In this issue of Clinical Diabetes, Amanda H. Salanitro, MD, MSPH, and Christianne L. Roumie, MD, MPH, review the importance of blood pressure control in individuals with diabetes (p. 107). Although blood pressure control is important for people with or without diabetes, the relative importance is accentuated for people with a condition such as diabetes, for whom complications abound.
In their careful review, Salanitro and Roumie summarize several key clinical trials that have provided a robust basis for the current recommendations on blood pressure control. Whereas a variety of interventions in individuals with diabetes ameliorate this or that outcome, the benefit of blood pressure control extends to both micro- and macrovascular complications. And although the recent Action to Control Cardiovascular Risk in Diabetes trial1 did not justify expanding control efforts beyond current recommendations as some observational studies have suggested, the benefit of achieving current goals is not the subject of dispute.
Yet, the ability to achieve current goals remains challenging because the problem of blood pressure control is probably more than the sum of the issues highlighted in the aforementioned review. No one doubts that a variety of patient, provider, and systemic variables contribute to our inability to translate clinical findings into practice. Still, an unrecognized problem may be one of ownership. Hypertension as a disease, even more so than dyslipidemia, seems to have many guardians and no parents.
In different settings, blood pressure control “lives” in different areas. In some places, it is the domain of nephrologists; in others, it is the domain of cardiologists. Elsewhere, clinical pharmacologists or endocrinologists manage it. Certainly many, if not most, primary care physicians feel ownership for this, the most common chronic condition they see.
It is not surprising that a common, relatively easy-to-treat condition would have so many suitors. But many suitors may also mean freedom to manage without clear ownership of the problem. Whereas, for some conditions, only one type of health care professional is ultimately “in charge” of management and therefore feels responsibility for the outcomes, hypertension management, including the prescribing and modifying of necessary medications, can occur when patients attend clinic visits with their endocrinologist, cardiologist, nephrologist, and internist.
However, this seemingly ubiquitous desire to manage hypertension has not yielded success, as demonstrated by the low rates of population-level blood pressure control. Especially as the excitement about the efficacy of hypertension management wanes over time (it has been nearly 50 years since we first learned about the benefits of blood pressure control), few health care professionals seem to have maintained a passion for a topic that seems as staid as penicillin for strep throat.
That is truly a shame. As Salanitro and Roumie remind us, blood pressure elevation is important and imminently treatable to the benefit of both individuals and society as a whole. Especially among people with diabetes, greater attention to this “old” problem will avert many complications.
Someone needs to own it and take responsibility for getting the job done.
