospital dollars ($1.348 to $2.052 billion) annually, based on otherwise unexplained variations in medical costs.[6]

Heterogeneity of Hypertension

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Hypertension is a complex condition that varies greatly in severity. Although there was once the hope that a single medication, given once daily, might be able to control blood pressure (BP) in the majority of patients with the condition, recent data indicate that the majority of patients require ≥2 medications to achieve and maintain BP control (traditionally defined as BP <140/90 mm Hg). US national and international expert panels have recommended that high-risk hypertensive patients (eg, those with diabetes,[7] chronic kidney disease,[8] or established heart disease[9]) should have their BP controlled to even lower thresholds: typically <130/80 mm Hg, although very recent US recommendations have de-emphasized these lower target BPs that are not based on clinical trial data.[10, 11]

Challenges in Hypertension

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

In population-based surveys in the United States, approximately 15% (range: 9%[12] to 21%[13]) of people with hypertension are considered “resistant:” whose BP remains elevated despite prescription of at least 3 properly chosen medications or who require ≥4 medications to achieve control.[14, 15] Patients with this condition are challenging to diagnose and treat, and are often referred by primary care physicians (including cardiologists, nephrologists, endocrinologists, and other medical subspecialists) to physicians who have special knowledge and expertise in the field of hypertension (“Hypertension Specialists”).

Although the majority of patients with hypertension have no known cause for their condition (so-called primary hypertension), about 5% of the hypertensive US population do have a secondary cause for their condition. Because people with a secondary cause typically need special attention, either because the cause is (by definition) uncommon, or because the BP responds only to an intervention specific to each secondary cause of hypertension, these patients are often referred to a Hypertension Specialist, for further evaluation and management of their secondary cause of hypertension.

Limited Supply of Hypertension Specialists

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

There are currently <1500 US physicians who have become designated as Hypertension Specialists by meeting the specified criteria (outlined below) and passing the examination given by the American Society of Hypertension's (ASH's) Specialist Program. Thus, to meet the nationwide demand for these physicians' services in caring for patients with complex, resistant, or secondary hypertension, many more Hypertension Specialists will be required. Because of the important role that these Hypertension Specialists can, do, and will play in the prevention of adverse cardiovascular and renal disease outcomes, it is necessary to describe the current criteria for the designation of “Specialist in Clinical Hypertension.”

Current Criteria for the Designation of Specialist in Clinical Hypertension

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References
  • Medical degree (MD, DO, or equivalent) and unrestricted license to practice medicine.
  • Specialty board certification in a discipline recognized by the American Board of Medical Specialties (eg, internal medicine, cardiology, nephrology, endocrinology, family medicine, pediatrics, obstetrics/gynecology) or the American Osteopathic Association's Bureau of Specialists.
  • Competent in all modalities involved in the diagnosis and treatment of hypertension.
  • Passed the examination produced and offered by ASH's Specialist Program.

Clinical Functions of a Hypertension Specialist

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

It is expected, based on current standards and practices, that the majority (at least 50%) of the Hypertension Specialist's clinical time and effort will be devoted to care of patients with hypertension and related disorders. The major activities that the physician is likely to be involved with include, but are not limited to:

