Implementation of recommendations on hypertension: the Canadian Hypertension Education Program

'Inequalities in prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment in 429 districts of Iran; a population-based STEPS 2016 small area spatial estimation model'

Purpose

While many studies have reported hypertension (HTN) and pre-hypertension (PHTN) in large geographic locations of Iran, information regarding district levels is missing. We aimed to examine inequalities in the prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment of adults in districts of Iran.

Methods

We used 27,165 participants' data from the STEPS 2016 study in Iran. A small area estimation model was carried out to predict HTN in the 429 districts of Iran. HTN and PHTN were defined based on the American Heart Association Guideline. Awareness of being hypertensive, treatment coverage, and effective treatment were also estimated.

Results

HTN's crude prevalence was estimated to be in the range of 11.5-42.2% in districts. About PHTN, it was estimated to be 19.9-56.1%. Moreover, for awareness, treatment coverage, and effective treatment crude estimates ranged from 24.3 to 79.9%, 9.1 - 64.6%, and 19.5 - 68.3%, respectively, indicating inequalities in the distribution of aforementioned variables in 429 districts of Iran. Overall, better conditions were detected in central geographical locations and in females.

Conclusion

The inequality of increased blood pressure disorder and related measures are high in districts of Iran and pave the way for policymakers and local health organizers to use the findings of this study to address the inequity of existing resources and improve HTN control.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01186-5.

Ups and downs of hypertension control in Canada: critical factors and lessons learned

As the leading risk for death, population control of increased blood pressure represents a major challenge for all countries of the Americas. In the early 1990’s, Canada had a hypertension control rate of 13%. The control rate increased to 68% in 2010, accompanied by a sharp decline in cardiovascular disease. The unprecedented improvement in hypertension control started around the year 2000 when a comprehensive program to implement annually updated hypertension treatment recommendations started. The program included a comprehensive monitoring system for hypertension control. After 2011, there was a marked decrease in emphasis on implementation and evaluation and the hypertension control rate declined, driven by a reduction in control in women from 69% to 49%. A coalition of health and scientific organizations formed in 2011 with a priority to develop advocacy positions for dietary policies to prevent and control hypertension. By 2015, the positions were adopted by most federal political parties, but implementation has been slow.

This manuscript reviews key success factors and learnings. Some key success factors included having broad representation on the program steering committee, multidisciplinary engagement with substantive primary care involvement, unbiased up to date credible recommendations, development and active adaptation of education resources based on field experience, extensive implementation of primary care resources, annual review of the program and hypertension indicators and developing and emphasizing the few interventions important for hypertension control. Learnings included the need for having strong national and provincial government engagement and support, and retaining primary care organizations and clinicians in the implementation and evaluation.

Lowering blood pressure by changing lifestyle through a motivational education program: a cluster randomized controlled trial study protocol

BACKGROUND

High blood pressure is an independent risk factor of cardiovascular disease (CVD) and is a major cause of disability and death. Managing a healthy lifestyle has been shown to reduce blood pressure and improve health outcomes. We aim to investigate the effectiveness of a lifestyle modification intervention program for lowering blood pressure in a rural area of Bangladesh.

METHODS

A single-center cluster randomized controlled trial (RCT). The study will be conducted for 6 months, a total of 300 participants of age 30 to 75 years with 150 adults in each of the intervention and the control arms. The intervention arm will involve the delivery of a blended learning education program on lifestyle changes for the management of high blood pressure. The education program comprises evidence-based information with pictures, fact sheets, and published literature about the effects of high blood pressure on CVD development, increased physical activity, and the role of a healthy diet in blood pressure management. The control group involves providing information booklets and general advice at the baseline data collection point. The primary outcome will be the absolute difference in clinic SBP and DBP. Secondary outcomes include the difference in the percentage of people adopting regular exercise habits, cessation of smoking and reducing sodium chloride intake, health literacy of all participants, and the perceived barriers and enablers to adopt behavior changes by collecting qualitative data. Analyses will include analysis of covariance to report the mean difference in blood pressure between the control and the intervention group and the difference in change in blood pressure due to the intervention.

