HYPERTENSION (Screening, Counseling and Treatment)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 6/6/2011

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force recommends that clinicians screen all adults aged 18 years and older for hypertension.1

Evidence Rating: A (Strongly Recommended/Good Evidence)
The U.S. Preventive Services Task Force (USPSTF) found good evidence that (1) screening for high blood pressure can identify adults at increased risk for cardiovascular disease, (2) treating high blood pressure can significantly decrease the incidence of cardiovascular disease, and (3) the benefits of screening outweigh the harms.1,2,3

Centers for Disease Control and Prevention (CDC) Guidance
The Centers for Disease Control and Prevention (CDC) supports the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure4 recommendations for blood pressure screening, prevention, and control (described in the next section). More information on the CDC's hypertension-related guidance is available online at http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm.5,6



Condition / Disease Specific Information

Explanation of Condition
Blood pressure is often expressed as two numbers-the top (systolic) number represents the pressure while the heart is beating, while the bottom (diastolic) number represents the pressure when the heart is resting between beats. Normal blood pressure is a systolic blood pressure less than 120 mm Hg and a diastolic blood pressure less than 80 mm Hg.

A person is considered to have high blood pressure (also called hypertension) when he or she has a systolic pressure of 140 mm Hg or above, a diastolic blood pressure of 90 mm Hg or above, or both after 2 or more elevated readings are obtained on at least 2 visits over a period of 1 to several weeks.3 Once hypertension occurs, it generally remains a life-long, chronic condition. A person who is being treated for high blood pressure, even though repeated blood pressure readings are recorded in the normal range, still is considered to have hyptertension.2,4 If treatment stops, the hypertension will almost invariably recur.

Pre-hypertension is defined as systolic pressure of 120-139 mm Hg or diastolic pressure of 80-89 mm Hg.2, 4 Persons with pre-hypertension are at increased risk of progressing to hypertension. About 30% of American adults aged 18 and older have pre-hypertension.7

Information on the classification and management of blood pressure for adults aged 18 years and older is provided in Table 1. The table lists lifestyle modification and drug therapy recommendations for adults by risk category.

Table 1: Classification and Management of Blood Pressure for Adults Aged 18 Years and Older

Explanation of Condition Lifestyle Modifications (e.g., Increasing Physical Activity, Reducing Dietary Salt Intake) Recommended Drug Therapy for Patients Without a Compelling Indication Recommended Drug Therapy for Patients With Compelling Indications (Heart Failure, Post-Myocardial Infarction, High Coronary Disease Risk, Diabetes, Chronic Kidney Disease, Recurrent Stroke)
Normal: systolic blood pressure <120 mm Hg and diastolic pressure <80 mg Hg Encourage    
Pre-hypertension: systolic blood pressure 120-139 mm Hg or diastolic pressure 80-89 mm Hg Yes No antihypertensive drug indicated Drug(s) should be given for the compelling indications. Patients with chronic kidney disease or diabetes should be treated with antihypertensive drugs to achieve a blood pressure of less than 130/80 mm Hg.
Stage 1 hypertension: systolic blood pressure 140-159 mm Hg or diastolic pressure 90-99 mm Hg Yes Thiazide-type diuretics are appropriate for most patients with stage 1 hypertension. Clinicians may consider angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, ß-blockers, calcium channel blockers, or a combination of these drugs. Drug(s) should be given for the compelling indications. Other anti-hypertensive drugs (diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, ß-blockers, calcium or channel blockers) should be given as needed.
Stage 2 hypertension: systolic blood pressure 160 mm Hg or higher, or diastolic pressure 100 mm Hg or higher Yes Two-drug combinations (usually thiazide-type diuretics and angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or ß-blockers) are recommended for most patients with stage 2 hypertension. Initial combined therapy should be used cautiously in those at risk of orthostatic hypotension. Drug(s) should be given for the compelling indications. Other antihypertensive drugs (diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, ß-blockers, calcium, or channel blockers) should be given as needed.

Note: Initial treatment should be determined by the patient's highest blood pressure category (e.g., a patient with a systolic blood pressure of 110 mm Hg and a diastolic blood pressure of 90 mm Hg should be treated for stage 1 hypertension).

Source: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289:2560-72.