  • Referral destination for difficult-to-manage (“resistant”) hypertension.
  • Referral destination for investigation for secondary causes of hypertension.
  • Referral destination for investigation of white-coat and masked hypertension.
  • Referral destination for assessment of global cardiovascular and renal risk using sophisticated techniques.
  • Serves as community resource for hypertension and related disorders, eg, formulary committees, credentialing committees, training programs (see Table 1), medical insurance companies, outreach programs.
  • Referral destination for integrating lifestyle modifications in hypertension treatment strategies.
Table 1. Hypertension Academic Training Programs
InstitutionDirectorProgram Link(s)
University of California, San Diego & VASDHSDaniel T. O'Connor, MD, PhD http://nephrology.ucsd.edu/fellowship/
Baylor College of MedicineAddison A. Taylor, MD, PhD http://www.bcm.edu/medicine/hypertension/?PMID=4103
Oregon Health & Science UniversitySusan P. Bagby, MD http://www.ohsu.edu/nephrology/
Cleveland ClinicMarc A. Pohl, MD
University of Chicago-Pritzker School of MedicineGeorge Bakris, MD http://medicine.uchicago.edu/endo/non_acgme_program.html
Tulane Health Science CenterL. Lee Hamm, MD http://tulane.edu/som/departments/medicine/hamm-bio.cfm
Yale University School of MedicineAldo Peixoto, MD http://medicine.yale.edu/intmed/nephrol/education/index.aspx
Georgetown Department of MedicineChris Wilcox, MD, PhD http://medicine.georgetown.edu/nephrology/fellowship_program.htm
University of Pennsylvania Health SystemRay R. Townsend, MD http://www.uphs.upenn.edu/renal/about_us/research.html
UCLA Health SystemAlan Wilkinson, MD http://www.uclahealth.org/body.cfm?id=453&action=detail&limit_department=15&limit_division=1052&limit_program=5137&CFID=42831550&CFTOKEN=91811765
Virginia Commonwealth UniversityDominic Sica, MD
University of Connecticut, Pat & Jim Calhoun Cardiology CenterWilliam B. White, MD
University of Colorado School of MedicineRichard J. Johnson, MD http://www.ucdenver.edu/academics/colleges/medicine/Centers/Obesity/Membership/Pages/Johnson.aspx
University of Louisville School of MedicineAtul Chugh, MD http://louisville.edu/medschool/pulmonary/diseases/pulmonary-hypertension-program-2013-uofl.html
University of Mississippi Medical CenterMarion Wofford, MD https://medicine.umc.edu/Divisions/Profiles/ProfileIndex.asp?div =General&Type=F#
University of Alabama at Birmingham School of MedicineSuzanne Oparil, MD http://hypertension.dom.uab.edu/
SUNY Buffalo/Erie County Medical CenterRocco C. Venuto, MD
Brigham & Womens Harvard Medical SchoolNorm Hollenberg, MD, PhD http://www.brighamandwomens.org/Departments_and_Services/medicine/services/cvcenter/medical/ClinicalCardioFellow.aspx
UT-Southwestern Medical CenterWanpen Vongpatanasin, MD
Cedars-Sinai Medical CenterRonald G. Victor, MD

Impact of the Hypertension Specialist in “Resistant Hypertension”

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Although there are no randomized clinical trials examining the quality of care of hypertensive patients delivered by Hypertension Specialists vs other physicians, a large and increasing body of evidence indicates that Hypertension Specialists excel in controlling BP and other cardiovascular risk factors. This is particularly true for patients with resistant hypertension. One report from the Cleveland Clinic indicated that 95% of such patients at that institution received an appropriate diagnosis after a suitable but limited evaluation.[16] A much earlier report from the Yale University Hypertension Center indicated that in 91 patients with resistant hypertension (who by definition had uncontrolled BP when first seen by the Hypertension Specialist at that Center), a specific diagnosis was made in 91% and BP control was achieved in 53%.[17] A more recent report from the RUSH University Hypertension Center included 141 such patients; 94% received a specific diagnosis for their resistant hypertension and 53% had their BPs brought under control (<140/90 mm Hg).[18] These two reports are particularly important, as one of the entry criteria for each study was that all patients had failed to achieve BP control when seen by at least one other physician. Many patients were referred to these Hypertension Specialists after consultation with more than one other physician, many of whom were cardiologists, nephrologists, endocrinologists, or other medical subspecialists. The fact that 53% of these patients achieved controlled BP, sometimes after even a single visit to a Hypertension Specialist, highlights the high cost-effectiveness of such referrals, and the wisdom of such referrals. One randomized controlled study compared the care of a Hypertension Specialist with changes to an antihypertensive regimen suggested by a more intensive (and expensive) testing design using a bioimpedance device in 104 resistant hypertensive patients at The Mayo Clinic. The proportion of patients achieving BP control (≤140/90 mm Hg) after 3 months was significantly different (P<.05) between the two groups: 56% for the tested group vs 33% for those seen by Hypertension Specialists.[19] This result is likely to have been confounded by the 13 excluded patients, the high proportion (34%) of secondary causes that were identified but not addressed during follow-up (at the patient's request), and the fact that all 119 eligible patients were seen by a Hypertension Specialist before randomization to either group, to make it more likely that a suboptimal drug regimen was responsible for their “resistance.” Other groups have not been as successful in using such a device to modify an antihypertensive drug regimen in patients with resistant hypertension, suggesting that a Hypertension Specialist may be able to control BP very well, without wasting more time or money on expensive testing.

Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Several preliminary reports have suggested that Hypertension Specialists are expert not only at controlling BP but also other cardiovascular risk factors in their populations of patients. Annual chart reviews at the RUSH University Hypertension Center (staffed by ≥3 Hypertension Specialists) were performed from 2001 to 2007 to assess the proportion of its patients who achieved controlled BP (<140/90 mm Hg, the standard used by the NHANES).[20-28] The results are shown in the Figure 1, as the dark bars (compared with the dark horizontal line, representing the national prevalence of controlled hypertension in NHANES). At all time points studied, the prevalence of controlled hypertension was about double that of the general hypertensive population. This result is all the more remarkable because more than half of the patient population in this Hypertension Center was referred by other physicians due to inadequate BP control in their offices.

image

Figure 1. Prevalence of controlled cardiovascular risk factors in one Hypertension Clinic staffed by Hypertension Specialists. The vertical bars represent the prevalence of controlled hypertension (blood pressure [BP] <140/90 mm Hg, as used by the National Health and Nutritional Examination Surveys [NHANES]) in chart reviews of the population served by the Hypertension Specialists. The horizontal lines represent the prevalence of controlled hypertension in the national survey (NHANES). LDL-c indicates low-density lipoprotein cholesterol; NCEP, National Cholesterol Education Program; A1c, hemoglobin A1c.

Download figure to PowerPoint

Similar, albeit less frequent, surveys of all charts corresponding to patients seen at that Hypertension Center were also reported for control of other cardiovascular risk factors (eg, low-density lipoprotein [LDL] cholesterol, hemoglobin A1c levels in diabetics.).[29-31] These are shown as stippled bars and horizontal lines in the Figure 1. Again, the proportion of patients seen by Hypertension Specialists in the Hypertension Center who achieved their targets for these cardiovascular risk factors was 2 to 3 times that seen in the general US population, as reported by NHANES. These data indicate that Hypertension Specialists excel not only at controlling BP, but also other modifiable cardiovascular risk factors that are amenable to treatment.

Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Since 1999, ASH's Registry Initiative, a program initiated by the ASH Carolinas, Florida, and Georgia Regional Chapter—based at the Medical University of South Carolina—has enrolled community-based medical practices in a quality-improvement program, based on practice data, audit, and feedback reporting. This framework offers the capability: (1) to reveal areas of and reasons for high and low hypertension control rates; and (2) to track physician prescribing patterns, “therapeutic inertia,”[32] (the technical term for the reluctance of physicians and other healthcare providers to intensify antihypertensive treatment when faced with a patient who is NOT at or below goal BP), frequency of key laboratory tests, and the control of hypertension, dyslipidemia, and/or diabetes in their patients.

ASH is committed to quality-improvement initiatives, to improving hypertension outcomes, and to serving as the agent for change in modifiable cardiovascular risk factors. The data collection protocol developed by the ASH Carolinas, Florida, and Georgia Chapter's Hypertension Initiative offers the capability to accomplish these objectives. Plans for its adoption by other regional ASH Chapters are currently underway.

The process and outcomes for ASH Registry Initiative includes a Health Information Portability and Accountability Act (HIPAA)–compliant mechanism for recording and tracking individual patients in a physician's practice, so that quarterly “dashboard report cards” can be generated for each physician regarding control rates, using established NCQA/Product Quality Research Institute (PQRI) indicators (BPs <140/<90 mm Hg in hypertensive patients aged 18 to 85 years; BPs <140/<90, <130/<80 and <140/<80 mm Hg in diabetics, LDL cholesterol levels <100 mg/dL for diabetics, or patients with ischemic cardiovascular disease, and hemoglobin A1c <7%, <8%, and >9% for diabetics). The report also includes control rates by age, sex, and race/ethnicity subgroups; medication class and number of medications prescribed; therapeutic inertia score; frequency of visits; and frequency of evidence-based laboratory testing for each of the 3 major risk factors (cited above). Physicians also receive individualized performance reports on 4 recognition programs: heart disease/stroke, coronary artery disease, heart failure, and diabetes. The first and last programs are recognized by the NCQA, and all 4 are recognized by Bridges-to-Excellence. Providers can securely access a list of their patients who have uncontrolled risk factors, have not been seen in the past 6 months, or have not had the recommended laboratory tests performed in the prior year. The ASH Registry Initiative currently covers more than 1.5 million unique patients, and is expected to increase in size during the next few years, as the ASH Midwest Chapter (and potentially other Regional Chapters) join the effort. ASH is currently considering proposals to extend enrollment in the Hypertension Initiative to all other ASH Regional Chapters nationwide, which has the potential to easily double the numbers of included patients and providers.

