National Hypertension Taskforce of Australia: a roadmap to achieve 70% blood pressure control in Australia by 2030

Abstract

Raised blood pressure or hypertension is by far the leading risk factor for preventable deaths in Australia, contributing to over 25 000 deaths annually (Supporting Information, figure 1 and figure 2),1-3 mainly due to stroke, heart disease, kidney disease, heart failure, atrial fibrillation and dementia.3, 4 The reduction of blood pressure to less than 140/90 mmHg is only achieved in 32% of people with hypertension in Australia, and control rates have stagnated for a decade (Supporting Information, figure 3).5, 6 As our control rates compare poorly to other high income countries (eg, 68% in Canada),5-7 we published a call-to-action to urgently bring about changes.5 In response to our call-to-action, the National Hypertension Taskforce of Australia (Taskforce) was formed, hosted by the Australian Cardiovascular Alliance and Hypertension Australia (Supporting Information), and launched by the Minister for Health and Aged Care in 2022.8, 9 The Taskforce partners are reflected in the authorship of the roadmap, and are listed in the Supporting Information, figure 4. This article describes the key actions to be taken by the Taskforce, including a roadmap to help implement identified actions. The methods for identifying the key actions and the structure of the Taskforce are described in the Supporting Information, figure 5 and table 1. Background. Raised blood pressure is the leading preventable cause of death in Australia. One in three Australian adults (6.8 million people) have hypertension, defined as clinic or office blood pressure greater than or equal to 140/90 mmHg, based on randomised population data.10 Screening campaigns found that about half of these adults (3.4 million) have not had their high blood pressure values detected and are unaware of their hypertension,11 hence are not receiving appropriate treatment. Of those who are diagnosed with hypertension, and treated in the general population, only 32% (2.2 million) are treated effectively, that is, reducing their blood pressure to less than 140/90 mmHg (Box 1).10, 11 Australians who visit primary care centres have somewhat different rates, where 55% of patients are treated and have their blood pressure effectively controlled.12 Goal. Increase current population blood pressure control rates (< 140/90 mmHg) from 32% to at least 70% by 2030.5, 10 Targets and strategies. The roadmap for 2024–2030 (Box 2) is built on three pillars: (A) prevent; (B) detect; and (C) effectively treat raised blood pressure. An international modelling study recommended 80–80–80 blood pressure targets, which translates to 80% of individuals with hypertension being screened and aware of their diagnosis; 80% of those who are aware being prescribed treatment; and 80% of those on treatment having achieved blood pressure targets.13 However, because 20% remain unaware, and 20% of those aware remain untreated, and 20% of those treated not achieving target, this model would only achieve 51% blood pressure control. To achieve the Taskforce's target of 70%, a 90–90–90 model is required for Australia, as this approach would achieve a 73% blood pressure control rate. The prevention of blood pressure-related disease will be achieved through system-based strategies that promote target blood pressure levels of less than 130/80 mmHg across the nation. Setting a target blood pressure of less than 130/80 mmHg recognises that up to half of blood pressure-related morbidity occurs at a systolic blood pressure less than 140 mmHg.14 Population-based strategies that shift the whole distribution of risk factors would produce substantial reductions in cardiovascular disease (CVD) burden,14 and will benefit children, older people, people living in rural and remote areas, culturally and linguistically diverse populations and First Nations peoples, as well as those not accessing primary care services. Such strategies would reduce the risk for people at all blood pressure levels.15 The Taskforce will support initiatives to ensure the full implementation of the National Preventive Health Strategy 2021.16 For the prevention of raised blood pressure, a taskforce working group will develop economic tools to make healthy choices the most affordable ones. We will develop context-specific strategies to target preventive actions with the greatest attributable risk for hypertension development, such as reducing sodium and increasing potassium intake (eg, using potassium-enriched salt substitutes), a nutritious food supply, a healthy bodyweight, increasing physical activity and avoiding alcohol intake.17 Box 3 lists the top ten key priority areas for action. In this list, Pillar A was identified as key priority action 9 for the Taskforce. The Taskforce has also identified other key priority actions targeting Pillar A, including actions 2, 6 and 10. Developing up-to-date, simple blood pressure management tools for health care providers Brief, user-friendly, easy to access guidance on relevant aspects for adequate blood pressure management such as accurate blood pressure measurement (in office and out-of-office blood pressure), simplified medication treatment algorithm tools, preferred use of single pill combination therapy, and others with reference to existing HealthPathways where feasible. Increasing patient activation and engagement Key for ensuring positive care outcomes and patient self-management through information, engagement, empowerment, partnering and ongoing support. Elements such as improving health literacy, activities to improve how people already diagnosed with hypertension can be “activated” to improve their own health, and others should be addressed. Raising and maintaining awareness at all levels Raising awareness on the importance of blood pressure for cardiovascular health in general, its accurate measurement and management, among the community, health care providers, allied health, pharmacists, government and any other stakeholders. Establishing a systems- and data-based approach to blood pressure management Establishing a national blood pressure surveillance system in primary care based on currently available infrastructure to optimally use data for patient monitoring and evaluation. Set up processes to ensure integration of standardised blood pressure data across the health sector, ensuring health care providers have access to electronic health records, establish blood pressure