Getting to 90%: what better hypertension care looks like

Hypertension care is often a series of disconnected events. Blood pressure is measured, advice is given, a prescription is written, and follow-up is advised. The patient disappears back into everyday life until the next visit. It’s six months later — three months after the script has run out. A complete lapse in treatment is not uncommon. Complications sometimes sadly intervene.

Better hypertension care is a “managed journey”, carefully designed to reduce risk and to make sure that treatment is both effective and sustained. Communication lines are open, the patient understands their condition and why medicine is needed, and knows who to ask for help and when. The clinical team has well-defined triggers for shifting from routine to more specialised care when needed.

A report from Kaiser Permanente Northern California, a US healthcare organisation that prides itself on more integrated care, shows what a well-managed journey looks like at scale. Between 2000 and 2013, in a population of 650,000 adults with hypertension, blood pressure control improved from 44% to 90% as registry-based follow-up, standard treatment algorithms, simpler medicine regimens and team-based workflows were built into routine care.^[2]

The success of these programmes comes from a common set of ingredients: standardised treatment protocols, team-based care, reliable measurement and regular feedback. ^[3,4]

The good news is that better care consists mostly of doing ordinary things more reliably.

Start earlier: prevention, risk reduction and proper detection

Start care before the prescription pad comes out.

Not all hypertension can be prevented but some of it can be delayed or mitigated. Salt intake, excess weight, physical inactivity, alcohol, smoking, poor sleep and metabolic factors including diabetes or pre-diabetes are important risk factors. Good care therefore includes advice and support for reducing salt intake, stopping smoking, improving diet quality, increasing activity, moderating alcohol and improving sleep.  ^[1,6,7]

This support should not be a lecture or sermon, and it should not pretend that lifestyle and behaviour change is easy. It should help people understand why treatment matters and that disease symptoms are largely absent for many years. Family support is critical, because food, physical activity, and clinic attendance are behaviours involving other family members.

Lifestyle advice is not however an excuse for treatment delay. When drug treatment is indicated, it should be started. Lifestyle and medication should be used together.

HEARTS is the World Health Organisation’s technical package for improving cardiovascular risk management in primary care. It has been implemented in more than 10,000 primary-care facilities across the Americas and other regions, and reaches tens of millions of adults. ^[3,4]

Like the Kaiser Permanente programme, HEARTS uses a small number of standardised elements: healthy-lifestyle counselling, evidence-based treatment protocols, access to essential medicines and technology, team-based care, risk-based management and systems for monitoring progress.^[5]

Because hypertension is usually silent, detection depends on routine measurement. Blood pressure checks should be part of the adult primary care visit and should be offered at other convenient access points, such as pharmacy-linked clinics and community touchpoints. ^[1,5,7]

Unless extremely high, a single blood pressure reading is not sufficient for diagnosis. Elevated readings need confirmation. ^[6,7]

Make treatment simple

Once hypertension is confirmed, treatment should be straightforward to begin and to sustain. ^[6,7]

Standardised protocols do not replace clinical judgement but make good care easier to deliver consistently to many patients and at many differing sites.

The HEARTS programme regards standardised treatment protocols as a core element of large-scale hypertension control. . ^[5,7,11]
Standardisation does not mean rigid adherence to a single drug or regimen. Kidney disease, diabetes, pregnancy, occasional drug-related adverse effects, drug interactions and established cardiovascular disease require clinical judgement, adjustment to drug choice and dosage, and to blood pressure targets and other aspects of care.

WHO recommends single-pill combinations for many adults with hypertension because fewer pills mean less complexity, better adherence and faster control.[6]

The routine pathway needs to be simple for most patients while making exceptions easy to recognise and to refer for specialist care.

Build follow-up into the pathway

Better care means follow-up that does not rely on memory, motivation or luck. There should be some way of knowing who is controlled, who is uncontrolled, who needs treatment adjustment and who is overdue for a check or has disappeared. Registries, scheduled reminders, outreach when scripts are not filled, and simple review rules contribute to reliability.

This is where team-based care comes in. Primary care physicians stay in charge of diagnosis, interpretation, prescribing, intensification and referral. But GP-led care works best when supported by nurses, pharmacists, assistants, community-based staff, and automated recall systems. ^[5,7,11]

In the Kaiser Permanente experience, improvement was driven by a dependable operating model that included a hypertension registry, regular reporting, standard treatment algorithms and medical-assistant-led follow-up visits. ^[2,11,12]

Lifestyle support has to be reinforced. Long-standing habits rarely change with a single brief consultation. Risk reduction, medication adherence and blood pressure review need continuous attention and effort.

Use home blood pressure measurement, connected to care

Home blood pressure monitoring helps confirm the diagnosis, distinguishes white-coat from sustained hypertension, detects poor control between visits and supports timely treatment adjustment. It gives patients a more active role in their care, provided they understand what the readings mean and know what should happen when readings are high. ^[6,11]

But a BP cuff at home is not a blood pressure treatment programme. The measurements need to feed into a system that enables medication adjustment, coaching, review and follow-up.

