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Research Article
Originally Published 14 June 2021
Free Access

Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups

Graphical Abstract

Abstract

Hypertension control (United States) increased from 1999 to 2000 to 2009 to 2010, plateaued during 2009 to 2014, then fell during 2015 to 2018. We sought explanatory factors for declining hypertension control and assessed whether specific age (18–39, 40–59, ≥60 years) or race-ethnicity groups (Non-Hispanic White, NH [B]lack, Hispanic) were disproportionately impacted. Adults with hypertension in National Health and Nutrition Examination Surveys during the plateau (2009–2014) and decline (2015–2018) in hypertension control were studied. Definitions: hypertension, blood pressure (mm Hg) ≥140 and/or ≥90 mm Hg or self-reported antihypertensive medications (Treated); Aware, ‘Yes” to, “Have you been told you have hypertension?”; Treatment effectiveness, proportion of treated adults controlled; control, blood pressure <140/<90. Comparing 2009 to 2014 to 2015 to 2018, blood pressure control fell among all adults (−7.5% absolute, P<0.001). Hypertension awareness (−3.4%, P=0.01), treatment (−4.6%, P=0.004), and treatment effectiveness (−6.0%, P<0.0001) fell, despite unchanged access to care (health care insurance, source, and visits [−0.2%, P=0.97]). Antihypertensive monotherapy rose (+4.2%, P=0.04), although treatment resistance factors increased (obesity +4.0%, P=0.02, diabetes +2.3%, P=0.02). Hypertension control fell across age (18–39 [−4.9%, P=0.30]; 40–59 [−9.9%, P=0.0003]; ≥60 years [−6.5%, P=0.005]) and race-ethnicity groups (Non-Hispanic White [−8.5%, P=0.0007]; NHB −7.4%, P=0.002]; Hispanic [−5.2%, P=0.06]). Racial/ethnic disparities in hypertension control versus Non-Hispanic White were attenuated after adjusting for modifiable factors including education, obesity and access to care; NHB (odds ratio, 0.79 unadjusted versus 0.84 adjusted); Hispanic (odds ratio 0.74 unadjusted versus 0.98 adjusted). Improving hypertension control and reducing disparities require greater and more equitable access to high quality health care and healthier lifestyles.

Introduction

See Editorial, pp 588–590
Hypertension carries greater population attributable risk for cardiovascular disease (CVD) than any other medically modifiable risk factor.1 Hypertension control has received national attention since the National High Blood Pressure Education Program began in 1972.2 Hypertension control to a blood pressure (BP, mm Hg) target of <160/<95 rose from 16.5% in 1971 to 1972 to 34.1% in 1976 to 1980. Moreover, in the first decade of the National High Blood Pressure Education Program, stroke deaths declined 44.4% and coronary heart disease deaths fell 28.6%.
The Joint National Committee on Hypertension Reports in 1980 and 1984 focused on a diastolic BP goal of <90 mm Hg, although treatment of isolated systolic hypertension, BP≥160/<95, was recommended.3,4 In 1988, goal BP <140/<90 was first established, a control level that persisted for most adults until 2014.5 BP control to <140/<90 improved from 10% in 1976 to 1980 to 27% in 1988 to 1994 and 32.2% in 1999 to 2000.2,6 Adoption of a national hypertension control metric to <140/<90 likely played a key role in the rapid improvement in control from 32.2% in 1999 to 2000 to 53.8% in 2009 to 2010.6,7 Hypertension control plateaued in 2009 to 2014 with control at 53.8% in 2013 to 2014.8,9 Hypertension control then declined to 43.7% in 2017–2018.10 Of note, slight methodological variations between the various reports yield small differences in estimated hypertension control rates.6,8,9
Previously reported demographic disparities were recently confirmed including lower BP control rates in younger (18–44 years) and older (≥75 years) adults and in non-Hispanic Black and Hispanic than non-Hispanic white adults.9 Adults with a usual source of health care and those with a health care visit in the past year were significantly more likely to have their hypertension controlled than those without these attributes. The temporal relationship of these predictors to the decline in BP control overall and in demographic groups was not specified.
The principal objectives of this study were to (1) assess changes in variables known to impact hypertension control and (2) determine if the decline in hypertension control during 2015 to 2018 was broad-based or whether it magnified preexisting disparities. Addressing these objectives may inform quality improvement programs aimed at reversing the decline and improving equity in hypertension control.

Methods

The National Health and Nutrition Examination Surveys (NHANES) assess national health status in a representative sample of the US civilian, noninstitutionalized population. Our study included adults ≥18 years old in 5 consecutive NHANES 2-year, cross-sectional cycles from 2009 through 2018. The surveys were approved by the National Center for Health Statistics Research Ethics Board. All adults provided written consent to participate, and public use data are made available on a biannual basis.