DISCUSSION

The study will assess the effects of physical activity and lifestyle modification in controlling high blood pressure. This study will develop new evidence as to whether a simple lifestyle program implemented in a rural region of a low- and middle-income country will improve blood pressure parameters for people with different chronic diseases by engaging community people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04505150 . Registered on 7 August 2020.

Evaluation of the agreement between guidelines and initial antihypertensive drug treatment using a national health care reimbursement database

RATIONALE, AIMS AND OBJECTIVES

To test the agreement between guidelines for the management of hypertension and medical practices while avoiding frequent limitations such as the use of non-representative samples of practitioners and self-reporting of their practices over a short period of time.

METHODS

The characteristics of initial antihypertensive drug treatment in a large representative sample of the French population aged 50-80 (n = 17 855) were collected from a national health care reimbursement database and compared with national guidelines over a 5-year period.

RESULTS

Major discrepancies are observed including the use of non-recommended drug classes such as loop and potassium sparing diuretics alone or in association and the absence of distinction between patients according to their age. More minor discrepancies are the preferential use of mono-therapies over drug combinations and of some bi-therapies among those recommended. Some degree of concordance with the guidelines is also observed including the specific characteristics of the treatment of diabetics compared with other categories of patients and the preferential use of long-acting dihydropyridine calcium antagonists and of low-dose thiazide diuretics when these drug classes are chosen. Several of these discrepancies or concordances, which mainly reflect general practitioner (GP) activity, show time trends over the entire follow-up period with no significant effect of the guideline released during this period.

CONCLUSIONS

At the French national level, the agreement between initial antihypertensive drug treatment and guidelines varies considerably depending on the characteristics of the treatment that are considered. The GPs who delivered the treatment do not seem to have been influenced by the guidelines released over the last decade.

A framework for discussion on how to improve prevention, management, and control of hypertension in Canada

Increased blood pressure is a leading risk for premature death and disability. The causes of increased blood pressure are intuitive and well known. However, the fundamental basis and means for improving blood pressure control are highly integrated into our complex societal structure both inside and outside our health system and hence require a comprehensive discussion of the pathway forward. A group of Canadian experts was appointed by Hypertension Canada with funding from Public Health Agency of Canada and the Heart and Stroke Foundation of Canada, Canadian Institute for Health Research (HSFC-CIHR) Chair in Hypertension Prevention and Control to draft a discussion Framework for prevention and control of hypertension. The report includes an environmental scan of past and current activities, proposals for key indicators, and targets to be achieved by 2020, and what changes are likely to be required in Canada to achieve the proposed targets. The key targets are to reduce the prevalence of hypertension to 13% of adults and improve control to 78% of those with hypertension. Broad changes in government policy, research, and health services delivery are required for these changes to occur. The Hypertension Framework process is designed to have 3 phases. The first includes the experts' report which is summarized in this report. The second phase is to gather input and priorities for action from individuals and organizations for revision of the Framework. It is hoped the Framework will stimulate discussion and input for its full intended lifespan 2011-2020. The third phase is to work with individuals and organizations on the priorities set in phase 2.

Do recommendations for the management of hypertension improve cardiovascular outcome? The canadian experience

The Canadian Hypertension Education Program (CHEP) was established in 1999 as a response to the result of a national survey that showed that a high percentage of Canadians were unaware of having hypertension with only 13% of those treated for hypertension having their blood pressure controlled. The CHEP formulates yearly recommendations based on published evidence. A repeat survey in 2006 showed that the percentage of treated hypertensive patients with the blood pressure controlled had risen to 65.7%. Over the first decade of the existence of the CHEP, the number of prescriptions for antihypertensive medications had increased by 84.4% associated with a significant greater decline in the yearly mortality from stroke, heart failure and myocardial infarction and a significant decrease in the hospitalization for stroke and heart failure. Therefore, the introduction of the CHEP and the yearly issue of updated recommendations resulted in a significant increase in the awareness, diagnosis and treatment of hypertension and in a significant reduction in stroke and cardiovascular morbidity and mortality. The CHEP model could serve as a template for its adoption to other regions or countries.

The Canadian effort to prevent and control hypertension: can other countries adopt Canadian strategies?

PURPOSE OF REVIEW

To indicate the key elements of current Canadian programs to treat and control hypertension.

