Mission 70/26 Project: improving blood pressure control in Portugal.

Abstract

Purpose

As reported in most European countries, the percentage of treated hypertensive patients achieving a well-controlled blood pressure (e.g. < 140/90 mmHg) is insufficient. This represents a major health concern particularly in countries with a high prevalence of cardiovascular events such as stroke. Therefore, there is a need to develop national programs to increase not only the awareness regarding elevated blood pressure but also the percentage of treated patients achieving recommended blood pressure targets. The present paper describes the new initiative of the Portuguese Society of Hypertension (PSH) to achieveat least 70% of controlled hypertensive patients, followed in primary care, in 2026.

Materials and Methods

The strategies used to improve blood pressure control are aimed at healthcare professionals and general population and include governmental and organizational interventions. To be able to analyze the control rate of HTN patients, and using BI-CSP reports (the Primary Care health unit platform), every six months, we will be addressing the proportion of HTN patients (age: 18-65 years) with BP < 140/90 mmHg and the proportion of HTN patients with at least one blood pressure recorded in the last semester.

Conclusion

With Mission 70/26, the PHS aims to improve awareness among all health professionals and community alike about the problem of uncontrolled HTN and its role in the consequent disability and high mortality rate from cardiovascular causes.

Plain Language Summary

• Hypertension is the most prevalent cardiovascular risk factor worldwide, affecting 42,6% of adult portuguese population.

• Only 52,8% of hypertensive patients followed in primary public care had their HTN controlled.

• Mission 70/26 project was designed by the Portuguese Society of Hypertension with the purpose of achieving 70% control of hypertensive patients under Primary Healthcare by 2026.

• The strategies used to improve blood pressure control are aimed at healthcare professionals and general population and include governmental and organizational interventions.

Keywords:

• Hypertension
• primary care
• health care professionals
• Missão 70/26

Introduction

Hypertension (HTN) is the most prevalent cardiovascular (CV) risk factor in the world and, according to the World Health Organization (WHO), it affects about 1.28 billion adults aged 30–79 years worldwide, two-thirds of them living in low-income and middle-income countries. In 2019, the global age-standardized average prevalence of hypertension in adults aged 30– 79 years was 34% in men and 32% in women¹. In Portugal, it is estimated that the prevalence of this disease in the adult population is 42.6%², approximately 70% of hypertensive patients are pharmacologically medicated, however only 46% are controlled³.

Based on data of the BI-CSP, a Primary Care health unit platform where Portuguese health professionals working in the national public primary care network register data of the patients observed, we know that, in February 2023, only 52,8%^4,5 of hypertensive patients followed in primary public care had their HTN controlled (Figure 2). We believe that the extent of uncontrolled hypertension for patients outside the public system, to be higher, since the literature⁶ reveals that most hypertensive patients show a deficit of adherence to therapy, which also largely contributes to poor control of hypertension and consequent cardiovascular complications.

In this sense, especially in a country where the main cause of death is cerebrovascular disease⁷, it is urgent to develop actions that enhance the control of blood pressure values, through adherence to therapy in all by patients afflicted by HTN, thus improving the quality and effectiveness of the care provided, and contributing to much needed health gains in the population. Considering the above-mentioned reality, the Portuguese Hypertension Society (PHS) has developed the Mission 70/26 Project.

Methodology

The Mission 70/26 Project is a movement, scientifically supported by the PHS and financially supported by Servier, taking place from February 2023 to June 2026, with the purpose of achieving 70% control of hypertensive patients under Primary Healthcare by 2026. The PHS aims to promote health literacy and awareness for the prevention, management and control of cardiovascular diseases and health conditions associated with HTN. It also aims to motivate optimized management of hypertensive patients by healthcare professionals, reducing medical inertia and increasing patient adherence to therapy through a multifaceted action program with various levels of intervention as illustrated in Figure 1 and discussed below.

