• Hypertensive Disease

• Cardiology & Cardiovascular Medicine
• Hypertensive Disease

It is estimated that about two-thirds of patients with hypertension (HTN) are located in the developing world, such as the Caribbean. Despite effective medications and other tools for the management of HTN, the prevalence of poorly controlled HTN remains high. Thus, additional measures are needed to improve the control of HTN, particularly in the developing world. Kenneth Connell, MBBS, DM, PhD, Queen Elizabeth Hospital Barbados, Bridgetown, Barbados, discussed the standardization of the Global Standardized Hypertension Treatment Project (GSHTP) and the Caribbean Public Health Agency (CARPHA).

It is estimated that in 2020, 80% of HTN deaths will be in low- to middle-income countries. In addition, there is substantial economic burden that is linked to HTN. In Barbados, 60% of the budget for drugs is applied to treating HTN; yet, HTN is controlled in < 30% of patients. Recent work to address the problem of HTN has focused on updating the guidelines, increasing the focus on the need for blood pressure control, and increasing government involvement. Despite these efforts, the control of HTN remains inadequate.

The GSHTP began in April 2014 and is focused on making the “process” of treating HTN more efficient. It aims to improve the control of HTN by identifying a core set of medications, making those medications widely available, improving the delivery of care, and increasing the use of medications. Data collected from the Winston Scott Polyclinic and the Edgar Cochrane Polyclinic, including the direct observation of physician practice, medical records, health care provider questionnaires, and interviews with stakeholders, helped to inform the development of the CARPHA HTN guidelines. It is hoped that these guidelines will encourage providers to use new treatment protocols and create systems to track the use of these protocols. These guidelines are expected to be published in late 2014.

Although there are multiple guidelines that have been updated recently for the management of HTN, Prof. Connell pointed out that there are differences among these guidelines, and there is a need for a regionally specific guideline informed by regional data.

Pragna Patel, MD, MPH, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA, further discussed the goals of the GSHTP. The GSHTP was conceived following a World Health Organization assembly focused on noncommunicable diseases and was formed with a goal of reducing HTN by 25% by the year 2025.

Multiple patient-, provider- and systems-based barriers to blood pressure control have been identified. For example, patients may have limited access to care or have poor adherence to treatment. Health care providers may be reluctant to treat an asymptomatic condition, have insufficient time with individual patients, or fail to follow guidelines. In addition, patients often have poor follow-up and difficulty obtaining medications. Health systems fail to use nurses and other providers who can assist in the management of hypertension.

In response to these barriers, the GSHTP has developed a framework based on prior experience with tuberculosis that includes a structured approach to deliver high-quality and standardized health care with sufficient support systems [Seita A, Harries AD. Int J Tuberc Lung Dis 2013]. In addition, the GSHTP has created treatment targets and indicators to expand services and reduce the overall burden of disease.

A similar framework was applied by the Kaiser Permanente Northern California HTN organization that resulted in an increase of HTN control from 44% to 80% [Jaffe MG et al. JAMA 2013]. The 6 care processes that were implemented to achieve this substantial improvement were the development of an evidence-based treatment guideline, initiation of an HTN registry, development of a performance measure, dissemination of these quality improvement initiatives, promotion of a single-pill combination therapy to improve adherence, and development of blood pressure checks by nonphysicians.

The goal of the framework of the GSHTP is to standardize the pharmacologic treatment of HTN and to encourage the use of evidence-based guidelines. The core medications were categorized based on whether therapies were considered first line or backup. These medications were then further classified based on class and whether fixed combinations were available as a single pill.

To facilitate the availability of medications, the Pan American Health Organization (PAHO) Strategic Fund was created to procure the medications at a low cost for Latin America. Countries within this region can choose to purchase HTN medications through the fund. Following a workshop with GSHTP, the PAHO Strategic Fund added 4 of the primary medications and 3 of the backup medications on the core medication list to the fund's procurement.

To improve the treatment of HTN, GSHTP held a workshop to assess several key elements, including standard treatment guidelines, creating registries and information systems, standardizing medications and making them available, encouraging patient-centeredness to improve self-management interventions, improving the organizational management of care systems, and promoting community involvement. In addition, a clinical toolkit was developed by the GSHTP for health care providers and administrators that included an overview of HTN, webi-nars on using registries and standardized treatment protocols, educational materials for providers and patients, and clinical tools for managing HTN and improving patient adherence to medications. This toolkit will be available on the US Centers for Disease Control and Prevention website.

In conclusion, Dr. Patel highlighted that the goal of the GSHTP is to develop a framework for managing HTN that is feasible and able to be used throughout the developing world. In addition, she stressed that the GSHTP is not meant to replace any current HTN guidelines but is to facilitate the control of HTN.

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