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CDC Vital Signs: High blood pressure is out of control for too many Americans, Telebriefing

Wednesday, September 4 at Noon ET

OPERATOR: Welcome and thank you for standing by.  At this time all participants are on a listen only mode. During the question and answer session of today’s call you may press star 1 to ask a question. Today’s conference is being recorded and at this time I will turn the call over to Tom Skinner. You may begin sir.

TOM SKINNER: Thank you Shirley and thank you all for joining us today for September release of the Vital Signs from the CDC.  This Vital Signs one is on awareness and treatment of uncontrolled hypertension among adults United States 2003 to 2010.  With us today, who will give some brief opening remarks is the director of the CDC, Dr. Thomas Frieden. We are also joined by Dr. Amy Valderrama; I will spell that last name its V-A-L-D-E-R-R-A-M-A. She is with the Division for Heart Disease and Stroke Prevention and she will be available to help answer questions when we get to the Q & A. So, I will turn it over to Dr. Frieden, right now who will speak for about 3 to five minutes and we will get to your questions. Dr. Frieden.

TOM FRIEDEN: Good afternoon everyone and thanks for joining us. This month Vital Signs is about high blood pressure and specifically that 36 million Americans who have high blood pressure but don’t have it under control. That’s nearly half, 46 percent of all Americans with high blood pressure don’t have it under control and because of that high blood pressure is public health enemy number two. Number one is tobacco which kills more people than any other cause of disease. But high blood pressure, specifically and especially, uncontrolled high blood pressure is the next most deadly condition. It causes strokes and heart attacks, kidney failure and many other health problems. One in three Americans, 67 million people has high blood pressure. About half of them, 36 million don’t have it under control. The result of high blood pressure is about 131 billion dollars a year in healthcare cost and even more importantly high blood pressure contributes to about 1,000 deaths per day. Today and every day this year, we have to roll up our sleeves and make blood pressure control a priority, every day with every patient that every doctor’s visit.   Similarly to tobacco control, we actually know what to do about high blood pressure. We have great medicines, they work really well. We know how to get high blood pressure under control, patients can take medications as prescribed, doctors and other health care providers can go to simpler treatment courses with single pill per day, combination pills as appropriate and make sure that they are tracking their outcomes. Health centers, health insurers, and other providers can use electronic health records, they can do things like using 90 day refills and if possible, no or low co-payments. We can use the whole healthcare team. We know that when pharmacists, nurses practitioners, allied health workers, office staff are all involved in care, we can see dramatic and rapid improvements in blood pressure control. There are lots of opportunities for people with high blood pressure to get it under control, but it has to be a priority at every doctor’s visit. Of the 36 million Americans, who have uncontrolled high blood pressure, 26 million had seen a doctor at least twice in a previous year. And, quite a few, about 16 million are aware of their blood pressure and are on treatment, but the treatment is not sufficient to control their blood pressure. There are another 14 million who say they are unaware of having high blood pressure and we have some hints of why that might be from a few different systems. We know that in at least three different well-functioning systems, until they looked carefully at their electronic health records, as many as a third of all patients or more who had multiple high blood pressure readings were not diagnosed as having high blood pressure, they weren't on treatment for it, it wasn't on their problem list, and the patients, of course, were not aware. So a lot can be done to make sure that patients get their blood pressure down to below 140/90, and that's particularly important because with high blood pressure you're four times as likely to die from a stroke, you're three times as likely to die from heart disease. Implementation of the affordable care act means that more Americans will have access to care, there is a focus on improving the quality of care, and improving the coordination between clinical and community prevention. It also increases opportunities for getting a whole health care team engaged in supporting patients and for ensuring that electronic health records have meaningful use of information, particularly things like control of blood pressure. At CDC working with CMS, with insurers, with the private sector, with nongovernmental organizations such as American Heart Association, we've launched a Million Hearts initiative to reduce blood pressure and our goal is to work together as a society to reduce by at least 10 million the number of Americans whose blood pressure is out of control. Tomorrow, September 5th, we'll be launching with the Surgeon General a new program, "Team up. Pressure down," to promote team-based care for health professionals to improve medication adherence so people can more effectively manage their blood pressure. It's a whole host of time-saving things that support pharmacists in providing advice and counsel to patients with high blood pressure and it can be used in any pharmacy setting. We're also working with employers and kicking off in September at our own clinics at CDC and throughout the country to support them to better monitor blood pressure and feed that information back to patients and to their physicians. Bottom line is that 36 million Americans with high blood pressure, most of those in the country who have it don't have their numbers under control, and because of that we have a very high burden of disease. 1,000 people a day dying from high blood pressure and 130 billion dollars a year in health care costs. We know that providers who focused on high blood pressure can get it under control and get it under control quickly. So systems, large and small, in different environments, private doctors’ offices, large practices, the veterans administration, some large health care systems, have been able to drastically improve the proportion of their patients who have their blood pressure under control. It takes focus. Nationally there's agreement among all the national quality forums indicate, which is known as national quality forum number 18, is the proportion of patients in a system who have their blood pressure controlled. That piece of information is crucially important and we're working with insurers and with providers to make sure that every system is aware of their results and is working to improve them. The systems that have focused on the results have shown that it's possible to make rapid and substantial improvement. Five years from now, there should be at least 10 million fewer Americans with blood pressure out of control and that will prevent many of the more than 1,000 deaths per day that we're experiencing today from public health enemy number two, high blood pressure. Thanks very much.

