BACKGROUND:There exists an accelerating pace of availability and expanding variety of new blood pressure (BP) measurement technologies worldwide that seek to measure BP in entirely different ways than through the traditional "BP Cuff" commonly used for office and home measurements. A growing number of these devices are viewed by many clinicians and patients as potentially complementary sources of data when combined with office and home readings. However, wearable devices are intentionally designed to provide a more patient-centered experience and may have an important future potential to replace these traditional methods. METHODS:BP is a continuous biologic variable (like body temperature, heart rate, blood oxygenation, etc.) that can now be measured much differently than by commonly used methods of obtaining random serial point in time BP measurements. For example, new technologies now exist that can combine beat-to-beat BP measurements (3,600 measures per hour on average) with additional complex physiologic data such as 24-h BP variability and real-time vascular biomechanical phenomena, including pulse wave amplitude, velocity, and contour analysis. RESULTS:Such data could provide previously unavailable information for identifying potential new therapies for reducing modifiable vascular and endothelial dysfunction, thereby reducing the risk and progression of atherosclerotic cardiovascular disease. CONCLUSIONS:Patients and their clinicians may soon be able to demystify extensive continuous personal BP measurement patterns from this evolutionary process through meaningful correlation with daily and life activities, and hence further achieve optimal cardiovascular health.

An estimated 45% of adult Americans currently have high blood pressure (HBP). Effective blood pressure (BP) control is essential for preventing major adverse events from cardiovascular and other vascular-related diseases, such as chronic kidney disease, stroke and dementia. A large and growing number of medical professional societies, health care organizations, and governmental agencies have now endorsed a clinical practice guideline-based target for adequate control of HBP to a systolic BP of less than 130 mm Hg. However, adequate BP control to this goal has been recently estimated to be as low as 30%. The first and most important steps to guide effective BP control include accurate, standardized BP measurement and formal assessment of overall atherosclerotic cardiovascular disease risk. In addition to appropriate pharmacologic treatment, optimal BP management must also include multifaceted guideline-directed lifestyle modifications. High-quality evidence now supports effective uniform HBP control that is consistently achievable for most of people from diverse backgrounds. This can be accomplished through identification and prioritization of social determinants of health enabled by shared decision making that is delivered via team-based care. Such integrated approaches can have a substantial impact for simultaneously reducing several major modifiable atherosclerotic cardiovascular disease risk factors. Hence, moving the "Big Needle" of improved overall cardiovascular, kidney, and brain health of the US population must no longer be solely relegated to primary care and will require a major and coordinated reprioritization of capital and evidence-based human resource allocations by all health care stakeholder organizations.

Michaels, Maria MBA; Jakhmola, Priya MBA, MS; Lubin, Ira M. PhD; Fochtmann, Laura J. MD, MBI; Casey, Donald E. Jr MD, MPH, MBA; Opelka, Frank G. MD, FACS; Skapik, Julia MD, MPH, FAMIA; Larsen, Kevin MD, FACP; Tailor, Amrita PhD, MPH; Matson-Koffman, Dyann DrPH, MPH, CHES Author Information

1Thomas Jefferson University, College of Population Health, Philadelphia PA Corresponding Author: Donald E. Casey Jr, MD, MPH, MBA, Thomas Jefferson University, College of Population Heath, 20 North Clark Street, Suite 3300, Chicago, IL 60602.E-mail: [email protected]

In this issue of AJMQ, Graduate Medical Education leaders from a large nationally renowned academic medical center describe in detail the "Residents and Fellows Leading Interprofessional Continuous Improvement Teams" program with a focus on the collaboration within their health system in alignment with Clinical Learning Environment review since its inception. In addition, the authors share key outcomes of the program using the reach, effectiveness, adoption, implementation, maintenance framework, additional structural (eg, timeline) and outcome (eg, scholarship) measures for further context within Graduate Medical Education and Undergraduate Medical Education, and describe elements which supported the program's success and lessons learned.

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.

This poem is the epilogue to the author’s original poem “Ode to Korotkov.”.

