Thursday, May 04, 2006

Does blood pressure control require a Cuban-style revolution?

My thanks to Walter Lippmann, who forwarded this article. If you really want to educate yourself about the Cuba issue, you must visit Walter's webpage: www.walterlippmann.com

I have put the key paragraph in bold.

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Journal of Hypertension: Volume 24(5) May 2006 p 811-812

Does blood pressure control require a Cuban-style revolution?
Alderman, Michael H

Albert Einstein College of Medicine, Department of Epidemiology and Population Health, New York, New York, USA

Correspondence and requests for reprints to Dr Michael H. Alderman, Albert Einstein College of Medicine, Department of Epidemiology and Population Health, 1300 Morris Park Avenue, Bronx, New York, NY 10461, USA Tel: +1 718 4302281; fax: +1 718 43087870; e-mail: alderman@aecom.yu.edu

For at least 30 years, discussions about cardiovascular disease, either in print or from the lectern, have invariably begun with a lament to the universal failure to control blood pressure. In this issue of the journal, the report from Cuba by Ombudez-Garcia et al. [1] may therefore come as an unexpected and most welcome surprise. We should be grateful to the multinational team of investigators for their careful study reporting that effective anti-hypertensive treatment can be achieved on a community-wide scale.

The investigators assembled a probability sample of some 1667 adults according to a rigorous study design to reflect the experience of 95 000 residents of Cienfuegos in south central Cuba. Achieved levels of awareness, treatment, and control were markedly superior to those in other resource-constrained societies. Indeed, control rates were two to three-fold higher than those seen in Europe, and one-third above that seen in the USA. Even more striking, approximately two-thirds of those undergoing treatment had achieved blood pressure control (compared to approximately 50% in more resource-rich settings). The study is limited, as the author's note, by the imprecision of classification based upon three readings at a single encounter. However, the approximately 20% prevalence of hypertension appears to be appropriate for a population whose mean age was 44 years. In addition, because this was a cross-sectional study, pretreatment blood pressures were not available. However, because prevalence seems reasonable, it is likely that the patient population did not differ dramatically from that of other countries.

Why do the Cubans do so well? Part of the answer must surely be found in the unique nature of their social structure and, more specifically, the Cuban National Health Care System [2]. Since the 1959 revolution, Health and Medical Care has been a national priority. Universal access to free health and medical care is a state responsibility and a high national priority. All elements of health care are nationalized, including professional personal, the pharmaceutical industry, and the hospital system. Decentralization has devolved responsibility to the municipal level. The primary service unit is the neighbourhood clinic where a physician and nurse are responsible for preventive services, provision of chronic care, and an annual check-up for between 500-800 residents. Cuba, now a net international doctor donor, has increased its physician cadre by ten-fold to 30 000 physicians since 1960 [2].

This comprehensive and coherent system does offer free care, generous human resources, and well defined responsibility at a level where the physician/nurse team can realistically enjoy a substantial personal relationship with each citizen. Clearly, this would appear to be an ideal structure through which to deliver long-term chronic care. The study by Ombudez-Garcia et al. [1] indicates that it works.

Why do the rest of us do so poorly? Expecting the current personal encounter medical care system (i.e. designed to respond to sickness) to effectively provide chronic care may be an impossible dream. In Cuba, self-conscious national planning led to the realization that, by 1980, chronic disease had replaced acute deficiency and infectious conditions as primary health threats. They modified their medical care system to address the needs of long-term care. In much of the rest of the world, this has not taken place. Instead, we continue to focus on the traditional medical model in which the principle role of the physician is to diagnose, prognosticate, and devise a plan of therapy. That model does not fit the world of chronic disease. Diagnosis, prognostication, and even a plan of therapy are not the major challenges in hypertension management. But, long-term care (the hard part) is not high on the educational, research, or practical radar screen of our highly sophisticated, technologically intensive medical care system.

Surely, more than 30 years of well funded campaigns exhortating physicians to improve compliance is simply not working. Endless 'compliance' research has produced little demonstrable change in outcomes.