management based on datasets rather than individual data points to inform practice and team-based care, facilitate identification of high risk patients. Detection (screening) of people with elevated blood pressure to identify those at risk Systematic screening for raised blood pressure for all patients visiting general practitioner clinics, also through team-based care. Opportunistic community-based screening initiatives such as those of the Stroke Foundation and May Measure Month awareness campaigns. Health economic analyses to inform discussions with the federal government as well as state and territory government officials Detailed health economic analysis to estimate the current cost to treat hypertension, and estimations on cost-effectiveness of implementing evidence-based approaches to prevent, detect and manage hypertension. Set up structured pathways to involve government in activities. Explore and drive implementation of multidisciplinary team-based care approaches to manage hypertension Evaluate international successes and co-design pathways with local health care providers, government and consumers accounting for the potential roles of sharing tasks such as the detection, long term monitoring and care of patients, including practice nurses, pharmacists, exercise physiologists, dieticians, physiotherapists and other professionals. Ensuring standardised accurate blood pressure measurement Implement standardised automated office blood pressure monitoring in all health care settings. Ensure provision of validated office blood pressure devices capable of automated office blood pressure measurement. Deliver related educational programs. Develop and implement toolkits for home blood pressure monitoring for health care providers and consumers. Educate on and expand the use of 24-hour ambulatory blood pressure monitoring for diagnosis (Medicare Benefit Schedule item 11607) and monitoring. Expand Medicare items for home and 24-hour measurements for long term blood pressure monitoring. Implement population-based actions to reduce blood pressure across Australia Determine how best to contribute and support ongoing initiatives to ensure the full implementation of the National Preventive Health Strategy 2021, including the development of economic tools to make healthy choices the most affordable ones. Target lifestyle factors with the greatest attributable risk for hypertension development, such as reducing sodium (increasing potassium) intake, healthy food supply for a healthy body weight, increased physical activity and avoiding alcohol. Regularly re-evaluate and update the current roadmap via engagement with all relevant stakeholders, and consolidate and guide actions of the Hypertension Taskforce Keep track of activities, update and adapt the roadmap based on progress and lessons learnt. The Taskforce identified several key priority actions targeting Pillar B (Box 3), including actions 2–8 and 10. When raised blood pressure is detected, it is crucial that a diagnosis is made, and blood pressure is treated effectively. With about 37 000 general practitioners across Australia,20 and with hypertension being the most common condition managed,21 it is crucial that processes in primary care are optimised to improve health outcomes. In primary care, only 55% of people with hypertension have their blood pressure controlled to the conservative target of 140/90 mmHg.12 The Australian Government's 10-year primary care reform plan has a strong focus on consumer-centred primary care,22 and improving team-based care. The implementation of MyMedicare in 2023 is a step in the right direction as it incentivises continuity of care (beneficial to achieving blood pressure targets).23 Current fee-for-service models (paying for each time a service is delivered) work against team-based care. The fee-for-service models lead to financial drivers to maintain the number of services by that professional. A shift towards value-based care (paying for delivering care that improves patient health outcomes) would ensure optimal use of funding across multiple providers to achieve better health outcomes. These notions were echoed by the 2022 Strengthening Medicare taskforce report.24 International guidelines recommend a blood pressure target for most patients of less than 130/80 mmHg,25, 26 emphasising that it is insufficient to lower blood pressure to less than 140/90 mmHg. A target of less than 130/80 mmHg will account for factors frequently associated with poor blood pressure control, including individual patient blood pressure fluctuations and general practitioner visit-to-visit fluctuations.27 Age is the greatest driver of risk.28 Effective treatment of older patients is thus essential. Two major trials in patients (average age of 6829 and 84 years30) demonstrated clear benefit from reducing blood pressure, including reduced mortality, and safety.29, 30 Also, orthostatic hypotension should not be a deterrent to more intensive blood pressure lowering therapy — those receiving intensive therapy had reduced risk of cardiovascular and all-cause deaths regardless of orthostatic hypotension.31 Education is required to overcome the perception of adverse risks of treatment. An important reason for the low blood pressure control rates is missing a diagnosis of secondary hypertension (eg, primary aldosteronism).15 Specific recommendations for identifying secondary causes should be integrated into routine clinical practice. To optimise hypertension management, the Taskforce adopts the World Health Organization successful32 HEARTS technical package for cardiovascular disease management in primary health care,33 tailored to the Australian setting: Lifestyle modification is the first-line treatment for hypertension and has crosscutting benefits such as reducing the risk for cancer and diabetes. Lifestyle coaching modules delivered at the time of diagnosis should ideally be made by the general practice team, including nurses, exercise physiologists, physiotherapists, dieticians, and community pharmacy. Messages should be reinforced with an in-person follow-up, eHealth, mHealth or telehealth. Most people diagnosed with hypertension will persist with uncontrolled blood pressure despite lifestyle changes and thus should be given medication while simultaneously making lifestyle changes. Low control rates (55%) in Australian primary care12 are largely due to treatment inertia — the hesitancy to start or intensify treatment after elevated blood pressure readings. A 1-page