Participants

Race and ethnicity were determined by self-report and separated into Hispanic ethnicity of any race, non-Hispanic white, non-Hispanic black, and other non-Hispanic race including non-Hispanic multiracial (other).
Key study variables were defined as follows:
BP (mm Hg) was measured by trained professionals using mercury sphygmomanometry after 5 minutes of seated rest, including NHANES 2015 to 2016 and 2017 to 2018.6,10–12 The first BP was excluded in estimating mean systolic and diastolic values for individuals with >1 value as recommended in NHANES procedures manuals.6,10–12
Hypertension was defined as (1) mean systolic BP≥140 or mean diastolic BP ≥90 or (2) a positive response to the question, Are you currently taking medication to lower your BP? An affirmative response to the latter question defined hypertension treatment.6,9,10
Hypertension awareness was defined by “Yes” in response to, “Have you been told by a physician that you have hypertension?”
Treatment effectiveness equated to the proportion of treated adults with controlled BP.
Hypertension control was determined primarily by BP <140/<90 in adults with hypertension. Hypertension control to BP <130/<80 was assessed as a secondary outcome.13
Diabetes (diagnosed) was defined by a positive response to the questions, “Have you ever been told by a doctor that you have diabetes?” or “Are you now taking insulin?” or “Are you now taking diabetic pills to lower your blood sugar?”6
Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate, calculated <60 mL/1.7 m2 per minute or urine albumin:creatinine >300 mg/g.14,15
CVD was defined as an affirmative response to one or more questions of having ever been told that you have had a heart attack, heart failure, or stroke.16
Education was defined by participant responses to highest degree of education completed and categorized as (1) denied or (2) endorsed having a high school or General Education Development diploma and (3) some college or associate degree and college education or higher.17
Income relative to the federal poverty level was determined by dividing family income by the number of family members appropriate for each year and state in the United States per the NHANES database.17
Health care insurance status was dichotomized as insured or uninsured based on participant responses to “Are you covered by health insurance or some other health care plan (include health insurance through employment, purchased directly, or government program like Medicaid or Medicare that provides medical care or help to pay medical bills)?17
Visit frequency is based on responses to the question “During the past 12 months, how many times have you seen a doctor or other health care professional about your health at a doctor’s office, a clinic or some other place? Do not include times you were hospitalized overnight, visits to hospital emergency rooms, home visits or telephone calls.”17
Access to care was defined by affirmative responses to health insurance, a usual source of care, and one or more health care visits annually.18

Data Analysis

All statistical analyses were conducted with SAS/STAT SAS version 9.4 survey procedures to account for the NHANES complex sampling design. Sampling weights (WTMEC2YR) were used to adjust for oversampling of Hispanic and NHB subjects. Weights were rescaled to be representative of the population at the midpoint (i.e., for the combined years 2009-2014, 2011-2012 was midpoint).
All surveys were age-adjusted to the US 2010 census. In 2010, 39% of adults were aged 18 to 39 years, 37% were aged 40 to 59 years, and 24% were 60 years or older, with weights of 0.39, 0.37, and 0.24, respectively, which were used in calculating overall prevalent hypertension. For age-adjusting hypertension awareness, treatment, and control across time, additional weights were calculated, since prevalent hypertension varies by age group. The proportion of adults in each age group that were hypertensive (calculated based on NHANES 2009–2010) was multiplied by their respective year 2010 weight for all adults. Weights were then calculated by dividing the product for each age group by the sum of products for all 3 age groups.
Population means and proportions were estimated for demographic and clinical characteristics for all adults with hypertension and stratified by 3 age (18–39, 40–59, ≥60) and race-ethnicity groups (NHW, NHB, Hispanic), and 2 time periods (2009–2014, 2015–2018) as shown in Tables 1–3. The age group ≥60 years was selected, since the BP treatment goal for this group has been debated.19–21 The Rao-Scott χ2 Test was used to test for differences in categorical variables, and the Wald F test was used to test for differences in continuous variables. For subpopulations of interest, for example, age- and race-ethnicity group, domain analysis was used, since the formation of subpopulations was unrelated to the sample design. Domain analysis accounts for this variability by using the entire sample in calculating variance of domain estimates. Age-adjusted means and proportions were provided for combined time periods 2009 to 2014, 2015 to 2018.
Antihypertensive medication class and specific agents in each class were defined according to JNC7 and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline.13,22 Drug classifications included α1-adrenoceptor blockers, renin-angiotensin system blockers, β-blockers, α,β-blockers, CCBs, diuretics, and other. The renin-angiotensin system blocker category included 3 drug classes: ACE (angiotensin-converting enzyme) inhibitors, angiotensin receptor blockers (ARB), and direct renin inhibitors. When determining the number of medications for each participant, medications in the same class were counted only once except for subclasses of CCBs (dihydropyridines, nondihydropyridines) and diuretics (thiazide or thiazide-like, loop diuretics, aldosterone antagonists, potassium sparing). When multiple BP meds within the renin-angiotensin system blocker category were reported, the different classes were counted separately.
Unadjusted and adjusted survey logistic regression models were used to provide odds ratio on BP Control to <140/<90 in NHB and Hispanics relative to BP control in NHW. Adjustments were made for key modifiable and nonmodifiable variables. Modifiable variables included health care visits annually, having a usual source of care, health care insurance, obesity, and education. Nonmodifiable variables included age, sex, and income. Two-sided P values <0.05 were accepted as statistically significant.

