Volunteerism, and alignment, are needed for a major paradigm shift in approaches to hypertension control: 2016 World Hypertension League Excellence Award in Hypertension Prevention and Control and the Distinguished Service Award

High and increasing blood pressure (BP) over time is a major global concern.1-6 High BP remains the leading risk for death and disability globally, following dietary risks.7 Notably, among the dietary risks, sodium is the leading risk for death and disability and a major causal risk factor for increased BP.7, 8 Much needs to be done. While governmental organizations have a major role, the nongovernmental organizations and especially hypertension and cardiovascular organizations can play very important roles.9-11 Experts in nongovernmental organizations can advocate for needed policy and health system changes as well as working to enhance clinician, patient, and public skills and knowledge about hypertension prevention and control. It is essential to align governmental and nongovernmental organization approaches to optimize prevention and control of hypertension. In September 2016, “HEARTS” was published by the World Health Organization and the Center for Disease Control and Prevention to provide guidance in prevention and control of cardiovascular diseases.10 HEARTS outlines a central role for control of hypertension and the various actions that are needed. The World Hypertension League (WHL) has been playing a major nongovernmental role in advocating for a variety of the actions outlined in the HEARTS program.6, 8, 11-24 I feel privileged to have been associated with the WHL as a council member representing Canada on and off since 1999 and more recently on the WHL board as president-elect, president, and past president. I am truly honored to receive the second Distinguished Service Award from the WHL, following Professor Liu Lisheng, who was president of the WHL for 10 years and has been the central figure in hypertension prevention and control in China for over 50 years. The WHL has tremendous potential to reduce the burden of disease associated with increased BP. However, for the WHL to fulfill its potential, hypertension-related organizations and individuals need to provide much greater volunteerism in the WHL and its programs. I have found my personal experiences in the WHL to be rich, filled with constant learning from amazing global experts who share a common passion for improving global health through prevention and control of hypertension. For potential volunteers, I would predict your experiences in the WHL to be similarly fulfilling. The HEARTS program provides a basis for alignment of experts and cardiovascular organizations to advocate for badly needed paradigm shifts in approaches to improve hypertension control.10 It outlines the need to share tasks or to shift the tasks from doctors to either other healthcare providers or appropriately trained nonhealthcare providers. Importantly, optimal management of hypertension and other chronic health risks are beyond the capacity of doctors and, in low-resource settings, would overwhelm all healthcare providers. Even in high-resource settings, lower-cost healthcare providers (eg, nurses, pharmacists, and trained nonhealthcare providers) can provide improved BP control relative to solo physicians perhaps by following more systematic approaches to care.25, 26 Having trained nonhealthcare providers or healthcare professionals other than physicians measure BP is especially important as physicians cause a large alerting reaction in patients, markedly increasing BP.27 It is time all healthcare professionals work together as teams to improve hypertension control in overcoming traditional roles and “turf.” Physicians need to support enhanced clinical roles for other healthcare and nonhealthcare providers. The caveat, of course, is adequate training and support of all staff involved in hypertension management. The HEARTS program advocates use of care algorithms to identify overall cardiovascular risk and guide hypertension management, with registries and performance reporting to facilitate improvement in the quality of hypertension care. To my knowledge, all the clinical trials that examined the effectiveness of antihypertensive drugs used care algorithms in at least one of the intervention arms. These trials also used registries with performance reporting and many also had audits to ensure investigators were adhering to the study algorithm (protocol) and BP reduction goals. In trials, where usual clinical practice has been compared with a standardized algorithm-based care, the algorithm-based care has been superior.28 The Kaiser Permanente Group has implemented a simple hypertension care algorithm with a registry and performance reporting as part of their quality improvement program for hypertension management and has achieved 90% hypertension control.29 I am aware of no clinical trial evidence that shows that hypertension management based on individualized approaches without a registry and performance reporting is effective and yet this is the approach advocated in most hypertension clinical guidelines. It is noteworthy that the traditional recommended individualization of hypertension management is associated with low rates of hypertension control throughout the globe.1 Part of the badly needed paradigm shift in hypertension management is the adaptation of clinical care algorithms to guide clinical hypertension management. Hypertension guidelines, in my opinion, should reflect the need for care algorithms, registries, and performance reporting. A caveat is that hypertension care algorithms require adaptation based on local resources and the availability and affordability of high-quality medication. Hypertension Canada is currently considering how to incorporate hypertension management algorithms with registries and performance reporting and has for several years supported task shifting. I feel proud to also be the third person to receive the Excellence Award in Hypertension Control from the WHL (again following in Professor Liu Lisheng' s steps), recognizing my efforts to enhance hypertension control activities in the WHL and for past leadership in efforts to control hypertension in Canada.30 I encourage others to follow Professor Liu Lisheng's, the other WHL award recipients', and my path of volunteerism in the effort to prevent and control hypertension.

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