High blood pressure control continues to improve in England

Awareness, treatment and control of high blood pressure have increased significantly in England, according to a nationally representative health survey reported in Hypertension: Journal of the American Heart Association.

Researchers evaluated blood pressure management in 2006 compared to 2003, focusing on heart disease and its prevention. The key findings showed that among those treated, 53 percent of women and 52 percent of men achieved control of high blood pressure in 2006 compared to 44 percent of women and 48 percent of men in 2003.

"This is the first time in England that the majority of those on treatment are actually controlled," said Neil R. Poulter, M.B.B.S., M.Sc., F.R.C.P., senior author of the study and professor and chairman of Preventive Cardiovascular Medicine at Imperial College London. "That's a first and that's good news." Analyzing 7,478 people (3,314 men and 4,164 women) ages 16 and older (average age 47), researchers found:

• Awareness of high blood pressure reached 71 percent of women and 62 percent of men in 2006 compared to 64 percent of women and 60 percent of men in 2003.
• Treatment was under way in 62 percent of women and 47 percent of men in 2006 compared to 52 percent of women and 43 percent of men in 2003.
• Overall control was achieved in 32 percent of women and 24 percent of men in 2006 compared to 23 percent of women and 21 percent of men in 2003.

"This increase in the rate of awareness, treatment and control of hypertension continues a trend that was started in 1994," said Emanuela Falaschetti, M.Sc., lead author of the study and a statistician at University College London.

Researchers also found the use of medications changed from 2003 to 2006. In 2006, more than 60 percent of those treated were receiving two or more anti-hypertensive medications compared to 56 percent in 2003. Of one-, two-, three- or four-drug regimens, the single biggest percentage of people were on a two-drug regimen in 2006.

In April 2004, the Quality and Outcomes Framework (QOF) was introduced in the new General Medical Services (GMS) contract in the UK. In this pay-for-performance system, general practitioners receive compensation for achieving various clinical targets, with points and payments awarded according to the level of achievement. As a voluntary part of the new GMS contract, general practices can aspire to achieve all, part or none of the points available in QOF. Most practices with a GMS contract have participated fully.

One of the measured achievements is lowering blood pressure levels to less than 150 millimeters of mercury (mm Hg) systolic and less than 90 mm Hg diastolic. The potential impact of this aspect of practitioners' new contract on blood pressure control in the population has not been evaluated in any rigorous way using a population-based sample in England. However, a recent study on data from general practices from April 2004 to March 2007 attributed for the first time improved blood pressure monitoring and control in the UK to the physician pay-for-performance incentives.

"Controlling blood pressure is one of the most cost-effective ways of reducing the risk of heart attacks, strokes and deaths," Poulter said. "The control rates we have witnessed in England are big, probably the best in Europe in controlling blood pressure. This can be put down to the increased use of medications and highlights the fact that it can be done."

In an accompanying editorial, Sailesh Mohan, M.D., and Norm R.C. Campbell, M.D., of the University of Calgary, Canada, wrote: "It is critical to discern the impact of Performance for Pay on hypertension management so that other countries can assess the potential to improve hypertension management using this tactic. The basis for improved hypertension in England prior to and following the introduction for pay for performance requires more rigorous exploration."

Despite improving trends, hypertension rates in England are far from the optimum and "more intensive efforts are clearly warranted to prevent and control hypertension so that a meaningful impact can be achieved in reducing hypertension-associated cardiovascular disease," they wrote.