TOM SKINNER: Shirley, I believe we're ready for questions, please.

OPERATOR:  Thank you. Some are ready to begin the question and answer session. If you would like to ask a question, please press star 1 and record your name clearly. Again, press star 1 to ask a question. And one moment for our first question. Our first question comes from Mandy Gardner, with HealthDay. You may ask your question.

MANDY GARDNER: Hi. Thanks so much for taking my question. I was wondering if somebody could discuss the role of prevention in this picture.

TOM FRIEDEN: We know that many things contribute to high blood pressure and there is a lot that can be done to reduce it in society as a whole. But today in this country more than two-thirds of people over the age of 65 have high blood pressure and realistically for the foreseeable future, one of the most important things we will be able to do is improve treatment. Now, certainly the case that if you have high blood pressure and work to maintain a healthy weight and you get more physical activity you are much more likely to be able to get that blood pressure under control. It's also the case as a society that if we can work with the food industry to voluntarily steadily reduce the amount of sodium in food, we can see a reduced level of high blood pressure and the burden of high blood pressure on health care in this society. So prevention is important. In the case of high blood pressure, our major progress is probably going to be made through more effective treatment. And we've already seen remarkable examples of that. As one example, the Kaiser Permanente has been able to get their rate of blood pressure controlled up to 80 percent, 85 percent. And with it, they're not just seeing better numbers in terms of blood pressure control they're seeing dramatic decreases in heart attacks and strokes. So treatment can make a really big difference here in the short and medium term.

MANDY GARDNER:  Thank you.

TOM SKINNER: Next question, Shirley.

OPERATOR:   Thank you. Next question comes from Robert Lowes, Medscape medical news. You may ask your question.

ROBERT LOWES: Yes. Thank you for taking my call. Do these numbers, particularly the fact that nearly 90 percent of the people with uncontrolled hypertension have a usual source of health care, they have insurance coverage, and they received health care in the last year, do those numbers cast a bad light on our health care system in the sense that it's underperforming? This is a basic illness, easily treated, if people focus, but would you say to that these numbers cast a poor light on health care industry and providers?

TOM FRIEDEN:  The fact is that controlling blood pressure is not easy. It means taking medications, often multiple medications, every day, usually for the rest of your life and ensuing that patients get the support and follow-up and that systems have the tracking systems in place to allow that to happen is very important. What's encouraging is that there are systems around the country that have done such a good job at this. It tells us that it's possible, not just in the VA, not just in Kaiser, but in private doctor's offices, not just in one part of the country but in many parts of the country. So, I think there's clearly a lot of room for improvement. We’re only at 46 percent controlled, and we know from systems that have looked carefully at their electronic health records, programs, that many patients who have multiple readings, high blood pressure, are not having hypertension listed in their problem list, they're not being treated, they're not being told. And I suspect that that's why 14 million Americans with high blood pressure say that they're not aware of having blood pressure. They may not have been told. Some of them may never have been in care. I suspect that a great majority have actually had a measurement of high blood pressure before the examination in this survey. Some of them may have been told and forgotten, but many of them wouldn't have been recognized. So there are important things that doctors can do, one is to make sure that they're identifying everyone's high blood pressure, look at their results, NQF-18, the national quality forum indicator on blood pressure control, and to provide that kind of feedback, provider by provider, on a monthly basis as a way of supporting doctors to do a better job. What we've seen in system after system is that doctors want to do a better job. When you empower them with information, they use it immediately to improve care of their patients.

ROBERT LOWES:  Follow-up question. You're suggesting that they might record a high blood pressure reading, electronic health record, but they don't review it and decide to say on the basis of this we need to, you know, diagnose this patient with this condition?

TOM FRIEDEN:  Yes. We've seen two consistent trends, one is from multiple systems, even from our highly performing systems, that multiple elevated readings don't translate into a diagnosis of hypertension or appropriate treatment, and the second is that when people are on treatment for high blood pressure and they come in with an out of control reading, there's often insufficient attention to addressing that. That may be a discussion with the patient about whether they still are taking their medication or it might be an intensification of the medication regimen with higher doses or an addition of higher medicine. That’s up to the individual doctor. But the point is that an elevated blood pressure reading is a life-threatening reading and prompt action of some sort needs to be taken.

TOM SKINNER:  Next question, Shirley.

OPERATOR:   Thank you. This question comes from Lily Kuo, Reuters.

LILY KUO: Still, uncontrolled high blood pressure, does that basically mean people with hypertension who are not getting better? Secondly, is that reason because it is not getting sufficient treatment or they don't know about it? Could you describe a little bit more about why it is that they're not getting better?

