Controlling High Blood Pressure

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period

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High blood pressure (HBP), also known as hypertension, is when the pressure in blood vessels is higher than normal (Centers for Disease Control and Prevention [CDC], 2023). The causes of hypertension are multiple and multifaceted and can be based on genetic predisposition, environmental risk factors, being overweight and obese, sodium intake, potassium intake, physical activity, and alcohol use. High blood pressure is common; according to the American Heart Association, between 2013-2016, approximately 121.5 million US adults >= 20 years of age had HBP and the prevalence of hypertension among US adults 65 and older was 77.0 percent (Virani et al., 2021). In an analysis of adults with hypertension in National Health and Nutrition Examination Survey (NHANES), the estimated age-adjusted proportion with controlled blood pressure (BP) increased from 31.8 percent in 1999 to 53.8 percent in 2014. However, that proportion declined to 43.7 percent in 2017 to 2018 (Tsao et al., 2022).

HBP increases risks of heart disease and stroke which are two of the leading causes of death in the US (CDC, 2023). A person who has HBP is four times more likely to die from a stroke and three times more likely to die from heart disease (CDC, 2021). The National Center for Health Statistics reported that in 2020 there were over 670,000 deaths with HBP as a primary or contributing cause (CDC, 2022). Between 2009 and 2019 the number of deaths due to HBP rose by 65.3 percent (Tsao et al., 2022). Managing and treating HBP would reduce cardiovascular disease mortality for males and females by 30.4 percent and 38.0 percent, respectively (Patel et al., 2015). Age-adjusted death rates attributable to HBP in 2019 were more than twice as high in non-Hispanic Black males (56.7 percent) when compared to rates for non-Hispanic White males (25.7 percent) (Tsao et al., 2022).

HBP costs the U.S. approximately 131 billion dollars each year, averaged over 12 years from 2003 to 2014 (Kirkland et al., 2018). A study on cost-effectiveness on treating hypertension found that controlling HBP in patients with cardiovascular disease and systolic blood pressures (SBP) of >= 160 mmHg could be effective and cost-saving (Moran et al., 2015).

Many studies have shown that controlling high blood pressure reduces cardiovascular events and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) investigated the impact of obtaining a SBP goal of <120 mmHg compared to a SBP goal of <140 mmHg among patients 50 and older with established cardiovascular disease and found that the patients with the former goal had reduced cardiovascular events and mortality (SPRINT Research Group et al., 2015). 

Controlling HBP will significantly reduce the risks of cardiovascular disease mortality and lead to better health outcomes like reduction of heart attacks, stroke, and kidney disease (James et al., 2014). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.

U.S. Preventive Services Task Force (USPSTF) (2021):

- The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. This is a grade A recommendation.  

American College of Cardiology/American Heart Association (2017):

- For adults with confirmed hypertension and known cardiovascular disease (CVD) or 10-year atherosclerotic cardiovascular disease (ASCVD) event risk of 10 percent or higher, a blood pressure target of less than 130/80 mmHg is recommended (Level of evidence: B-R (for systolic blood pressures), Level of evidence: C-EO (for diastolic blood pressure)) 

- For adults with confirmed hypertension, without additional markers of increased CVD risk, a blood pressure target of less than 130/80 mmHg may be reasonable (Note: clinical trial evidence is strongest for a target blood pressure of 140/90 mmHg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from blood pressure control earlier in life) (Level of evidence: B-NR (for systolic blood pressure), Level of evidence: C-EO (for diastolic blood pressure)).