simplified treatment protocol on targeting a blood pressure less than 130/80 mmHg is regarded as one of the most successful components of HEARTS,32 likely because it helps overcome inertia.34 The protocol will be developed in collaboration with general practitioners, professional colleges and societies to ensure feasibility for adoption. This protocol should include lifestyle coaching plus a linear, stepwise algorithm describing progressively more intensive medication treatment until blood pressure is controlled. The protocol should provide evidence-based medicines and doses,32 ideally single-pill combinations (SPC) of two or more drugs as initial therapy. For most patients, successful treatment requires two or more medications.26 SPCs can be cost-neutral or result in a cost saving35 and benefits include improved medication adherence;36 improved blood pressure control over a shorter period of time,37 with no increase in side effects.37 SPCs also lessen treatment inertia and the impact of infrequent following up of patients after prescribing. Current practice in Australia is to start treatment with monotherapy, where the dose is often increased at follow-up visits.35, 38 It is safer and more effective to add another blood pressure lowering drug than to double the dose,39 which is another benefit for SPCs as first-line treatment. However, at present, policy changes are required to allow prescription of SPCs as first-line treatment in Australia, as SPCs are not subsidised by the Pharmaceutical Benefits Scheme for initial treatment.35 The Taskforce has identified the development of a 1-page simplified protocol as key priority action 1 targeting Pillar C (Box 3). Medicines. Treating hypertension in primary care cost Australia about $1.2 billion in 2022, with 51% of that pharmacy-related, 29% general practitioner-related, and 20% medicine costs.40 With 58% of the cost from federal sources, and 42% from patient out-of-pocket payments, these expenses highlight a major equity issue.40 About 37 monotherapy regimens and 57 SPCs (including strength variations) are available in Australia35 and supported by the Pharmaceutical Benefits Scheme. Although prescriptions require a patient co-payment, in 2023 this cost was set to a maximum of $30 or $7.30 for those with a concession card. Also, several dual and triple SPCs are included in the 2023 update of medicines listed on the Pharmaceutical Benefits Scheme allowing increased dispensing from 30 to 60 days. Longer dispensing durations are likely to improve access, adherence and blood pressure control.7 Availability of different generic SPCs (with different strength variations) would ease effective prescribing. Blood pressure measurement devices. Clinically validated upper-arm cuff-based automated devices should be used for blood pressure measurement in the clinic, and for 24-hour ambulatory or home blood pressure monitoring. These automated devices eliminate human error associated with manual devices (eg, digit preference, hearing impairment) and require less training.41 of clinical is an of automated devices are not have not for by the Australian and or the not adequate such as provide lists of devices that are following the 2023 International on clinic blood pressure accurate diagnosis is more clinic measurement can be achieved by automated office blood pressure This using an automated that and multiple with or the of a health professional. To 24-hour ambulatory and home blood pressure monitoring are The is 24-hour ambulatory blood pressure, and is a Medicare available (Medicare Benefits Schedule item For ongoing automated office blood pressure or blood pressure monitoring is and patients in accurate blood pressure monitoring are and will be developed by the Taskforce. blood pressure devices are are not recommended until and in clinical practice have To access to medicines and the Taskforce has identified key priority actions 1 and targeting B and C (Box 3). patients at the risk of is a to improve health outcomes. risk is by factors such as blood pressure, disease such as or kidney disease, and The 2023 Australian risk include these components and recommend screening people in people with and First Nations people using an an risk of or high risk of more than or equal to of having a cardiovascular the is detected, guidelines recommend of in the and and blood pressure lowering therapy in the regardless of blood pressure and Health are to national guidelines to guide The national guidelines on the diagnosis and management of hypertension in was published in and requires an The Taskforce the use of the 1-page simplified hypertension protocol to be developed as of key priority action 1. 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The to team-based care as an of the of would ensure health are used to their full The Taskforce the of different team-based care models and implementing those with — with a focus on value-based care. To implement team-based care, the Taskforce has identified key priority action targeting B and C (Box 3). strategies are also effective in improving blood pressure control. The National the importance of team-based and care, with a clear focus to and The Taskforce to establish a group of people with to on actions related to the of and treatment. To increase patient activation and engagement, the Taskforce has identified key priority action targeting A, B and C (Box 3). An effective hypertension control requires the monitoring of blood pressure control at the primary care and health system In Australia, are two with this of of data from the general population to is available in the — the Taskforce on data from the Australian of National Health and of data and of national primary care data are not for national or primary health include the clinical used by general practitioner (eg, different clinical tools (eg, and different health used by primary health For the Taskforce track national blood pressure or track related medication use through the Pharmaceutical Benefits Medicare Benefits Schedule disease development, and health outcomes over access to general practitioner its management was to the Australian on and in health care and we to data available high data across at least a of general practitioner are including a care to better monitoring be to include blood pressure control as a as of the are to achieve of data through the primary health and the are not national or A national government is essential. 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