Results

Figure S1 in the Data Supplement captures the process for selecting adults with hypertension in NHANES 2009 to 2014 and 2015 to 2018, and the resultant age distributions used in the analyses.
Figure 1 displays the control, awareness, treatment, and treatment effectiveness of hypertension for all adults with hypertension and for the 3 age- and race-ethnicity groups for 2009 to 2014 and 2015 to 2018.
Figure 1. From 2009 to 2014 to 2015 to 2018, the percentage of all adults and various age- and race-ethnicity subgroups with hypertension (blood pressure [BP]) control and who were aware, treated, and had effective treatment for hypertension declined.
Figure 2 has 4 panels summarizing key study findings. The upper left depicts the significant decline in each step of the hypertension control cascade from 2009 to 2014 to 2015 to 2018 including awareness, treatment, and treatment effectiveness as well as control. Over this time span, access to care did not change, whereas antihypertensive monotherapy, obesity, and diabetes increased (lower left). Mean values for hypertension control fell across age- and race-ethnicity groups, although changes were not statistically significant for the groups who were 18 to 39 years or Hispanic (upper right). The unadjusted odds ratios for hypertension control were significantly lower in NHB and Hispanic than NHW adults (reference). After adjusting for health insurance and visits, regular source of care, education, and obesity, racial and especially Hispanic ethnicity differences in hypertension control were attenuated (lower right).
Figure 2. Upper left, the fall in components of the blood pressure [BP] control cascade drove the decline in control among all adults during 2015 to 2018 vs 2009 to 2014. Lower left, the fall in BP control was driven partly by a higher proportion of all adults with hypertension treated with monotherapy, despite a rise in obesity and diabetes which require more treatment to attain control. Access to care was unchanged. Upper right, BP control fell across age and race/ethnicity groups. Lower right, the lower odds ratios for BP control in NHB and especially Hispanic adults were reduced relative to NHW adults after adjusting for modifiable variables (health insurance, regular source of care, ≥1 health visit past year, education, obesity). *P≤0.05.
Tables 1–4 provide comparative data from the plateau (2009–2014) and subsequent decline (2015–2018) in hypertension control for adults with hypertension.
All adults with hypertension 2015–2018 versus 2009–2014 (Table 1). Systolic and diastolic BP rose. BP control to <140/<90 and <130/<80 fell and was associated with declines throughout the control chain or continuum including hypertension awareness, treatment, and treatment effectiveness (Figure 1). Age, sex, and race-ethnicity were not different between the 2 time periods. BMI and prevalent obesity increased. Mean income as a multiple of the federal poverty level was unchanged. Access to care was unchanged, although 2 of its 3 components including a usual source of health care fell, while health care insurance increased, and frequency of health care visits was unchanged. Among the clinical indicators, prevalent diabetes increased; prevalent CKD and CVD were unchanged.
Table 1. All Adults With Hypertension in NHANES 2009–2014 and 2015–2018
NHANES2009–20142015–2018P value
Subjects, n58754079NA
Systolic BP, mm Hg134.7 (133.6–135.8)137.8 (136.8–138.9)<0.0001
Diastolic BP, mm Hg72.9 (72.1–73.7)75.2 (74.3–76.1)0.002
BP <130/<80, %34.9 (32.5–37.3)28.6 (26.0–31.3)0.0005