Epidemiology of Condition/Disease
In the United States, high blood pressure affects approximately one-third of the adult population and is a major risk factor for death from cardiovascular disease.7,8,9. Data from the National Health Interview Survey shows that self-reported high blood pressure affects about 35.5% African-Americans, followed by 32.4% Native Americans, 24.9% white, 23.7% Hispanics and 21.7% Asians.10 High blood pressure was the primary or a contributing cause of death for about 326,000 people in the United States in 2006.8

Hypertension is the most common ambulatory care primary diagnosis in the United States and is responsible for 35 million office visits each year.4 Among hypertensive adults, only 44% of those treated had their hypertension controlled, putting them at an increased risk for heart disease and stroke.9 They also have an increased risk of developing peripheral artery disease, end-stage renal disease, retinopathy, and aortic aneurysm.9 Although hypertension control has improved from about 27% in 1988-1994 to 50% in 2007-2008,12 about 20% of those with hypertension remain unaware of their condition.

Condition/Disease Risk Factors
Risk factors for hypertension include increased age, family history, obesity, diabetes,13 smoking, heavy alcohol use, physical inactivity, and high salt intake.2,4 The prevalence of hypertension in African-Americans in the United States, in people with low levels of education or low socioeconomic status, and in those who live in the southeastern United States is among the highest in the world.9 The rate of fatal strokes is 1.8 times higher in blacks than whites, while their rates of death from heart disease are 1.5 times higher and of kidney disease are 4.2 times greater. These disparities are caused, in part, by their higher prevalence of hypertension.2




The Value of Prevention

Economic Burden of Condition/Disease
Using 2001 Medical Expenditure Panel Survey (MEPS), direct medical cost for a U.S. individual with hypertension has been estimated to be $1,141 per year, for a total yearly cost of $55 billion.14 While the estimated average costs for hypertension-related hospitalization were $31,106 for patients with a primary diagnosis of ischemic heart disease (IHD), $17,298 for those with a primary diagnosis of cardiovascular disease (CVD), and $18,693 for those without a primary diagnosis of IHD or CVD hypertension-associated costs for these patients were $3,540, $1,133, and $2,254, respectively.15

Workplace Burden of Condition/Disease
Hypertension is 1 of the 10 most expensive health conditions for U.S. employers. Its complications are a major cause of preventable absenteeism, reduced productivity, and disability.16

One study found that the overall economic burden of illness to employers was higher for hypertension than for nine other conditions-$392 per eligible employee per year (based on average impairment and prevalence estimates using 2001 average hourly wages and benefits). On-the-job productivity losses (employees with uncontrolled hypertension who were less productive at work than healthy employees) accounted for 63% of this total.17

Work site interventions are also effective for helping employees control this burden of high blood pressure. A systematic review of selected interventions for worksite health promotion found strong and sufficient evidence that assessing health risk factors with feedback to employees combined with health education counseling with or without other worksite interventions is effective for blood pressure control.18

Economic Benefit of Preventive Intervention
Screening, detection, and early treatment can significantly reduce the medical care costs associated with hypertension and the other diseases for which people with hypertension are at increased risk. Estimates of full economic benefits should also take into account productivity gains because of better on-the-job performance and added years of life, as well as to declines in disability, absenteeism, and employee turnover.

A 12- to 13-point reduction in blood pressure can reduce the number of heart attacks by 21%, strokes by 37%, and all deaths from cardiovascular disease by 25%.4 One computer model study for 60-year-old diabetic individuals with hypertension projected that reducing blood pressure from less than 140/90 mm Hg to less than 130/85 mm Hg would increase life expectancy by 16.5-17.4 years and decrease total lifetime medical costs by $1,450 because of the clinical events that are prevented.19 Another study with more than 3,000 50-year-old participants found that total life expectancy was about 5 years longer for adults with normal blood pressure than those with hypertension.20

These studies suggest that reducing blood pressure in patients with hypertension saves money and extends life expectancy. They also suggest that the medical, economic, and human costs of untreated and inadequately controlled high blood pressure are enormous.20,21,22,23

Estimated Cost of Preventive Intervention
The cost of screening for blood pressure in a clinician's office as part of a routine physical examination is minimal.