This poem advocates for patient involvement in managing their blood pressure and care decisions.

Recently published national data demonstrate inadequate and worsening control of high blood pressure (HBP) in the United States, outcomes that likely have been made even worse by the coronavirus disease 2019 (COVID-19) pandemic. This major public health crisis exposes shortcomings of the US health care delivery system and creates an urgent opportunity to reduce mortality, major cardiovascular events, and costs for 115 million Americans. Ending this crisis will require a more coherent and systemic change to traditional patterns of care. The authors present an evidence-based Blueprint for Change for comprehensive health delivery system redesign based on current national clinical practice guidelines and quality measures. This innovative model includes a systems-based approach to ensuring proper BP measurement, assessment of cardiovascular risk, effective patient-centered team-based care, addressing social determinants of health, and shared decision-making. The authors also propose building on current national quality improvement initiatives designed to better control HBP.

Population Health ManagementVol. 25, No. 3 CommentariesFree AccessMajor Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major ChangeDonald E. Casey, Andrew Kopolow, and Craig SolidDonald E. CaseyAddress correspondence to: Donald E. Casey, Jr, MD, MPH, MBA, Department of Medicine, Rush University, 1717 W. Congress Pkwy. 10th Floor, Chicago, IL 60612, USA E-mail Address: don.casey@ipo4health.comhttps://orcid.org/0000-0002-3820-598XJefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.Department of Medicine, Rush Medical College, Rush University, Chicago, Illinois, USA.Institute for Healthcare Informatics, University of Minnesota, Minneapolis, Minnesota, USA.*Coauthor.Search for more papers by this author, Andrew KopolowJefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.Population Health Division, United Healthcare Clinical Services, Minnetonka, MN, USA.Search for more papers by this author, and Craig SolidSolid Research Group, LLC, St. Paul, Minnesota, USA.Search for more papers by this authorPublished Online:7 Jun 2022https://doi.org/10.1089/pop.2022.0002AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Recent analyses of data from the National Health and Nutrition Examination Survey (NHANES) estimate that 115 million adults (46%) in the United States have hypertension (also referred to as High Blood Pressure or "HBP") as defined by systolic blood pressure BP ≥130 mm Hg or diastolic BP ≥80 mm Hg.1 Atherosclerotic cardiovascular disease (ASCVD) and stroke, when combined, remain the leading causes of death in the United States with more than 1 million deaths annually, translating to a rate of 2754 deaths per day.2 In addition, individuals with HBP face, on average, nearly $2000 more in annual health care expenditures than those who do not have HBP.3In this issue of Population Health Management, researchers and health economists from the Centers for Disease Control and Prevention (CDC) summarize a literature review of peer-reviewed articles published 2000–2019 to determine the types and extent of hypertension-associated work-related productivity loss among adults in the United States.4 Of the initial 411 relevant references screened, 27 articles met the selection criteria and were included in this review, which focused on hypertension-related productivity losses in the United States, paid work or unpaid home activities, and monetary or nonmonetary outcomes.All monetary outcomes were standardized to 2019 US dollars using the Employment Cost Index for total compensation for civilian workers. Nearly half (12) of the 27 articles meeting inclusion criteria presented monetary outcomes of productivity loss. Work characteristics were considered in 9 studies and several studies focused on specific companies and industries, such as financial/insurance services, manufacturing, oil, and health care. There was heterogeneity in statistical methods and sources of dollar values assigned in each of these 12 studies.The authors also note that there are different forms of productivity loss that can include short-term absences from work, reduced function while at work, the inability to work due to disability and premature mortality, and impairments to activities of daily living. In addition, multiple data sources were used to examine these categories of productivity loss, such as short-term disability claims or company personnel records of absenteeism, as well as data from several different commonly used standardized questionnaires.Absenteeism (14 articles) and presenteeism (8 articles) were most frequently assessed. Annual absenteeism attributable to hypertension was estimated as more than $11 billion nationally controlling for sociodemographic characteristics. Annual excess per capita costs related to workers with hypertension were estimated at $63 for short-term disability, $72–$330 for absenteeism, $53–$156 for presenteeism, and may be as high as $2362 for absenteeism and presenteeism when studied in combination, controlling for participant characteristics.Using Medical Expenditures Panel Survey (MEPS) data, the authors estimate that hypertension-associated productivity loss from absenteeism could be lowered by 15%–36% depending on the extent of controlling for sociodemographic characteristics, work characteristics, health risk factors (such as obesity, smoking, and physical inactivity), and common comorbidities related to HBP (such as diabetes, hyperlipidemia, cardiovascular disease, and stroke).Also using MEPS, hypertension-associated productivity loss from absenteeism was lowered by 51% after controlling for hypertension comorbidities (specifically, heart disease, stroke, diabetes, and mood disorders) and health conditions unrelated to hypertension (eg, cancer and arthritis) from estimates that controlled