RECENT FINDINGS

In the early 1990s Canada had a hypertension treatment and control rate of 13%. A Canadian strategy to prevent and control hypertension was developed and a coalition of national organizations and volunteers formed to develop increasingly extensive programs. The Canadian effort was largely based on annually updated hypertension management recommendations, an integrated and extensive hypertension knowledge translation program and an increasingly comprehensive outcomes assessment program. After the start of the annual process in 1999, there were very large increases in diagnosis and hypertension treatment coupled with dropping rates of cardiovascular disease. More recent initiatives include an extensive education program for the public and people with hypertension, a program to reduce dietary salt and a funded leadership position. The treatment and control rate increased to 66% when last assessed (2007-2009).

SUMMARY

The study describes important aspects of the Canadian hypertension management programs to aid those wishing to develop similar programs. Many of the programs could be fully or partially implemented by other countries.

Primary prevention, aging, and cancer: overview and future perspectives

Cancer-specific primary prevention efforts for the geriatric population are not understood well and currently are underused despite the rapidly growing elderly population. It has been established that lifestyle changes, such as smoking cessation, dietary changes, and increasing physical activity, decrease the incidence of cancer in younger populations. However, a multitude of conceptual, methodological, and dissemination challenges arise when the objective is to apply primary prevention of cancer to the elderly. For this article, the state of the science was reviewed to reveal barriers in the uptake of cancer-specific primary prevention practices, including the lack of data for the applicability of clinical research findings to older populations. Under-representation of older adults in behavioral trials and research programs is hindering progress in understanding the physical health and lifestyle choices of older individuals. Efforts directed toward prevention in terms of promoting health behaviors may be not only clinically advantageous but also cost-effective. In addition, models for translating research findings on primary prevention from younger individuals to the elderly population needs to be addressed. Practitioners need to gain a better understanding of the opportunities for cancer-specific primary prevention, because such an understanding could enhance the management of chronic disease.

Increases in Antihypertensive Prescriptions and Reductions in Cardiovascular Events in Canada

The Canadian Hypertension Education Program, an extensive professional education program to improve the management of hypertension, was started in 1999. There were very large increases in diagnosis and treatment of hypertension in the first 4 years after initiation of the program. The purpose of this study was to examine the association between the changes in antihypertensive therapy with changes in hospitalization and death from major hypertension-related cardiovascular diseases in Canada between 1992 and 2003. Using various national databases, Canadian standardized yearly mortality and hospitalization rates per 1000 for stroke, heart failure, and acute myocardial infarction were calculated for individuals aged ≥20 years and regressed against antihypertensive prescription rates. Changes in rates were examined in a time series analysis. There were significant reductions ( P <0.0001) in the rate of death from stroke, heart failure, and myocardial infarction starting in 1999. There was also a reduction in hospitalization rate from stroke ( P <0.0001) and heart failure ( P <0.0001) but not myocardial infarction in 1999. The changes in death ( P <0.001 for all 3 diseases) and hospitalization ( P <0.0001 for stroke and heart failure; P =0.018 for acute myocardial infarction) were associated with the increases in antihypertensive prescriptions. This study demonstrates that the reduction in cardiovascular death and hospitalization rates is associated with an increase in antihypertensive prescriptions and that it coincides with the introduction of the Canadian Hypertension Education Program. The Canadian Hypertension Education Program educational model for improving health care could be adopted by other countries with well-developed professional and scientific societies.

Trends in antihypertensive drug prescriptions and physician visits in Canada between 1996 and 2006

BACKGROUND

In 1999, the Canadian Hypertension Education Program (CHEP) was launched to develop and implement evidence-based hypertension guidelines.

OBJECTIVES

To determine temporal trends in antihypertensive drug prescribing and physician visits for hypertension in Canada, and correlate these trends with CHEP recommendations.

METHODS

Longitudinal drug data (Intercontinental Medical Statistics [IMS] CompuScript database; IMS Health Canada) were used to examine prescriptions over an 11-year period (1996 to 2006) for five major cardiovascular drug classes. The IMS Canadian Disease and Therapeutic Index database was used to determine trends in physician office visits for hypertension.