Estimated Cost of Counseling and Treatment
Lifestyle counseling to promote a healthy diet and physical activity is usually the first step in preventing or treating hypertension and remains important throughout all stages of treatment. The cost for these services varies.4 In 2008, the private-sector cost of annual visits to lower blood pressure in nondiabetic individuals averaged $74 per session.24

If lifestyle changes do not achieve blood pressure control, antihypertensive medications are typically used. Many types of antihypertensive medications are currently available. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) states that thiazide diuretics are among the most effective drugs for hypertension, are available in generic form, and are also among the least expensive.4,22 The JNC-7 further states that more than one antihypertensive medication may be needed to achieve hypertension control, the combination of which should be on the basis of the physician's treatment decisions to achieve the most optimal results.

The cost of follow-up or treatment-related appointments varies by type of provider, location, and practice setting.

Disease management programs and centralized blood pressure control clinics have been judged to be useful to encourage compliance with treatment and to meet treatment goals. The costs of these services also vary considerably.

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
Controlling blood pressure with medications is one of the most cost-effective methods of reducing premature cardiovascular morbidity and mortality.4,25 This is particularly true for older men and women and those with high pretreatment blood pressure levels.19,26 The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) concluded that thiazide-type diuretics are at least as effective as newer drugs in preventing one or more forms of cardiovascular disease and are less expensive.27



Preventive Intervention Information

Preventive Intervention: Purpose of Screening and Treatment
Screening for hypertension allows clinicians to identify affected patients and begin treatment early in the disease course to prevent the serious consequences of high blood pressure, including stroke, coronary artery disease, heart attack, and heart and kidney failure.4

High blood pressure is easily detectable and can be controlled by lifestyle modifications, such as increasing physical activity, reducing dietary salt intake, and using medications.

Benefits and Risks of Intervention, Risk Reduction, and Treatment
The benefits of screening and detecting high blood pressure are substantial. Screening identifies patients with hypertension and allows them to begin treatment for their condition early in the course of the disease.

Some studies have suggested that screening for hypertension and labeling individuals as having hypertension could result in adverse psychological effects and transient increases in absenteeism.28 However, these studies had inconsistent results and the causes of absenteeism related to screening and diagnosis were not well established.28 The risk of false-positive classification can be reduced by multiple measurements.4

The benefit-to-harm ratio of treating hypertension overwhelmingly argues for treatment. In clinical trials, antihypertensive therapy has been associated with a 35% to 40% mean reduction in stroke incidence, a 20% to 25% reduction in myocardial infarction incidence, and a decrease of more than 50% in heart failure incidence.4,29,30 Providing antihypertensive medications to adults with severe hypertension reduces their odds of developing congestive heart failure by 86% and active treatment of isolated systolic hypertension in elderly patients reduces the incidence of both stroke and coronary heart disease events by 30%, coronary vascular disease by 18%, and total mortality by 13%.2,31

The side effects of antihypertensive medications (such as dizziness, lightheadedness, or fainting) can interfere with patient adherence, but side effects can usually be minimized by patient education and by modifying medications or their dosages. Serious side effects (such as fever, chills, or joint or stomach pain) are rare and can be reduced or eliminated by switching medications or reducing drug dosage.28Clinicians should also discuss with their patients the benefits of adopting a healthy lifestyle (such as increasing physical activity and reducing dietary salt intake) to prevent and treat high blood pressure.4
Initiation, Cessation, and Interval Screening
Blood pressure screening should be conducted routinely among all patients aged 18 years or older, or as deemed necessary by a physician. Children older than 3 years who are seen in medical care settings should have their blood pressure measured at least once during every health care episode.6 Evidence is insufficient to determine the optimal interval for screening. Expert opinion captured in the JNC-7 indicates that people with a systolic blood pressure of under 130 mm Hg and a diastolic blood pressure of under 85 mm Hg should be screened every 2 years, while people with elevated blood pressure (130/85 mm Hg or above) should be screened more frequently.4

Counseling and Treatment
All patients with diagnosed hypertension should be counseled and encouraged to make therapeutic lifestyle changes in order to lower their blood pressure. Many patients will also require antihypertensive drug therapy. Once this is initiated, most patients should return for follow-up and adjustment of medications at monthly intervals or less until the blood pressure goal is reached. More frequent visits are necessary for patients with stage 2 hypertension or with complicating comorbid conditions. Comorbidities such as heart failure, diabetes, and the need for laboratory tests influence the frequency of visits. Other cardiovascular risk factors should be monitored and treated to their respective goals. After blood pressure is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals, or more often if necessary.4