Interestingly, the infectious disease community in New York invented Directly Observed Therapy as a compliance tool to combat a threatening tuberculosis epidemic in New York almost 20 years ago. This add-on to conventional care seemed effective then, but rigorous study suggests that it does not seem to be a magic solution that can be relied upon by itself to solve the tuberculosis problem [3]. Dysfunctional systems cannot be transformed by sticking plasters.

What can the answer be? Readers of the Journal of Hypertension are primarily medical care, not public health professionals. Our population is our patients. Our challenge is 'practice-wide' blood pressure (or lipid, or glucose) control. We are probably reasonably good at identifying cases and prescribing therapy. It is the long-term piece that does not appear to work.

Free and accessible care might seem like the magic bullet, but experience in the US Veterans Veterans Affairs (VA) health care system suggests that this, by itself, does not improve blood pressure control [4]. What does seem to matter are structural modifications to the system of care. There are examples of approaches to care that have the kind of success in treatment (a two-third control rate) similar to that achieved in Cuba. Recent clinical trials, including ALLHAT [5] with a traditional blinded therapeutic approach, and ANBPP [6], based upon open label therapy, did have these kinds of in-treatment control rates. In New York, a worksite [7] based treatment program has also achieved that degree of success for nearly three decades. These programs did provide free-to-the-patient care and involved patients who choose to participate. Nevertheless, as experience in the VA health care system in the US demonstrates [4], free care alone does not necessarily translate into successful long-term treatment success. Clearly, none of these programs had any unique therapeutic modalities, or special knowledge of the disease.

What all these programs did have was a protocol with defined practices and goals, an information system that permitted oversight and constant course correction, and significant participation by nurses and/or other non-physician personal. Is there any prospect that these elements could be adapted and transferred into general use? Information systems are becoming increasingly available, and groups of care givers organized into health care conglomerates responsible for defined patient populations are emerging in many different settings. Maybe the time for structural innovation has arrived.

The key may well be more vigorous application of the increasingly effective and available information technology. New York City has undertaken a program of mandatory haemoglobin HbA1c reporting to establish a registry to capture data on the 650 000 diabetic New Yorkers. The immediate plan is to provide feedback to physicians and patients. This may improve care by itself, but one can readily imagine other ways that this system might be leveraged to have an even greater impact.

The point seems pretty clear. Good blood pressure control is possible. The Cuban experience, coupled with evidence from settings where blood pressure control has been achieved, suggests that structural change and not some magic compliance bullet is necessary. Perhaps exploitation of the power of modern information systems to apply the idea of treatment goals, oversight of every patient, and directed care in which non-physician members of the health care team participate, will achieve much wider application and yield outcomes similar to those observed in Cuba.

References

1 Ordunez-Garcia P, Munoz JLB, Pedraza D, Espinosa-Brito A, Silva LC, Cooper RS. Success in control of hypertension in a low resource setting: the Cuban experience. J Hypertens 2006; 24:845-849.

[Fulltext Link] [CrossRef] [Context Link]

2 De Vos P. 'No one left abandoned': Cuba's National Health System since the 1959 revolution. J Health Serv 2005; 35:189-207.

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3 Brewer TF, Heymann SI. To control and beyond: moving towards eliminating the global tuberculosis threat. J Epidemiol Commun Health 2004; 58:822-825.

[Fulltext Link] [Medline Link] [CrossRef] [Context Link]

4 Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, Moskowitz MA. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998; 339:1957-1963.

[Fulltext Link] [Medline Link] [CrossRef] [Context Link]

5 ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981-2997.

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6 Frohlich ED. Treating hypertension - what are we to believe? N Engl J Med 2003; 348:639-641.

[Fulltext Link] [Medline Link] [CrossRef] [Context Link]

7 Alderman MH, Cohen H, Madhavan S. Distribution and determinants of cardiovascular events during 20 years of successful antihypertensive treatment. J Hypertens 1998; 16:761-769.

[Fulltext Link] [Medline Link] [CrossRef] [Context Link]

© 2006 Lippincott Williams & Wilkins, Inc.


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