RESULTS

Prescriptions for antihypertensive agents increased significantly over the 11-year period (4054% for angiotensin receptor blockers, 127% for thiazide diuretics, 108% for angiotensin-converting enzyme inhibitors, 87% for beta-blockers and 55% for calcium channel blockers). Time series analyses demonstrated increases in the growth rate for all drug classes, with the greatest annual change in prescriptions occurring during the 1999 to 2002 time period (except in angiotensin receptor blockers). An increase in prescriptions for fixed-dose combination products occurred, which was temporally related to the change in CHEP recommendations encouraging their use in 2001. The proportion of physician office visits for hypertension increased significantly from 4.9% in 1995 to 6.8% in 2005 (P<0.001).

CONCLUSIONS

The largest increase in antihypertensive drug prescribing occurred in the period immediately following implementation of CHEP (1999 to 2002). Although prescribing rates are still increasing, the rate of change has decreased, suggesting that the treatment market for hypertension may be becoming saturated. The impact of these changes on blood pressure control and clinical outcomes remains to be determined.

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

Antihypertensive medication use by recently diagnosed hypertensive Canadians

PURPOSE

The Canadian Hypertension Education Program (CHEP) was initiated in 1999 to improve hypertension management in Canada. The objective of the present study was to compare antihypertensive pharmacotherapy in Canada before and after the CHEP.

METHODS

Data were obtained from the longitudinal National Population Health Surveys, which consisted of five cycles at two-year intervals from 1994 to 2002. Recent hypertensive respondents 20 years of age and older were identified the first time hypertension was reported or treated, and were included in a study population of 1453 newly diagnosed hypertensive patients. Persistence with medication use was assessed in the cycle after the first report of hypertension.

RESULTS

Antihypertensive medication use within two years of hypertension diagnosis increased with age, from 35% in patients 20 to 39 years of age, to 72.1% in those 80 years of age and older. Antihypertensive medication use increased after the CHEP (from 49.2% to 53.8% of the population), as did the use of multiple antihypertensive medications (from 7.5% to 10.6%). The most commonly used antihypertensive medication for men was angiotensin-converting enzyme inhibitors (beta-blockers were second), but the most common medication for women was diuretics. The overall persistence rate for antihypertensive medication use was 73.2% over two years, which had increased after the CHEP (from 70.4% to 75.4%).

CONCLUSIONS

The implementation of the CHEP was followed by increased antihypertensive medication use, increased use of multiple antihypertensive medications and improved persistence with medication use. Although causality cannot be established with the design of the present study, improved hypertension management in Canada is heartening. Sex-related differences were observed in prescribed medications, even though clinical guidelines do not differentiate between sexes.

The Canadian Hypertension Education Program - a unique Canadian knowledge translation program

The Canadian Hypertension Education Program annually appraises data from hypertension research and updates clinical practice recommendation for the diagnosis and management of hypertension. Enormous effort is devoted to disseminating these recommendations to target groups throughout the country and, through the use of institutional databases, to evaluating their effectiveness in improving the health of Canadians by lowering blood pressure in people with hypertension. The mission of the Canadian Hypertension Education Program is to reduce the impact of hypertension on cardiovascular disease in Canada.

Canada Chair in hypertension prevention and control: a pilot project

A five-year pilot project was initiated in Canada to fund an individual to lead the effort in improving hypertension prevention and control. As the initial recipient of the funding, the author's objectives were to provide leadership to improve the management of hypertension through enhancements to the Canadian Hypertension Education Program, to increase public knowledge of hypertension, to reduce the prevalence of hypertension by reducing dietary sodium additives and to develop a comprehensive hypertension surveillance program. The initiative has received strong support from the hypertension community, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, and many Canadian health care professional and scientific organizations. Progress has been made on all objectives. The pilot project was funded by The Canadian Hypertension Society, the Canadian Institutes of Health Research and sanofi-aventis, in partnership with Blood Pressure Canada, and will finish in July 2011.