Figure 1. Graphical abstract

Figure 2. Estimation of the proportion of hypertensive patients with a BP <140/90 mmHg in age between 18 and 64, in Portugal regions (image on the right), using the hypertensive proportion [18;65 [with BP < 140/90 mmHg in the last 6 months (top left image) and the hypertensive proportion with BP measured in the same period (bottom left image);

Strategies to Improve Blood Pressure Control

Actions aimed at healthcare professionals

A website has been created for healthcare professionals involved with hypertensive patients. After individual registration, they are associated with a database. Every month, a teaching letter called "5 Minutes with HTN" is released for healthcare professionals, providing relevant and up-to-date information on hypertension and overall cardiovascular risk. In-person training sessions have been conducted at various Health Centers, focusing on a systematic approach to HTN. Emphasis is placed on a team-based care approach, moving beyond the classic follow-up by a single doctor to involve other professional classes. Nationwide, the "Missão 70/26 Award - 1st Edition - Adherence in HTN" has been created, offering a monetary prize for healthcare professionals to support the development of projects aiming for increasing adherence of hypertensive patients to therapy. Given the absence of national data regarding the follow-up of patients with hypertension in hospital consultations, a National Hypertension Clinics Registry Committee has been established with the purpose of developing a common database at this level.

Actions aimed at the population

To reach the general population, extensive digital campaigns with credible and high-quality content have been launched on social media platforms, radio, and newspapers since the beginning of the campaign, with peak activity around the celebration of World Hypertension Day, transformed into “World Hypertension Week”. The goal is to increase our presence and to deliver our message to the general population. In this regard, we have used social media digital free information and awareness sessions have been organized at various locations not traditionally associated with healthcare (squares, markets). Furthermore, outside the HTN Week, the "For the Health of Portugal - One Country, One Mission" initiative will be implemented. In this initiative, the PHS will travel the country with a bus that will visit 8 cities in Portugal between December of this year and June 2024, conducting HT screening and information activities for the population along the way.

Governmental and organizational intervention

Efforts are made to raise awareness among management bodies about the need to optimize blood pressure control, facilitating access to the healthcare system, available diagnostic tools, or their co-payment in the conventional system, especially concerning ABPM (Ambulatory Blood Pressure Monitoring). It is necessary to update software used in hypertension consultations, quality indicators in line with current recommendations, and foster the creation of internal national guidelines for patients with hypertension.

Data collection and analysis

To be able to analyze the control rate of our HTN patients, and using BI-CSP reports, every six months, we will be addressing the two following health indicators:

• Proportion of HTN patients (age: 18-65 years), with BP < 140/90 mmHg

• Proportion of HTN patients, with at least one blood pressure recorded in the last semester.

The data available on the Primary Care health unit platform, BI-CSP, have various indicators, but they only reflect information about those patients that go to primary care units. The BP control indicator is only available for patients between the age of 18 and 64 years, which implied excluding other age groups with the same control target. However, these data are available freely and can be monitored regularly. The two indicators mentioned, together, give us the proportion of HTN patients (already diagnosed) that have attended a primary care unit in the last 6 months, with blood pressure below 140/90 mmHg.

Conclusion

The evaluation of team-based care in hypertension found that interventions involving nurses or pharmacists are effective strategies to improve BP control⁸. With Mission 70/26, the PHS aims to improve awareness among all health professionals and community alike, about the problem of uncontrolled HTN, and its role in the consequent disability and high mortality rate from cardiovascular causes in our country. We, in Portugal, like in many public based health care systems, know that the overload of the health system will be reflected in less quality in the follow-up of hypertensive patients, as there will be greater inertia on the part of professionals and less availability for patients. This is where the role of a national society such as the PSH comes in, on the one hand in its role as a scientific society, keeping health professionals motivated with initiatives in this direction, and, on the other hand, as a league, involving the entire community in the higher responsibility of taking care of their own health, for the benefit of many.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article. The overall program is supported by a grant from Servier.