Strengthening of health systems can help address challenges to hypertension control by addressing a number of barriers to effective and sustained hypertension control.

Two healthcare delivery models relevant to treatment for and long-term control of hypertension are the Chronic Care Model (CCM) and an extension of CCM developed by the World Health Organization (WHO), the Innovative Care for Chronic Conditions Model. CCMs are comprehensive systems for chronic disease care within integrated health service delivery networks. CCMs are patient-centered, evidence- and population-based systems that were successfully established to improve care for patients with chronic conditions in all countries.^26–29 CCMs emphasize integrating preventive and treatment healthcare services, which can increase the effectiveness of treatment for chronic conditions, decrease the incidence of complications and preventable deaths, and increase the efficiency of primary and specialized care services. CCMs promote patient self-care and redefine the roles and responsibilities of physicians, nursing staff, and community workers. Setting up a CCM can lead to more comprehensive and sustainable cardiovascular care, strengthen patient self-care, and improve coordination of care.³⁰ The WHO Innovative Care for Chronic Conditions model has all the elements of a CCM and incorporates the following elements into delivering treatment for NCDs in low-resource settings: efficient use of limited healthcare resources; sustainable health-financing mechanisms; access to basic diagnostic tools and essential medicines; organized medical information and referral systems; and long-term care that is proactive, patient-centered, community-based, and sustainable.³¹ In addition to its Innovative Care for Chronic Conditions Model, WHO lists eight essential actions for improving care for chronic problems such as hypertension.²¹ CCMs were developed to address healthcare systems barriers to improve chronic illness management.^26–31 While we originally intended to identify care “models” for the effective treatment of hypertension, we concluded that focusing on key care delivery “elements” for hypertension control would be more appropriate because most countries already had invested in large care delivery models.

Standardized hypertension management involves key elements of healthcare delivery system improvement for effective treatment and control of chronic diseases such as hypertension to help overcome the barriers discussed and to ensure successful implementation (Table I). The rationale for the recommendations are discussed below.

Numerous guidelines have been developed for hypertension management.^22,24 Such guidelines should be used to set standards of care for managing patients with high BP, including lifestyle recommendations for physical activity, smoking cessation, reduction of excessive use of alcohol, healthy and lower-sodium diets, the presence of algorithms that address medication selection, frequency of BP monitoring, and strategies for improving patient medication and recommended lifestyle adherence. Guidelines may also specify decision points for referrals to specialty care or the need for communication with specialists via mobile technologies, telemedicine consultations, or review of medical records.³² To achieve optimal outcomes, guidelines must be actively integrated into clinical practice.²⁵ Organizational context and resource constraints, including the availability and cost of recommended medications, laboratory services, and diagnostic equipment, must be considered in adapting guidelines to local contexts.²¹ In an evaluation of the Chronic Care Model, high-performance organizations were more likely to have guidelines-based decision support and employ other elements such as computerized reminders, registries, and self-management support compared with lower performing organizations.^33,34 Standardized hypertension management promotes evidence-based practice and the use of guidelines-based standardized treatment protocols (Figure 1), which are valuable and effective as part of a multifactorial approach to improve BP control.³⁵

Clinical information systems, also referred to as registries, are important components of effective chronic care models. Specifically, registries of patients with hypertension can be created retrospectively from diagnoses on insurance claims and medical charts, or prospectively as patients visit their primary care provider.³² From a population perspective, registries can be used to monitor how well guidelines are implemented and to track trends in individual and population health outcomes, such as the proportion of patients whose hypertension is controlled.³³ Information systems can also be structured to give feedback on performance at the healthcare provider, team, or clinic level. This feedback serves as a benchmark for quality of care.²⁸ Registries can also be used to support clinical decision making⁴¹; to allow providers to be proactive rather than reactive,²¹ for example, by setting up patient reminders about needed services or follow-up visits³²; and to share data throughout a practice, among practices, and potentially throughout an entire healthcare system. Such a system decreases duplication, increases coordination, decreases costs, improves quality of care, and ultimately improves health outcomes.³⁵ Although computer-based or electronic records would be the ideal approach, if they are not available, registries and feedback systems for monitoring or evaluation can and should be done manually by creating a line-listing of patients in the cohort.

Significant effects on provider performance were documented by a systematic review of computerized clinical decision supports, including some studies that targeted hypertension-related care as the performance indicator of interest.⁴² Outcomes were positive across a range of support types, including diagnostic, disease management, and drug-dosing or -prescribing systems. A more recent review confirmed these positive effects on preventive care services for NCDs, including hypertension, and prescribing behaviors.⁴³ Therefore, the use of hypertension registries to collect and store clinical information on all patients within the system with the condition for cohort monitoring and quality assurance/ improvement is beneficial.