Use of beta-blockers for uncomplicated hypertension in the elderly: a cause for concern

Beta-blockers are less beneficial than other antihypertensive drugs in the elderly with hypertension. All elderly patients in Ontario, Canada (population over 3.5 million elderly) without co-morbidities who were first treated for hypertension with a beta-blocker were studied in a retrospective population-based cohort study (1994-2002) to determine the characteristics of those prescribed beta-blockers. Of the 194,761 patients in our cohort, 25 485 (13%) were prescribed a beta-blocker as their first antihypertensive agent. On multivariate analysis, factors significantly associated with being prescribed a beta-blocker as first-line therapy included male sex (adjusted odds ratio (OR) 1.06 [95% CI 1.03-1.09] vs women), younger age (adjusted OR 1.67 [95% CI 1.55-1.79] for patients aged 66-69 vs those aged 85 or older), residence in a long-term care facility (adjusted OR 1.19 [95% CI 1.04-1.35] vs living in the community) and lower socioeconomic status (adjusted OR 1.07 [95% CI 1.02-1.12], for lowest quintile vs highest quintile). Patients with diabetes were substantially less likely to be prescribed beta-blockers (adjusted OR 0.42 [95% CI 0.40-0.44]). Greater efforts are required to educate physicians to select other drugs for initial therapy in older patients with uncomplicated hypertension.

Comprehensive cardiovascular risk management--what does it mean in practice?

The continued movement away from the treatment of individual cardiovascular (CV) risk factors to managing overall and lifetime CV risk is likely to have a significant impact on slowing the rate of increase in cardiovascular disease (CVD). However, the management of CVD is currently far from optimal even in parts of the world with well-developed and well-funded healthcare systems. Effective implementation of the knowledge, treatment guidelines, diagnostic tools, therapeutic interventions, and management programs that exist for CVD continues to evade us. A thorough understanding of the multifactorial nature of CVD is essential to its effective management. Improvements continue to be made to management guidelines, risk assessment tools, treatments, and care programs pertaining to CVD. Ultimately, however, preventing the epidemic of CVD will require a combination of both medical and public health approaches. In addition to improvements in the "high-risk" strategy, which forms the basis of current CVD management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the "at-risk" stratum for CVD. This review outlines how a comprehensive approach to CVD management might be achieved.

Large increases in hypertension diagnosis and treatment in Canada after a healthcare professional education program

This study was conducted to compare the self-reported prevalence and treatment of hypertension in adult Canadians before and subsequent to the implementation of the Canadian Hypertension Education Program in 1999. Data were obtained from 5 cycles of the Canadian Health Surveys between 1994 and 2003 on respondents aged > or = 20 years. Piecewise linear regression was used to calculate the average annual increase in rates, before and after 1999. Between 1994 and 2003, the percentage of adult Canadians aware of being diagnosed with hypertension increased by 51% (from 12.37% to 18.74%; P<0.001), and the percentage prescribed antihypertensive drugs increased by 66% (from 9.57% to 15.86%; P<0.001). After 1999, there was approximately a doubling of the annual rate of increase in the diagnosis of hypertension (from 0.52% of the population per year before 1999 to 1.03% per year after 1999; P<0.001) and the percentage prescribed antihypertensive drugs (from 0.54% of the population per year before 1999 versus 0.98% per year after 1999; P<0.001). The proportion of those aware of the diagnosis of hypertension but not being treated with drugs was reduced by half between 1994 and 2003 (from 31.47% untreated to 15.34% untreated; P<0.001). There was a greater increase in awareness of hypertension and use of antihypertensive drugs among men compared with women after 1999. The large increase in the diagnosis and treatment of hypertension in Canada between 1994 and 2003 is consistent with an overall beneficial effect of the Canadian Hypertension Education Program, including a reduced gender gap in hypertension care.

The Canadian Hypertension Education Program--a unique Canadian initiative

While almost two-thirds of all strokes and one-half of all myocardial infarctions could be prevented if hypertensive individuals had their blood pressures optimally controlled, only a minority of hypertensive individuals (even in publicly funded health care systems with subsidization of medication costs) achieve target blood pressures. Traditional hypertension guidelines have had limited impact on hypertension management and control rates. As a result, the Canadian Hypertension Education Program was developed to address the perceived flaws in the traditional hypertension guideline approach. In the present article, the key features of the Canadian Hypertension Education Program methodology are reviewed, with attention to those factors thought to be critical to the successful translation of recommendations into practice.