Successes of the ASH Registry Initiative include: (1) Improving BP control in 208,517 hypertensive patients during a 5-year period from 49% in 2000 to 66% in 2005,[33] which exceeded the improvement observed in the general US population.[1] (2) Control in 82,442 diabetics (to a hemoglobin A1c level of <7%, hypercholesterolemia to an LDL cholesterol level of <100 mg/dL, and BP to <130/<80 mm Hg) all improved significantly during the same 5-year period of time. (3) The Registry also confirmed in a sample of >265,000 hypertensive patients that roughly a third of those with uncontrolled hypertension were prescribed ≥3 BP-lowering medications and, thus, appear to be treatment-resistant.[34]

The Registry has proved useful in identifying racial/ethnic (black vs white) differences in control of BP, lipids, and diabetes (disparities in control at Veterans Administration [VA] sites was roughly half those at civilian sites).[35-42] Further analyses suggested that better access to healthcare (more visits per year) and medications likely contributed to the narrowing of racial disparities in hypertension control at the VA sites.[36] The Registry database confirmed that white men with and without diabetes had better control of LDL cholesterol levels than white women and black men or women.[42] Of interest, the disparities in LDL control among nondiabetics could be explained by the fact that white men were more likely than other groups to receive prescriptions for lipid-lowering medications. However, among nondiabetics, the same relative differences were observed in LDL cholesterol levels, despite evidence that white men and women as well as black women were equally likely to receive lipid-lowering therapy. In a subsequent analysis of the Registry database, control of BP, lipids, and diabetes to the values noted previously[43] was significantly better in white men (at 23%) than African American women (at 9%). These differences were in large part attributable to differences in LDL cholesterol control.[43, 44] Of note, the work performed under the ASH Registry led to two separate awards from the US Department of Health and Human Services, with recognition as a “Best Practice Model” and for “Reducing Health Disparities.”

There are many potential research and quality-assurance programs that this outreach effort may eventually affect. One of the more interesting ones is the educational program spearheaded by the ASH Carolinas, Florida, and Georgia Chapters, which links very well with the Registry Initiative described above. In this program, Hypertension Specialists engage in Continuing Medical Education activities, sponsored by the ASH, which have as their purpose the improvement of BP (and other cardiovascular risk factor) control rates in the patients seen by the attendees at the educational activities. Preliminary data from these programs show that the attendees at the programs are quite likely to join the Hypertension Initiative to report their data in a timely fashion and to show a significant improvement in control rates not only for BP but also for other cardiovascular risk factors. These data have been sufficient for Blue Cross/Blue Shield of South Carolina to provide a one-time payment of $5000 for every physician who becomes an ASH-Designated Hypertension Specialist. The fact that the newly designated physician is likely to join the educational program, and to educate other healthcare providers to emulate his/her efforts to improve cardiovascular risk factor control, is an extension of the obvious benefit of having such ASH-Designated Hypertension Specialists in the community. Not only do they control their patient populations' cardiovascular risk factors better than their nondesignated colleagues, but they also pass on information on how to achieve these better levels of control to other colleagues as part of the educational programs.[45] Formal analyses of these educational programs have suggested that they are straightforward (eg, recommending initial combination drug therapy[46]), cost-effective,[47] and decreased the patients' office BPs by an average of 1.99/1.49 mm Hg.[48] Perhaps the most rewarding and impressive accomplishment of the ASH-supported Community-Based Practice Network is the change in state-specific ranking of South Carolina's cardiovascular disease mortality, which rose from 51st among all states in 1995, to 35th in 2006.[49]

Efforts to Establish a Taxonomy Code for Hypertension Specialists

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Since 2008, ASH has been pursuing the development of a specialty code for hypertension specialists to recognize the specialized knowledge, experience, and skills of the hypertension specialist. These efforts have included discussions, negotiations, and applications to the National Uniform Claims Committee (NUCC), the Centers for Medicare and Medicaid Services (CMS), and the American Medical Association.