Managing chronic diseases such as hypertension successfully requires the patient to be actively informed and engaged. Patient behaviors, including healthy eating and being physically active, adherence to medication regimens, and making and keeping medical appointments play a major role in hypertension control.^43–45 A patient-centered healthcare system focuses on preventing disease rather than on alleviating or curing symptoms and complications.²¹ In such a system, the patient-provider relationship is based on mutual respect.⁴¹ This approach to health care requires a multidisciplinary team and culturally appropriate communication.^41,44

Self-management support is central to empowering the patient. Managing hypertension successfully over the long term requires that patients have the skill, motivation, and confidence to adhere to proper diet and exercise and medication regimens, as well as, in some cases, measure their own BP.^45–47 Self-management support is no longer based on didactic patient education but has instead shifted to collaboration between patients, their families, and healthcare providers.^28,29,34,48 Support for self-management can be offered through primary care settings or through referral to community-based programs.

Successful standardized hypertension management requires that patient empowerment be made a priority. Patients should be informed about their hypertension, involved in decisions related to their treatment, and comfortable expressing their concerns to their healthcare providers reflecting mutual respect.

A system for the effective delivery of hypertension treatment should be led and managed in the primary care setting where patients receive most of their health care, including preventive medicine and referral to specialty medicine.^44,45,48 For patients with hypertension, a focus on continued care is essential. BP should be checked and addressed at every visit,⁴⁹ and care and support should be provided by a multidisciplinary team according to the individual needs of each patient.²¹ Treatment coordination can be improved when patients are assigned a “care coordinator” who assumes responsibility for coordination of care across all levels of care.²¹ Primary care can also link to nontraditional care settings and leverage relationships with community organizations to coordinate systematic screening, messaging, advocacy, and other interventions.

In terms of standardizing the management of hypertension, the effective delivery of hypertension treatment involves providing patients with hypertension care and support from a multidisciplinary team of healthcare providers in the primary care setting who communicate with each other and coordinate their care delivery (task sharing).

Links between healthcare systems and the community can strengthen programs to prevent, treat, and control hypertension. Existing chronic care models include a community component that calls for increased access to complementary community programs that offer related services (eg, self-management training and nutrition counseling)^36,37; healthcare providers to partner with nontraditional organizations or businesses, or pharmacies to promote screening for hypertension and offer guidance on self-management and medication adherence;⁵⁰ and community healthcare workers to improve hypertension prevention and control by offering, for example, educational services through home visits.⁵¹ Such links between the healthcare system and community organizations are cost-effective alternatives to offering self-management programs within the primary care setting. Establishing health-promoting public policies, creating cost-supportive environments, and strengthening community action have also been suggested.⁵² Broader community engagement in hypertension control acknowledges the importance of social determinants in disease prevention and self-management.⁴¹

Standardized hypertension management encourages community engagement to increase awareness and to address hypertension as a public health priority, which should be systematically supported by clinical systems.

This standardized hypertension management approach comes at an unprecedented time of global attention to NCDs. Hypertension is responsible for more deaths than any other single NCD risk factor, and improved control at the population level could have substantial positive impact. The WHO and its global membership recognized this when they created a set of global NCD indicators and targets that included a focus on improved hypertension control. Standardized hypertension management complements population approaches to primary prevention, particularly healthy diet and specifically salt reduction. A dynamic set of related tools and resources are available online (http://www.cdc.gov/globalhealth/ncd/hypertension-toolk-it.htm). A technical package is being developed to facilitate widespread implementation and pilots are underway in Malawi and Barbados.

In May 2013, the World Health Assembly, as part of a Global Monitoring Framework, endorsed a set of targets and indicators to be achieved by 2025, including five that the SHTP Project addresses: (1) a 25% reduction in the relative risk of mortality caused by CVDs, cancer, diabetes, and chronic respiratory diseases, (2) a 25% relative reduction of raised BP, (3) at least a 50% rate of eligible people receive drug therapy and counselling (including glycemic control) to prevent heart attacks and strokes, (4) 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities, and (5) a 30% reduction in salt and sodium intake. In addition, this approach, which is inherently flexible, fully supports the primary prevention of CVD and can be expanded to include other chronic diseases. It can be adapted to align with the availability of resources in a specific country and is consistent with and can enhance WHO's essential interventions for primary care. Furthermore, this approach is aligned with the World Heart Federation's road map on hypertension and secondary prevention, an initiative that requires collaborative efforts between different institutions for success. With political will and strong partnerships, the SHTP Project will facilitate global hypertension control and thus reduce CVD-related morbidity and mortality worldwide.