Intervention Process
Screening
Blood pressure screening is usually conducted in a clinician's office using an arm cuff and a calibrated sphygmomanometer (blood pressure meter). Ambulatory blood pressure measurement techniques, conducted outside of the clinical setting, can be particularly helpful in identifying patients who have elevated blood pressures only in the clinic environment, known as "white-coat hypertension." 32 However, because of its high costs, ambulatory blood pressure monitoring is rarely used to screen for high blood pressure.32 Because of natural variability in blood pressure in humans and the possibility of equipment or observer error, the U.S. Preventive Services Task Force recommends that a diagnosis of high blood pressure be made only after two or more elevated readings are obtained on two or more occasions over a period of several weeks.2

Counseling and Treatment
Beginning at the initial visit with a patient who has hypertension, the clinician should counsel and encourage the patient to make therapeutic lifestyle changes-such as dietary changes, increased physical activity, tobacco avoidance, and weight control-and monitor the patient's progress. Therapy begins with lifestyle modification. If the blood pressure goal is not achieved thiazide-type diuretics should be used as initial therapy for most patients, either alone or in combination with one of the other class of medications that have also been shown in clinical trials to reduce one or more hypertensive complications.4

Persons who are diagnosed with hypertension should start a treatment plan to lower their blood pressure. Treatment plans usually include non-pharmacological therapies, pharmacological therapies, or a combination of the two.4

Lifestyle Interventions (Initial Treatment/"First-Line" Therapy):
Healthy lifestyles are critical in preventing and managing hypertension.4 Lifestyle interventions decrease blood pressure, enhance antihypertensive drug efficacy, and decrease cardiovascular risk. The major lifestyle modifications that have been shown to reduce blood pressure are listed in Table 2. They include weight reduction in obese or overweight individuals,25 programs to assure adequate physical activity, and adoption of The Dietary Approaches to Stop Hypertension (DASH) Diet Action Plan, which calls for reduced consumption of saturated fat, cholesterol, and total fat and increased consumption of potassium and calcium,33 reduced intake of dietary sodium,34 increased physical activity,35 and moderation of alcohol consumption.36 The Plan has been clinically proven to enhance blood pressure reduction.4 See The DASH Diet Action Plan for more information
http://dashdiet.org/newdashdietbook.asp

This program recommends the following:
  • "Lifestyle modification is encouraged for those with a systolic blood pressure greater than 120 mm Hg or a diastolic blood pressure greater than 80 mm Hg.
  • People with multiple coronary heart disease risk factors that place them at "intermediate risk" for coronary heart disease (10-year cardiovascular event risk of 10% to 20%) should be encouraged to change their lifestyles to achieve their blood pressure goals. If lifestyle changes are unsuccessful, drug therapy should be considered.
  • People with coronary heart disease or atherosclerotic cardiovascular disease 10-year cardiovascular event risk greater than 20% need to reduce their blood pressure to the target level and should consider drug therapy in addition to lifestyle interventions if their systolic blood pressure exceeds 140 mm Hg or their diastolic blood pressure is higher than 90 mm Hg.
A risk assessment tool is available online at: http://hp2010.nhlbihin.net/atpiii/calculator.asp.

Table 2: Lifestyle Modifications to Prevent and Manage Hypertension*

Modification Recommendation Approximate Systolic Blood Pressure Reduction Range
Weight reduction Maintain normal body weight (body-mass index of 18.5 to 24.9) 5-20 mm Hg per 10-kg weight loss
Adopt Dietary Approaches to Stop Hypertension eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products, with little saturated and total fat 8-14 mm Hg
Dietary sodium reduction Reduce dietary sodium intake to no more than 2.4 grams of sodium or 6 grams of sodium chloride. (6 grams of sodium equals about 1 teaspoon of table salt (sodium chloride) 2-8 mm Hg
Physical activity Engage in regular aerobic physical activity, such as brisk walking, at least 30 minutes per day on most days of the week 4-9 mm Hg
Moderation of alcohol consumption Limit consumption to no more than two drinks per day (1 ounce or 30 ml ethanol [e.g., 24 ounces of beer, 10 ounces of wine, or 3 ounces of 80-proof whiskey]) for most men and no more than one drink per day for women and lighter-weight persons. 2-4 mm Hg

*Note: For overall cardiovascular risk reduction, individuals should stop smoking. The effects of implementing these modifications depend on dose and duration.