for sociodemographic characteristics, body mass index, and smoking. None of the studies evaluated in this article were noted to address the "silent killer" in terms of treatment versus nontreatment, or work-related causative and associative factors contributing to the development and worsening of high blood pressure.For the first time, we have a comprehensive summary of a structured evaluation of published peer-reviewed research on the monetary and nonmonetary impacts of productivity loss due to HBP for individual workers and their employers. For the first time, we are able to leverage a body of peer-reviewed research to better understand broader implications for effective control of HBP for larger populations (communities, regions, states, nationally, etc.). And through this literature review, 2 critical insights have emerged: (1) hypertension has a significant impact on workplace productivity on multiple levels and (2) economic estimates of these impacts vary widely in size and scope.In other words, hypertension research has proven problematic for more generalized impact estimation. Pulling this disparate body of research together is the necessary first step to begin doing just that. We applaud the authors for the breadth of the information provided and feel the sheer variability of the reviewed studies merits a concrete conceptualization to fully grasp their collective implications. In this vein, and purely for demonstrative purposes, imagine a hypothetical company we will call HTN, Inc. Using rates and dollar amounts pulled from the CDC's review and other previously published research on hypertension and related outcomes (available upon request), we can make a "back of the envelope" estimate of the cost of productivity loss due to HBP for this population.As the health care industry is well represented (cited in 4 of the 12 articles where specific industries are identified, more so than any other industry), we will make HTN a modest-sized health system in the nondescript suburban community of Anytown, USA. HTN's employee demographics are representative of the larger eligible US labor force (ie, adults 18 and older). Of HTN's 1000 employees, nearly half (470) have a diagnosis of hypertension. For more than a full third (390), it is uncontrolled hypertension. And the next 12 months will be precarious, both for this subgroup and HTN itself. From the employee perspective, 2 will have strokes, 3 will suffer acute myocardial infarction, 3 will require treatment for chronic kidney disease, and a dozen more will have chronic heart failure.Over the next year, HTN, Inc.'s workforce with hypertension will miss an additional 1034 days of work more than their nonhypertension counterparts. Those with uncontrolled hypertension will accrue roughly $600,000 in medical expenses and cost HTN an additional $400,000 in work disability, absenteeism, presenteeism, and general work-productivity loss.Is $1,000,000 per year in additional costs for a single business and its employees enough to grab your attention? If not, let us explore some additional implications. Estimates indicate an additional 20% of the population have undiagnosed hypertension due to lack of awareness, thereby further magnifying the costs for HTN, Inc. and its employees. Again, we acknowledge these estimates to be back of the envelope. They are nonetheless relatively conservative and reflective of the general adult population within the United States. Were we to slightly shift HTN, Inc.'s demographics toward an older population with more of its 1000-person work force >65 years of age or skewed toward certain comorbidities represented in the research, loss impacts could be far greater.With these new findings in mind, what are future opportunities and challenges for population health professionals and the US population health industry? In essence, the staggering overall annual economic and noneconomic losses from almost 50% of the overall US population with HBP (when including all age ranges for adults) are currently in the hundreds of billions of dollars. Since 80% of those with hypertension are currently considered "uncontrolled,"1 the opportunities are many for employers to partner with health care delivery systems, health insurers, and digital health industries to effectively implement more effective evidence-based recommendations from the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) HBP Guidelines.5For example, the authors note that none of the economic evaluations used in their review explicitly assessed or documented the use of recommendations outlined in these guidelines, which include specific standards for obtaining accurate BP measurement, evaluating 10-year ASCVD Risk and appropriately classifying patients with HBP. Incorrect and hence inaccurate measurement of blood pressure has also now become a major challenge in terms of correct identification and treatment of people with high blood pressure, an issue that could be addressed and reinforced within the workplace through standardized self-monitoring programs such as the national AHA/American Medical Association Target BP program.6It has also become clear that effective and consistent ongoing assessment of social determinants of health through team-based care and shared decision making is important to help guide treatment options with nonpharmacological interventions, lifestyle modifications, and (when appropriate) medications provide excellent opportunities for improved BP control.2Extensive empiric evidence evaluations of so-called "workplace wellness" programs designed to improve blood pressure control in employees with hypertension have not demonstrated to be of any consistent positive impact, although recent data from China has shown promise that may have some relevance.7,8 Unfortunately, national initiatives (such as the Health and Human Services [HHS]-sponsored "Million Hearts" model) have also (so far) only made small marginal