In 1967, the first multicenter randomized controlled trial of treatment for hypertension was published by the newly created Veterans Administration Cooperative Studies Program, demonstrating the remarkable effectiveness of drug treatment for what would now be considered severe hypertension (average diastolic pressure 115 to 129 mm Hg).1 During the ensuing 4 decades, there have been remarkable strides made to improve care for this very common condition, including development of effective new drugs and acceptance of lower blood pressure thresholds and targets. It is more than fitting that the Department of Veterans Affairs (VA) should remain a leading contributor to these efforts. Article see p 392 Despite these advances, however, efforts to improve awareness of high blood pressure and achievement of treatment goals remains suboptimal from a national perspective, particularly among blacks and other ethnic minorities.2 Increasingly it is being acknowledged that additional progress depends far more on improving systems of care than further advances in pharmacology. Because they are frequently characterized by defined populations, substantial administrative resources, infrastructure such as information systems, an emphasis on primary care, and coordinated benefits, large integrated health systems have been most successful in implementing improvements of care for chronic conditions. In this issue of Circulation: Cardiovascular Quality and Outcomes , Choma et al3 describe the results of efforts to improve the quality of monitoring and treatment of hypertension in 1 of the 21 regional networks (Veterans Integrated Service Networks [VISNs]) that comprise the VA health care system. To be appreciated, the results reported by Choma et al must be viewed in the larger context of the overarching Veterans Health Administration (VHA). The largest integrated healthcare system in the United States, VHA has more than 200 000 employees (including 17 000 physicians) and …
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