In these discussions, it was necessary to identify the specific healthcare need that the hypertension specialist fills, which was accomplished by pointing out that patients seen by hypertension specialists have a greater severity of hypertension, take a larger number of antihypertensive and other prescribed therapies, have more target-organ damage and more advanced cardiovascular and renal disease, and far more commonly have “uncontrolled” BP. Hypertension specialists are experts in the transformation of resistant or refractory hypertensive patients into controlled hypertensive patients.

To address concerns of the CMS regarding the number or percentage of Medicare patients served by Hypertension Specialists, an electronically mailed survey was sent in late 2010 to all 1324 ASH-Designated Hypertension Specialists in the United States. The response rate was 21%. On average, each Hypertension Specialist reported seeing 135 (interquartile range: 188) Medicare beneficiaries with complex or resistant hypertension annually. These data suggested that ASH-Designated Hypertension Specialists saw about 179,000 Medicare beneficiaries with complex or resistant hypertension annually (or about 0.4% of the Medicare population). Conservative projections of existing data suggest that if a mechanism existed to refer these patients to Hypertension Specialists (eg, a specialty code for such physicians), an additional 2.5 to 3.4 million Medicare beneficiaries could achieve controlled BP.[50]

In these discussions, it was also necessary to have the authorities recognize that ASH-Designated Hypertension Specialists are not currently recognized as “specialist physicians” by the American Board of Medical Specialties (for MDs) or the American Osteopathic Association's Bureau of Specialists (for DOs). All ASH-Designated Hypertension Specialists are, however, board-certified in at least one primary care specialty, as recognized by these bodies. As noted above, this is a requirement for consideration as an ASH-Designated Hypertension Specialist. In addition, ASH has ongoing relationships with most (if not all) other professional organizations involved in Continuing Medical Education activities that would be expected to be of joint interest. For example, ASH has sponsored and accredited symposia for Continuing Medical Education at recent national or regional meetings of the American Heart Association, American College of Cardiology, American Society of Nephrology, as well as other professional organizations.

In mid-2012, ASH was notified by the NUCC that its request for a taxonomy code for ASH-Designated Hypertension Specialists had been approved. How the new taxonomy code (207RH0005X) will be implemented, and its impact on physician reimbursement, will be determined by CMS in the near future.

Summary

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References

Collectively, these data make it likely that ASH-Designated Hypertension Specialists should enhance cardiovascular risk factor control rates, not just among the patients they see with resistant hypertension but also in their populations as a whole. In addition, ASH-Designated Hypertension Specialists have had, and are likely to continue to exert, a salutary effect on other healthcare providers in their local areas, who follow the lead of the ASH-Designated Hypertension Specialist in improving cardiovascular risk factor control in the short-term, and probably cardiovascular outcomes in the long-term. Such efforts have now been rewarded with a specialist taxonomy code for hypertension specialists.

References

  1. Top of page
  2. Abstract
  3. Heterogeneity of Hypertension
  4. Challenges in Hypertension
  5. Limited Supply of Hypertension Specialists
  6. Current Criteria for the Designation of Specialist in Clinical Hypertension
  7. Clinical Functions of a Hypertension Specialist
  8. Impact of the Hypertension Specialist in “Resistant Hypertension”
  9. Impact of the Hypertension Specialist in Controlling BP (and Other Cardiovascular Risk Factors) in Patient Populations Served
  10. Impact of the Hypertension Specialist Outreach Program in Improving BP Control in Patient Populations
  11. Efforts to Establish a Taxonomy Code for Hypertension Specialists
  12. Summary
  13. References
  • 1
    Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment and control of hypertension, 1988–2008. JAMA. 2010;303:20432051.
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