Source: Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Dietary approaches to stop hypertension. JAMA. 2003;289:2560-72.


Pharmacologic Treatment:
Lifestyle interventions may not be sufficient to reduce blood pressure in many patients. In those cases, the addition of pharmacological therapy to a treatment plan is often beneficial. In fact, most people with hypertension require two or more antihypertensive medications to achieve their target blood pressure.37,38 Clinical trial outcome data indicate that several classes of drugs-including angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, ß-blockers, calcium channel blockers, and thiazide-type diuretics-can reduce the complications of hypertension. A detailed list of antihypertensive drugs and recommended dose ranges is provided in Table 6 of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Express.(http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf) The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends that patients with pre-hypertension or stage 1 hypertension return for follow-up and adjustment of medications approximately once a month until they reach their blood pressure goal. More frequent visits are necessary for patients with stage 2 hypertension (160/90 mm Hg or higher) or who have complicating co-morbid conditions.



Other Important Information

The most effective therapy prescribed by clinicians will control hypertension only if the patient takes the prescribed medication as instructed and establishes and maintains a health-promoting lifestyle. Electronic and paper clinician decision support systems, self-monitoring, flow sheets, feedback and appointment reminders, and a multidisciplinary team approach that involves nurses, pharmacists, and other care providers are important program components for controlling hypertension.39-41 Educational interventions directed at patients or health care provides are also important, but appear unlikely to be effective by themselves. 40,42 Primary health care providers need to have an organized tracking system, and patient communication and follow-up to help hypertension patients implement a vigorous stepped-care approach of antihypertensive drug therapy until patients reach target blood pressure levels.40 Introducing simpler dosing regimens may also be effective in improving adherence.43 Furthermore, cost-effective health care interventions to prevent and control hypertension can only be implemented if the capacity of primary health care system, policy environment, and financing enable delivery of services.44

For more information on medication adherence please refer to Part VI of the Purchaser's Guide, "Leveraging Benefits: Promoting the Delivery and Use of Preventive Services."

See healthy diets, for more information. http://www.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm.




Strength of Evidence

The levels of evidence supporting the recommendations in this chapter are described below.
Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: A (Strongly Recommended/Good Evidence)
  • The USPSTF found good evidence to support the routine screening of all adults, aged 18 and above, for hypertension.1



Summary Plan Description Language: Hypertension (Screening)

Covered Screening
Conventional measure using an arm cuff and an appropriately validated aneroid (containing no liquid) or digital sphygmomanometer (blood pressure meter).

Initiation, Cessation, and Interval
Screening is a covered benefit for all children, adolescents, and adults and may be conducted as medically indicated.

Summary Plan Description Language: Hypertension (Counseling and Treatment)

Covered Counseling and Treatments
Covered treatment for hypertension includes the following:
  • Counseling to promote therapeutic lifestyle changes
  • Office visits to monitor hypertension and treatment efforts
  • Medications used to treat hypertension
Initiation, Cessation, and Interval
Six counseling, treatment, and monitoring sessions are covered per calendar year. Additional counseling sessions are covered, as medically indicated.

Beneficiaries undergoing treatment with hypertension-lowering medications qualify for additional medication management visits, as medically indicated.




CPT Codes

Hypertension (Screening)
  CPT code not applicable
Hypertension (Counseling, Treatment)
99401 Preventive medicine counseling/risk factor reduction, 15 minutes
99402 Preventive medicine counseling/risk factor reduction, 30 minutes
99403 Preventive medicine counseling/risk factor reduction, 45 minutes
99404 Preventive medicine counseling/risk factor reduction, 60 minutes




Other Information and Resources

Business Group Resource(s)

CDC Resource




Author(s)

Matson Koffman DM, Ayala C, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion. Update 2010.45




References

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4 Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
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