American Academy of Family Physicians (2022):   

- Treat adults who have hypertension to a standard blood pressure target (less than 140/90 mm Hg) to reduce the risk of all-cause and cardiovascular mortality (strong recommendation; high-quality evidence). Treating to a lower blood pressure target (less than 135/85 mm Hg) does not provide additional benefit at preventing mortality; however, a lower blood pressure target could be considered based on patient preferences and values. (Grade: strong recommendation, Quality of evidence: high)

- Consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence). Although treatment to a standard blood pressure target (less than 140/90 mm Hg) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. There was no observed additional benefit in preventing stroke with the lower blood pressure target. (Grade: weak recommendation, Quality of evidence: low)

American Diabetes Association (2022): 

- For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease or 10-year atherosclerotic cardiovascular disease risk >=15 percent), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained (Level of evidence: B)

- For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15 percent), treat to a blood pressure target of <140/90 mmHg (Level of evidence: A)

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'American Diabetes Association. (2022). 10. Cardiovascular disease and risk management: Standards of medical care in diabetes—2022. Diabetes Care 2022, 44(Suppl. 1), S144-S175. https://doi.org/10.2337/dc22-S010'

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2021). Team-based care for high blood pressure. Retrieved from https://www.cdc.gov/policy/polaris/healthtopics/highbloodpressure/tbctool.html'

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2023). Facts about hypertension. Retrieved from https://www.cdc.gov/bloodpressure/facts.htm'

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention, National Center for Health Statistics. (2022). About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention. Available from http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm#Mortality_Multiple'

Reference Type: CITATION

Reference Text: 'James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi: 10.1001/jama.2013.284427'

Reference Type: CITATION

Reference Text: 'Kirkland, E. B., Heincelman, M., Bishu, K. G., Schumann, S. O., Schreiner, A., Axon, R. N.,...Moran, W. P. (2018). Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003–2014. Journal of the American Heart Association, 7(11), e008731. https://doi.org/10.1161/JAHA.118.008731'

Reference Type: CITATION

Reference Text: 'Moran, A. E., Odden, M. C., Thanataveerat, A., et al. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. [published correction appears in N Engl J. Med. 2015;372:1677]. New England Journal of Medicine. 2015;372, 447-455. doi: 10.1056/NEJMsa1406751. [published correction appears on page 1677]'

Reference Type: CITATION

Reference Text: 'Patel, S. A., Winkel, M., Ali, M. K., et al. (2015). Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Annals of Internal Medicine, 163(4), 245-253. doi: 10.7326/M14-1753'

Reference Type: CITATION

Reference Text: 'Qaseem, A., Wilt, T. J., Rich, R., et al. (2017). Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), 430-437. Retrieved from https://annals.org/aim/fullarticle/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus'

Reference Type: CITATION

Reference Text: 'SPRINT Research Group, Wright, J. T., Jr., Williamson, J. D., et al. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103–2116.'

Reference Type: CITATION

Reference Text: 'Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S.,...Kissela, B. M. (2022). Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation, 145(8), e153–e639. https://doi.org/10.1161/CIR.0000000000001052'

Reference Type: CITATION

Reference Text: 'U.S. Preventive Services Task Force. Screening for hypertension in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. JAMA, 325(16), 1650. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening'

Reference Type: CITATION

Reference Text: 'Virani, S.S., Alonso, A., Aparicio, H.J., et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2021). Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation. 2021;143:e254–e743. doi: 10.1161/CIR.0000000000000950'

Reference Type: CITATION

Reference Text: 'Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. Hypertension. 71(6). https://doi.org/10.1161/HYP.0000000000000065'

Reference Type: CITATION

Reference Text: 'Coles, S., Fisher, L., Lin, K. W., Lyon, C., Vosooney, A. A., & Bird, M. D. (2022). Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP. American family physician, 106(6). Retrieved from https://www.aafp.org/pubs/afp/issues/2022/1200/practice-guidelines-aafp-hypertension-full-guideline.html'

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In reference to the numerator element, only blood pressure readings performed by a clinician or an automated blood pressure monitor or device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by an automated blood pressure monitor or device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record.

Do not include BP readings taken during an acute inpatient stay or an emergency department (ED) visit.

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled".

If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for numerator compliance.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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Patients 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period

Equals Initial Population

Exclude patients who are in hospice care for any part of the measurement period.

Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.

Exclude patients 66-80 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
- Advanced illness diagnosis during the measurement period or the year prior
- OR taking dementia medications during the measurement period or the year prior

Exclude patients 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period.

Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. 

Exclude patients receiving palliative care for any part of the measurement period.

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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