improvements on blood pressure control at the national level.9Hence, employers and their workers must work more closely with cardiovascular researchers, health economists, and public health officials to standardize measurement and monitoring of hypertension-associated productivity and nonproductivity costs, especially when implementing cost-effective national guideline-driven interventions designed to achieve better BP control. For example, employers could very easily provide and promote use of certified semiautomated oscillometric self-monitoring BP devices for home BP monitoring and patient/family digital educational resources on how to correctly measure BP in accordance with standard protocols espoused by Target BP,7 perhaps in partnership/collaboration with their health insurers and/or local health systems.Good quality scientific evidence now confirms that multilevel multicomponent strategies, including patient coaching and self-monitoring with home BP monitoring, provider training to address social determinants of health and lifestyle modification, clinical decision support within electronic health records, and multidisciplinary team-based care, when combined, are most effective for improving BP control in patients with hypertension.10 Hence, it is no longer necessary to argue about "The What," but instead, focus on successful implementation of "The How" and "By Who."This responsibility now lies simultaneously at the feet of not only employers, but health systems, insurers, and the digital health companies that provide so-called "solution" services to them. A group of nationally renowned health care and hypertension experts have recently published "The Blueprint for Change" model, which is a comprehensive evidence-based guideline-driven system of care for people with HBP, calling on managerial, clinical, and operational leaders of these organizations to actively collaborate at the local, regional, and national levels to create and support a coordinated system of guideline-based care delivery for adults with HBP.2The model is based on high-quality evidence-based guidelines and serves as the basis for (1) engaging and activating health system, payer, and employer leadership for organizational and financial support at every level; (2) continuously using transparent evidence-based standardized performance measurement and quality improvements to assess progress; and (3) insisting on effective shared accountability at all levels (including governance) of the US health system for ensuring access, infrastructure, and coverage (including proper and adequate payment).Without this type of active collaboration, current unrealistic and unfortunate expectations that employers, providers, payers, and digital health companies will be able to achieve population levels of effective patient-centered BP control in the current siloed environment will continue to lead to failure of the population health industry for millions of Americans.DisclaimerThe views expressed in this article include those of the aforementioned coauthors and should not be interpreted as policy of the American Heart Association, the American College of Cardiology, the National Hypertension Control Roundtable, or United Healthcare.Author Disclosure StatementDr. Casey: ACC/AHA 2017 Guideline for High Blood Pressure in Adults; Member, Advisory Board, National Hypertension Control Initiative (NHCI). Mr. Kopolow and Mr. Solid have no competing financial interests.Funding InformationNone of the authors have received any financial support for the research, authorship or publication of this article.References1. Facts About Hypertension | cdc.gov. https://www.cdc.gov/bloodpressure/facts.htm#:~:text=Nearly%20half%20of%20adults%20in%20the%20United%20States,with%20hypertension%20have%20their%20condition%20under%20control.%203 Accessed February 2, 2022. Google Scholar2. Casey DE, Daniel DM, Bhatt J, et al. Controlling high blood pressure: an evidence-based blueprint for change. Am J Med Qual 2022;37:22–31. Crossref, Medline, Google Scholar3. Kirkland EB, Heincelman M, Bishu KG, et al. Trends in healthcare expenditures among US adults with hypertension: national estimates, 2003–2014. J Am Heart Assoc 2018;7:e008731. Crossref, Medline, Google Scholar4. MacLeod KE, Ye Z, Donald B, Wang G. A literature review of productivity loss associated with hypertension in the United States. Popul Health Manag 2022;25:294–305. Google Scholar5. Whelton PK, Carey RM, Aronow WS, et al. A guideline for the prevention, detection, evaluation and management of high blood pressure. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71:e13–e115. Medline, Google Scholar6. Target:BP. targetbp.org Accessed February 2, 2022. Google Scholar7. Wang Z, Wang X, Shen Y, et al. Effect of a workplace-based multicomponent intervention on hypertension control: a randomized clinical trial. JAMA Cardiol 2020;5:567–575. Crossref, Medline, Google Scholar8. Sun Y, Li Z, Guo X, et al.; CRHCP Study Group. Rationale and design of a cluster randomized trial of a village doctor-led intervention on hypertension control in China. Am J Hypertens 2021;34:831–839. Crossref, Medline, Google Scholar9. Peterson GG, Pu J, Magid DJ, et al. Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on initiating and intensifying medications: a prespecified secondary analysis of a Randomized Clinical Trial. JAMA Cardiol 2021;6:1050–1059. Crossref, Medline, Google Scholar10. Mills KT, Obst KM, Shen W, et al. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis. Ann Intern Med 2018;168:110–120. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 25Issue 3Jun 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Donald E. Casey, Andrew Kopolow, and Craig Solid.Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change.Population Health Management.Jun 2022.291-293.http://doi.org/10.1089/pop.2022.0002Published in Volume: 25 Issue 3: June 7, 2022Online Ahead of Print:March 8, 2022PDF download

