Preventing and Controlling Hypertension for Improved Population Health

Abstract

The role of the nurse in improving hypertension control has expanded over the past 50 years, complementing and supplementing that of the physician. Nurses' involvement began with measuring and monitoring blood pressure (BP) and patient education and has expanded to become one of the most effective strategies to improve BP control. Today the roles of nurses in hypertension management involve all aspects of care, including (1) patient education, counseling, and skill building; (2) coordination of care; (3) population health management. In addition to their clinical roles, nurses lead clinic and community-based research to improve the hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants.

Background

Hypertension is a term used to describe high blood pressure. Flow of blood is based on the beat of which the heart pumps blood. The pressure of the heart does not always stay at the same level. It varies based on activities at a point in time. Hypertension occurs as a result to long duration of abnormal pressure of the main arteries. Hypertension is a global public health issue, and it is estimated that by 2025 more than 1.5 billion individuals worldwide will have hypertension, accounting for up to 50% of heart disease risk and 75% of stroke risk.

Hypertension is grouped into two main categories. These include primary and secondary hypertension. Primary hypertension, also known as essential hypertension, affects ninety-five percent of persons suffering from the disease. Reasons of hypertension are not yet known, however, factors as age, high salt intake, low potassium diet, sedentary lifestyle, stress as well as genes have been found as contributing to hypertension. High blood pressure occurring as a result to a consequence of another disorder or a side effect of medication is referred to as secondary high blood pressure. Such disorders may include renal failure or renovascular disease. This type of blood pressure is evident in about five to 10% of cases.

Patient Education, Counseling, and Skill Building

In most hypertension care settings, nurses provide the education, counseling, and skill building necessary to ensure that patients are undertaking lifestyle changes that may favorably influence BP. Nurses actively engage patients in care using a combination of strategies to prevent, recognize, and respond to adherence problems and thereby maximize long-term adherence and BP control (CDC, 2017). They also use effective, evidence-based strategies to promote BP control; these strategies are identified under the following general approaches: identify knowledge, attitudes, beliefs, and experiences; educate about conditions and treatment; individualize the regimen; provide reinforcement; promote social support; and collaborate with other professionals. It is important to consider that patient education is a means to an end. That is, knowledge is necessary but not enough to bring about desired behaviors without development of skills and multiple other reinforcing factors. The goal is for the patient to have the necessary skills and resources, including knowledge, to follow treatment recommendations and achieve and sustain BP control.

Racial and Ethnic Disparities

The affliction of heart diseases and stroke is unequally distributed across racial/ethnic groups in the United States. Age-adjusted mortality rates for coronary heart disease per 100,000 standard population were higher for African Americans (161.6) than for Caucasians (134.2), American Indians/Alaska Natives (97.4), and Asians/Pacific Islanders (77.1). Hispanic men and women had lower rates of heart disease and stroke mortality than non-Hispanic Caucasian men and women, respectively. African Americans also experienced a greater proportion of premature mortality (death before age 75 years) than other racial groups (Lori A. Spies RN, 2018). The proportion of deaths from coronary heart disease occurring among people aged 45 to 74 years was higher for African American men (61.5%) than for Caucasian men (41.5%) and higher for African American women (37.9%) than for Caucasian women (19.4%). Patterns for stroke mortality rates were like those for coronary heart disease, with rates for African Americans about 32% higher than rates for Caucasians. Untimely mortality highlights not only disparities in health but also issues of successful aging.

Coordination of Care

Long-term maintenance of hypertension control requires continual monitoring of BP, refilling of prescriptions, provision of counseling and reinforcement of behavior change efforts, and titration of therapy as indicated. Each patient's management must be individualized, with costs minimized. Patients often see different providers at several settings for various health problems, fill prescriptions in more than one pharmacy, receive varying messages, and experience disruption of therapy and inadequate communication among providers. Nurses are skilled at building and maintaining both informal and formal collaborative linkages among providers, resources, and services within and external to their practice setting. Further, nurses assist patients in understanding complex treatment regimen and navigating through the challenging and highly complex health care structure and systems.

Population Health Management

The paradigm shifts from care of one patient at a time, either in the dyad of one physician with one patient or, more recently, the team approach, to the responsibility to care for large numbers of patients has occurred in the past decade. New models of managing care promoted by health systems and governments have focused on measuring and reimbursing improved outcomes and controlling costs of care.

Improving health for populations of people to reduce risk factors, morbidity, and mortality calls for a combination of public health and prevention principles with traditional medical care. Hypertension is a prominent condition being targeted because of its prevalence and the benefits of controlling it. Public advocacy to improve health of large numbers of people and sensible policy making requires evidence of effective interventions.

Population health management requires a variety of skills, including care coordination, decision making, and project management, and is needed in communities where disparities in chronic conditions exist. By mapping health care services to the needs of the population, nurses formulate an overall health care strategy that improves hypertension care quality and reduces health disparities. Nurses can implement technology to recognize and examine these populations' most pressing health needs and, in collaboration with other health care team members, design appropriate interventions to anticipate or satisfy these needs.

Initiative

The Centers for Disease Control and Prevention (CDC) has several synergistic activities supportive of Healthy People 2020 HDS objectives. For example, Million Hearts, a U.S. Department of Health and Human Services initiative co-led by CDC and the Centers for Medicare and Medicaid Services, has a goal of preventing one million heart attacks and strokes over a 5-year period. The initiative aligns, coordinates, and advances activities within and among communities through diverse collaboration. The focus of efforts of Million Hearts in the clinical setting is on the ABCs of heart health (aspirin use when appropriate, blood pressure control, cholesterol management, and smoking cessation) with improving hypertension control as a key priority.

The National Institutes of Health (NIH) also supports research and programs that align with the Healthy People 2020 HDS objectives. In recent news, a groundbreaking trial co-sponsored by the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute on Aging and the National Institute of Diabetes and Digestive and Kidney Diseases, Systolic Blood Pressure Intervention Trial (SPRINT), was stopped early based on preliminary findings that aiming for a lower blood pressure target can save lives and reduce the risk of cardiovascular disease in adults 50 years and older with hypertension and without diabetes.

Conclusion

Nurses have been involved in hypertension care and control for as long as the field has been formally addressed by professional societies, voluntary nonprofit organizations, and governments, approximately 50 years. The roles originally involved assisting in office evaluation by measuring BP and educating patients. As nurses' skills evolved through on-the-job or graduate training, their roles in hypertension progressed to include physical assessment, medication and lifestyle prescription, and greater independent practice (Lori A. Spies RN, 2018). Nurse-led clinics and team models of care and research have evolved and contributed to increasing the number of patients receiving high-quality hypertension care and control. Nurses have assumed leadership roles in the conduct of research to improve hypertension care quality and reduce ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions geared at addressing these factors.

References

• CDC. (2017). Best Practices for Cardiovascular Disease Prevention Programs. Division for Heart Disease and Stroke Prevention (DHDSP) in the Centers for Disease Control and Prevention (CDC).
• Lori A. Spies RN, P. N.‐C.‐B. (2018). Nurse‐Led Interventions for Hypertension: A Scoping Review With Implications for Evidence‐Based Practice. Sigma: Global Nursing Excellence, 247-256.
• P.M. Kearney, M. W. (2015). Global burden of hypertension: analysis of worldwide data. Lancet, 217-223.