TOM FRIEDEN: Sure, so high blood pressure defined as a blood pressure higher than 140/90 so either the first number is over 140 or the second number is over 90, or both.

LILY KUO: Right.

TOM FRIEDEN: Predict the higher risk of heart attack, stroke, and other serious health problems, most Americans, 54 percent, who have had high blood pressure at some point still are over 140/90. So,  they're still at a very high risk of a heart attack or a stroke that would be prevented if they were on treatment more effectively. The greatest proportion of those who are out of control are on treatment, but that treatment either isn't optimal or they're not taking it, in some way or another, it's not working for them. Not because their medicines don't work, medicines for high blood pressure work for nearly all patients. The issue is often that they're not receiving an optimal combination of medicines or that their doctor may not have seen them or may not recognize that they're having trouble paying for their prescriptions. One problem or another gets in the way of patients taking their medicines and, therefore, their blood pressure stays in the danger zone.

LILY KUO: Okay.so how is that different throughout -- out of control blood pressure, how is that different from just high blood pressure?

TOM FRIEDEN: If you have high blood pressure but you're on treatment and that treatment is effective, your blood pressure, when it's measured today, might be 110/70. If you stopped taking your medicines it would bounce right back up to, say, 200/100, but as long as you take your medicines you're keeping the pressure down, you're protecting your brain from stroke and your heart from a heart attack. Is that clear?

TOM SKINNER:  Shirley, next question, as we move to the next question, will you remind callers of the instructions to ask questions, please?

OPERATOR:  Thank you. And again, if you would like to ask a question, press star 1. The next question comes from Deborah Kotz, Boston Globe. You may ask your question.

DEBORAH KOTZ: Hi there. Thank you for taking my question. I was wondering also with my follow-up question that relates to the first one, first of all why doctors are not -- it seems like in this day and age, when the doctor sees a number of false high blood pressures, why they're not responding to that, why they're not, you know, putting patients on medication, if there's any indication from the statistics in the study, why that would be. And, also, what is Kaiser doing right that they have so much higher numbers than the national averages?

TOM FRIEDEN:  I think the reason that this is difficult is that it's a condition that requires treatment every day for the rest of people's lives. So people do have a tendency to hope that it's going to go away if they just don't take medications. There’s also a critical lack of information in many doctor's offices, so when doctors are made aware of how they're doing through electronic health records we see an immediate bump in the proportion of patients who have their blood pressure under control. Doctors are busy. They’re dealing with many different challenges. And getting that information so that before each visit, during each visit, and after each visit there's critical information of what they can do for patients and emphasizing that treating blood pressure effectively is, in all likelihood, the single most important thing the health care system can do to save lives. There is nothing that will save more lives than controlling blood pressure better than we're doing today. That’s why it's so important that doctors get blood pressure under control. Interestingly, it's not just Kaiser which has certain advantages of being a relatively controlled system, but private doctors' offices and others. And there are certain things that we're seeing as consistent findings. Some more than others, in different programs, but the first is, quite simply saying, this is crucial and tracking their performance on national quality forum 18 so they know what proportion of their patient are under control and they get that feedback on a monthly or quarterly basis so they can quickly get a list of who is out of control, call them back in for care, address any problems that patients are having. Second is the importance of using electronic health records, so they can do that. With the click of the mouse say, a list of my patients who need further attention and then I can call them or have an assistant call them and invite them back in for care. Perhaps talk with their pharmacists about titrating their medication to get them more appropriate. That’s the third key component, is a team approach to supporting patients. Getting pharmacist, office staff, nurses, nurse practitioners, doctors, all involved so that the doctor can be the quarterback and make sure that the right things are being done, but doesn't have to do everything her or himself, the whole team can do that. So that kind of approach is critically important in helping systems help patients get their pressure under control.

OPERATOR:  I am showing no further questions.

TOM FRIEDEN:  Okay. All right. So thank you all very much for joining us. Bottom line, again today, high blood pressure is public health enemy number two. We know what to do about it, but most Americans with high blood pressure, 54 percent, 36 million Americans, don't have their blood pressure under control. The largest group of those are on treatment but perhaps not adequate to control their blood pressure or not taking their medications regularly, however, we've seen large and small systems and urban and rural areas and all parts of the country get their control numbers much higher than they were just a year or two ago by focusing on getting blood pressure under control, by supporting doctors, pharmacist, nurse, nurse practitioners, and others with information by ensuring that patients have their questions answered and access to treatment ideally at low or no co-payment. So I am optimistic that in a few years we will be able to see significant reductions in those numbers and our goal in the million hearts program is that 10 million fewer Americans will have blood pressure out of control. Thank you all very much.

TOM FRIEDEN: Thank you, Shirley. Thank you all for joining us. Should you have any follow-up questions or need initial information on this vital signs, please call the CDC press office at 404-639-3286.thank you very much.

OPERATOR:  Thank you. This concludes today's conference. We thank you for your participation, at this time you may disconnect your line.

 

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