The 2025 IMPACT-BP trial in rural KwaZulu-Natal shows what this looks like locally. Reported in the New England Journal of Medicine, it tested home-based care delivered by community health workers with nurse support. Over six months, hypertension control increased from 57.6% to 82.8%, with systolic blood pressure 8–9 mmHg lower. ^[8,9] The dramatic improvement was attributed to ease of follow-up and close support.

Newer cuffless wearable devices make home and community-based care even more attractive and feasible. Repeated measurement is easier and more acceptable but does not yet replace cuff-based measurement for major clinical decisions. ^[10]

Support persistence not just prescribing

Because the condition is silent, as noted, many patients stop treatment or take it inconsistently. Treatment complexity, inconvenience, side-effects, and long-term treatment fatigue also play a part. ^[6,11]

What helps is the opposite: simple regimens, convenient repeat prescribing and medicine collection, clear information, supportive follow-up, and early action when refill gaps are noticed.

Persistence is more likely when patients are equipped with information and develop understanding. They know what hypertension is, why control is important, what the medicines are doing, what side-effects to report, and why medicine and lifestyle changes go together.

Good hypertension care has to take account of the patient’s full health and risk profile. Hypertension should be part of a patient-centred rather than a disease-centred chronic care model. . ^[1,5,7]

Recognise when the routine pathway isn’t right

Most high blood pressure has no identifiable cause. But in a small minority of patients, roughly 5 to 10%, blood pressure resists standard treatment. In other cases it is unusually high, begins earlier in life than is typical, or has other features that raise concern for an underlying cause such as an endocrine (glandular) condition.

Some patients have chronic kidney disease or cardiovascular disease that complicates blood pressure management. ^[6,7]

Better care includes defined triggers for review, escalation of treatment and specialist referral. ^[5-7,11]

Three perspectives on better care

For patients, better care means risk is identified and managed earlier, follow-up is more reliable, home measurement is routine, and a path opens up when treatment needs to change.

For GPs and other primary care professionals, better care means clearer protocols, better information, follow-up tools, and less fragmentation of care between hypertension and the chronic conditions that accompany it.

For funders, better care means better value with fewer expensive and avoidable complications, and lower downstream costs. Funder-instituted networks can play a role in improving access to devices, data, and specialist referral.

In South Africa’s public healthcare system, direct hypertension-related healthcare costs have been estimated at R10.1 billion a year, with societal costs of R29.4 billion. ^[13] Stroke, heart failure, kidney failure and disability are expensive consequences of a pathway that fails too often for too long.

The next article brings these pieces together as a hypertension control system that includes visible control status, GP-supported pathways, patient support, referral rules, aligned incentives and accountability.

The Institute for Healthcare Improvement uses the term “care operating system” for the background “machinery” that links clinical decision making, care processes, information and analysis so that chronic care is reliably delivered. ^[12]

The overall aim, then, is a chronic care operating system. Hypertension is a good starting point for designing one.

References

[1] WHO hypertension fact sheet.

https://www.who.int/news-room/fact-sheets/detail/hypertension

[2] Kaiser Permanente Northern California: improving hypertension control from 44% to 90% in 13 years.

https://pubmed.ncbi.nlm.nih.gov/26939059/

[3] PAHO / WHO HEARTS in the Americas.

https://www.paho.org/en/hearts-americas

[4] PAHO progress update noting more than 10,000 primary care facilities implementing HEARTS.

https://www.paho.org/en/pahos-progress-2025-protecting-health-all

[5] WHO HEARTS technical package.

https://www.who.int/publications/i/item/WHO-NMH-NVI-18-14

[6] WHO guideline for the pharmacological treatment of hypertension in adults.

https://www.who.int/publications/i/item/9789240033986

[7] South African primary-care cardiovascular disease risk management guideline.

https://extranet.who.int/ncdccs/Data/SAU_NCD_CMR_CPG_Book_2021.pdf

[8] IMPACT-BP trial paper: Home-Based Care for Hypertension in Rural South Africa.

https://pubmed.ncbi.nlm.nih.gov/40888742/

[9] ESC press summary of IMPACT-BP.

https://www.escardio.org/news/press/press-releases/Home-based-hypertension-care-is-effective-in-rural-South-Africa/

[10] AHA scientific statement on cuffless devices for blood pressure measurement.

https://www.ahajournals.org/doi/10.1161/HYP.0000000000000254

[11] Million Hearts Hypertension Control Change Package.

https://millionhearts.hhs.gov/tools-protocols/action-guides/htn-change-package/index.html

[12] IHI Care Operating System overview.

https://www.ihi.org/partner/consulting/ihi-care-operating-system

[13]Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study (BMJ Open, 2022).

https://www.ihi.org/partner/consulting/ihi-care-operating-system