Recently published national data demonstrate inadequate and worsening control of high blood pressure (HBP) in the United States, outcomes that likely have been made even worse by the coronavirus disease 2019 (COVID-19) pandemic. This major public health crisis exposes shortcomings of the US health care delivery system and creates an urgent opportunity to reduce mortality, major cardiovascular events, and costs for 115 million Americans. Ending this crisis will require a more coherent and systemic change to traditional patterns of care. The authors present an evidence-based Blueprint for Change for comprehensive health delivery system redesign based on current national clinical practice guidelines and quality measures. This innovative model includes a systems-based approach to ensuring proper BP measurement, assessment of cardiovascular risk, effective patient-centered team-based care, addressing social determinants of health, and shared decision-making. The authors also propose building on current national quality improvement initiatives designed to better control HBP.

Hui Zhou, MSc; Mi Yao, MD; Xiaodan Gu, MBBS; Mingrui Liu, BP; Ruifeng Zeng, MBBS; Qin Li, MNS; Tingjia Chen, MD; Wen He, MD; Xiao Chen, PhD; Gang Yuan, MD, PhD

Nash, David MD, MBA, FACP, FACMQ, AJMQ, Editor in Chief; Casey, Don MD, MPH, MBA, FACP, FAHA, DFAAPL, CPE, DFACMQ, ACMQ PresidentAuthor Information

Bhatt, Jay DO, MPH, MPA, FACP1; Correa, Ricardo MD, FACP, FACE, FACMQ2; Afable, Richard MD, MPH, FACP3; Agrawal, Abha MD, FACP, FACHE4; Casey, Donald MD, MPH, MBA, DFACMQ5,6 Author Information