Hypertension Curriculum Review Series

This series of review articles should be of particular interest to those clinicians desiring an intensive review of selected topics in hypertension and for those preparing for the next American Society of Hypertension (ASH) Specialist in Clinical Hypertension certification examination. Despite prolonged and extensive public and physician education programs over the past 30 years, blood pressure in the majority of treated hypertensive patients remains above recommended treatment goals.1 Hypertension is clearly a worldwide problem, and concerns over poor treatment efforts have been repeatedly reported by the World Health Organization, in addition to numerous national health organizations. There are multiple factors that impact management and control efforts, some related to both patients and providers, and others to the health care delivery system. Poor long-term adherence with prescribed medications is clearly a major patient factor in poor control rates relating partially to medication side effects, difficulty remembering to take medications, and poor acceptance of their disease. However, inadequate patient education and poor understanding of treatment goals and expected outcomes also appear to play a significant role. On the part of the provider, inadequate education and establishment of treatment goals, intent on controlling blood pressure with monotherapy and/or acceptance of sub-optimal blood pressure control, as well as poor systems of follow-up also represent major contributors to poor control rates. For the health care delivery system, declining reimbursement, increased volume of patients, and limited quality assurance efforts would also appear to be contributing factors. As an example of the latter, the Health Plan Employer Data Information Set (HEDIS) introduced a standardized performance measure for blood pressure control (<140/90 mm Hg) in 2001. Performance of health maintenance organizations in achieving this Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended initial goal for blood pressure control has steadily improved. However, HEDIS failed to initiate the lower blood pressure goal (<130/80 mm Hg) recommended for patients with diabetes and chronic renal disease. As a result, goal achievement by health maintenance organizations for this important sub-population of hypertensive patients has remained extremely poor. There is also concern that undergraduate medical education may not be as consistent and as focused as needed to prepare young physicians for the management of their patients with chronic conditions such as hypertension. There is evidence to suggest that a major determinant of patient adherence to therapeutic recommendations relies on the clinician's ability to relate and to motivate patients.2 Special attention for the development of these interpersonal skills in undergraduate medical education is needed. Evidence also suggests that an improved understanding and compliance with hypertension management guidelines is dependent upon the availability of a teaching staff with an interest in hypertension.3 A recent survey of primary care physicians has suggested that nearly one in four reported that the scope of care they were expected to provide was greater than it should be. In addition, one in three specialists reported that the complexity or severity of patients conditions at the time patients were referred to them by primary care physicians was greater than it should be.4 The above observations have suggested that for most chronic conditions, such as hypertension, there is a need to increase available expertise in the community regarding the evaluation, diagnosis, and management of hypertension. In May of 1998, a working committee of ASH elected to establish a process of formal recognition for those physicians who, by training, expertise, and peer respect, merit the title “Specialist in Clinical Hypertension.” It was felt that recognized specialists in clinical hypertension should function as both consultants to patients and to physicians, in addition to providing individual patient care. The first phase of the ASH Specialist Program was designed to recognize those individuals who by training, experience, current practice, and peer respect would merit the title of a “Specialist in Clinical Hypertension.” Future applicants for this title will include both established physicians, who by their own study, including relevant continuing medical education courses, have acquired the requisite knowledge, as well as recent graduates within the medical specialties and subspecialties who have received the appropriate training to enable passage of the certification examination. We believe that a specialist in clinical hypertension should be prepared to manage selected special problems in hypertension and should serve as a valuable resource to the community by participating in both patient and physician education regarding hypertension. He or she should be a consultant to the primary care physician for difficult problems in the diagnosis, evaluation, and management of hypertension. The rapid proliferation of new antihypertensive agents and the large numbers of clinical trials being performed in selected patient subgroups make it difficult for the primary care physician to maintain optimal expertise relative to the clinical pharmacology of new drugs, the potential for drug-drug interactions and/or adverse effects, and optimal combinations of drugs to maximize blood pressure reduction and maintain the lower goal blood pressures being recommended. To date, 962 physicians in the United States and Canada have received the designation of Specialist in Clinical Hypertension. Specialists developed in nephrology, cardiology, and endocrinology will be insufficient in numbers to provide the consultation resources required to optimally manage the magnitude of the hypertension problem. We are strongly encouraging physicians certified in family practice or in internal medicine with an interest in hypertension to apply for certification. I am hopeful that this hypertension curriculum review series, which commenced in the July 2004 issue of The JCH, will provide an intensive review of selected topics in hypertension and will also be of utility to those certified family physicians and internists contemplating application for the next certification examination. For information regarding the ASH Specialist in Clinical Hypertension certification examination, please contact the American Society of Hypertension, 148 Madison Avenue, 5th Floor, New York, NY 10016; phone: 212-696-9099; fax: 212-696-0711; Web site: http://www.ash-us.org.

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