The U.S. has slid backward on control of high blood pressure, despite ready access to medicines and other tools to moderate its risks. Dan Jones, former president of the American Heart Association, thinks the nation can learn from China.
Researchers there recently detailed the success of community health workers — well trained people but not M.D.s — helping thousands of people living with high blood pressure in rural regions. People who received a combination of blood pressure monitoring, medication adjustments, and health coaching from these nonclinicians saw their blood pressure readings go down significantly during the study’s four years, a testament to the impact of people known as “village doctors” who went beyond usual care in the health care system.
Why can’t we do that here? Jones poses that question in light of hypertension’s critical role in heart attacks, strokes, heart failure, and sudden cardiac arrest.
Despite safer, cheaper, more effective, and more tolerable medications, “it is quite evident that efforts to control blood pressure and reduce risk for cardiovascular disease are inadequate,” he wrote in an editorial appearing with the study. “Our efforts are failing patients.”
Those patients are not well served by a physician community that limits the scope of practice for other practitioners, said Jones, a general internist who has focused on prevention of cardiovascular disease and racial disparities in cardiovascular outcomes. He has visited China since 1985 and also practiced medicine in South Korea for seven years. He spoke with STAT about why the U.S. is not doing better with the tools at hand to improve blood pressure control rates, which have worsened since 2014, following several years of improvement before then. This conversation has been lightly edited for length and clarity.
Where does the problem of poor blood pressure control start?
There are a lot of challenges, but certainly a major one is clinical apathy. You know, clinicians are just simply not paying enough attention to controlling blood pressure. There’s certainly patient apathy as well.
Why is prevention so hard in the U.S.?
We’re just not built to deal with prevention. We like quick results. We like high tech, and as a culture, we’re not very interested in simple things, and things that take a long time to show results. We have a health care system built on rewarding innovation and end-of-disease in the treatment of cardiovascular disease.
So if you have a new catheter for putting into coronary arteries or a new drug that either affects lipid levels or coagulation, there’s a lot of interest in it, so there’s a lot of money in it. But if you’re talking about treating high blood pressure, there’s just not a lot of interest in health care systems and not enough interest among physicians and other health care providers.
High blood pressure is the “silent killer.” Is that also what makes it hard?
It’s the fact that the risk factors for both elevated cholesterol and blood pressure are not associated with symptoms. So you find it difficult to get people to do the lifestyle things and continuous use of medication to manage those problems. In today’s health care world, physicians have less and less time to deal with the patient and are more likely to focus on the complaint at hand, rather than the long view of trying to help this person live a longer and healthier life.
What’s the history of this model in China, both in health care delivery and outcomes?
From the mid-’80s until now in China, their life expectancy has gone from 10 to 15 years lower than the U.S. to, in parts, maybe even a little bit better than the U.S. And they do it with much less investment in health care but with smarter investment.
I was fascinated in the mid-’80s with the concept of the “village doctor,” focused primarily on infectious disease then, with a big focus on tuberculosis and on immunization for preventable diseases. They would take a minimally trained person and make them responsible for 300 people at the time when I first began looking at the village doctor model.
As the study authors noted, the model that they use can be replicated in other low-resource countries. And I’ve made the point that the model would be useful in high-resource countries as well.
How did that work there?
The early attempts at using someone other than a physician and something other than coming to an acute care center for a visit at first had community health workers measure blood pressure and tell the patients that their blood pressure was not controlled. “Well, you need to go to your doctor and get something done.” Those models made very little difference.
What was missing in China, and in a U.S. trial?
Beginning about 10 years ago, researcher Ron Victor — now deceased — began doing this kind of thing among African-American men in the U.S., using barbershops as a place to engage the community and begin measuring blood pressures there and educating patients about their blood pressure.
In the first couple of studies he reported very little difference in blood pressure control. And then he used the same model in barbershops but added to it pharmacists specially trained in blood pressure management. It was a physician-developed protocol, but the pharmacist had the authority to change the dose of medications.
That was the secret: not only understanding what the blood pressure was, but immediately responding to it.
Is that being applied elsewhere in the U.S.?
We replicated it using telemedicine with totally remote interactions, using nurse practitioners instead of pharmacists. The key is to have a protocol that can be followed. We’ve been doing this for years in our blood pressure research.
In my practice at the University of Mississippi Medical Center, I would recruit patients to participate in clinical trials, testing new drugs or some lifestyle therapy. I would have nurses who were two-year community college graduates who had R.N.s at the interface with the patient, using the protocol that I developed. They would measure blood pressure and then they would make decisions per protocol. Blood pressure control rates were controlled so much better in that model than waiting for the patient to see me at the next three-month visit to go ahead and get the change made.
Does this idea get pushback from physicians?
Part of the problem in the U.S. is going to be scope of practice. I don’t want to be too harsh on my own profession, but the physician community has been very successful in limiting scope of practice for other practitioners. This is part of the problem that has to be addressed in our health care delivery structure, to find a way to accept a wider scope of practice for pharmacists, nurse practitioners, nurses, and perhaps even community health workers in applying a protocol developed by physicians or someone else knowledgeable enough to to develop a protocol.
What are other barriers to seeing more “village doctors” in the U.S.?
In some places it’s easier to make the decisions. I don’t want to be overly political. I’m a big fan of democracies, but in autocratic countries like China, you can make changes a lot easier than you can in a democratic society like the United States. A central authority can make the decision: Let’s do it this way and get it done. It’s changing the health care model. Delivery of care is a very complicated process in the United States and somewhat in Europe as well.
How has this approach gone over with your patients?
Acceptance has been good. Patients actually like the ability to talk to somebody at a level other than a physician. They like somebody they can go to for questions. And the model that we used in one of our studies in Mississippi was totally telehealth. The patients were very responsive to giving them an iPad to report their blood pressure, and then the nurse practitioner getting back to them later in the day with a note that says you’re doing well, keep it up, or we need to work on sodium restriction or we need to increase the dose of of your calcium channel antagonist.
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