Age, y59.9 (59.6–60.1)59.9 (59.7–60.2)0.37
Female, %51.3 (49.5–53.0)50.5 (48.3–52.7)0.66
Non-Hispanic White, %70.3 (66.1–74.6)65.2 (59.8–70.6)0.11
Non-Hispanic Black, %14.5 (11.7–17.3)14.3 (10.7–17.9)
Hispanic, %9.3 (6.7–11.9)11.4 (8.4–14.5)
Other, %5.9 (4.7–7.1)9.1 (7.1–11.1)
Body mass index ≥30, %49.6 (47.9–51.2)53.6 (50.7–56.6)0.02
Health care insurance, %89.1 (88.0–90.3)91.6 (89.7–93.6)0.04
Health care visits/y, 0, %7.1 (6.2–7.9)7.5 (6.4–8.6)0.11
 1, %10.5 (9.3–11.7)11.9 (10.1–13.7)
 2–3, %29.5 (27.3–31.6)31.4 (29.5–33.4)
 ≥4, %52.9 (50.5–55.4)49.0 (47.1–50.9)
Usual source of care, %94.1 (93.2–95.0)91.3 (90.0–92.6)0.0003
Access to care, %*82.9 (81.5–84.4)82.7 (80.6–84.8)0.97
Federal poverty level, %2.9 (2.8–3.0)3.0 (2.9–3.2)0.25
Education, <high school, %20.2 (18–22.4)14.4 (12.4–16.4)0.0003
 High school, %24.2 (22.1–26.2)27.2 (24.6–29.7)
 ≥Some college, %55.5 (52.9–58.1)58.3 (55.2–61.5)
Diabetes, %22.0 (20.5–23.4)24.3 (22.8–25.8)0.02
Chronic kidney disease, %18.3 (17.2–19.5)16.4 (14.6–18.2)0.14
Cardiovascular disease, %18.7 (17.5–19.9)18.5 (16.8–20.2)0.97
Data are presented as mean and 95% confidence limits. BP indicates blood pressure; NA, not applicable; and NHANES, The National Health and Nutrition Examination Survey.
*
Access to care, health care insurance, ≥1 health care visit/past year, usual source of care.
Age groups 2015 to 2018 versus 2009 to 2014 (Table 2). Systolic and diastolic BP increased in all 3 age groups. Although adults 18 to 39 years had higher BP in 2015 to 2018 than 2009 to 2014, changes in BP control, hypertension awareness, treatment, and treatment effectiveness were not statistically significant. In adults 40 to 59 years, the decline in hypertension control was associated with significant decrements in hypertension awareness, treatment, and treatment effectiveness. Adults ≥60 years had a significant decline in hypertension control and treatment effectiveness with marginally significant reductions in hypertension awareness and treatment (P>0.05 to <0.10).
Table 2. Selected Characteristics of Adults With Hypertension by Age Group in NHANES 2009–2014 and 2015–2018
Age group18–39 yP value40–59 yP value≥60 yP value
NHANES2009–20142015–20182009–20142015–20182009–20142015–2018
Subjects, n463306NA18291258NA35832515NA
SBP, mm Hg134.2 (132.5–135.9)137.8 (135.8–139.9)0.01132.0 (130.3–133.7)135.4 (134.1–136.8)0.002136.7 (135.7–137.7)139.6 (138.1–141)0.002
DBP, mm Hg82.7 (80.8–84.5)86.2 (84.1–88.4)0.0178.1 (77.0–79.2)80.8 (79.4–82.1)0.00267.5 (66.6–68.4)69.4 (68.5–70.3)0.004
<130/<80, %21.6 (15.8–27.4)15.0 (8.8–21.2)0.1136.5 (32.5–40.5)28.1 (23.9–32.4)0.00436.0 (33.4–38.6)31.3 (27.9–34.6)0.03
Age, y32.5 (31.8–33.2)33.1 (32.4–33.8)0.2251.3 (50.9–51.6)51.6 (51.2–52.1)0.1570.6 (70.2–70.9)70.4 (69.9–70.9)0.53
Female, %38.4 (34.1–42.7)32.4 (25.1–39.7)0.1647.1 (44.0–50.3)46.2 (42.1–50.3)0.7156.4 (54.5–58.2)56.6 (54.5–58.7)0.87
BMI≥30, %64.3 (59.8–68.8)69.6 (62.1–77.1)0.2355.6 (52.8–58.4)59.0 (53.7–64.2)0.2542.8 (40.4–45.1)47.1 (43.9–50.4)0.02
Health insurance, %76.4 (72.0–80.9)77.4 (70.4–84.5)0.883.9 (81.5–86.3)88.9 (85.5–92.3)0.0295.0 (94.1–96.0)95.9 (94.8–97.1)0.22
Health care visits/y, 0, %14.5 (10.6–18.4)20.3 (14.7–25.8)0.2310.4 (8.4–12.3)10.2 (8.1–12.3)0.183.5 (2.6–4.4)3.4 (2.4–4.4)0.08
 1, %16.8 (13.5–20.0)19.5 (13.5–25.6)11.1 (9.1–13.0)14.7 (11.7–17.8)9.0 (7.6–10.5)8.6 (6.9–10.3)
 2–3, %30.7 (24.6–36.8)26.0 (20.1–31.8)30.6 (27.3–34.0)30.8 (26.8–34.8)28.4 (26.0–30.9)32.9 (30.5–35.4)
 ≥4, %38.1 (32.2–43.9)34.3 (26.5–42.0)47.9 (44.3–51.6)44.3 (40.0–48.6)59.0 (55.9–62.1)55.1 (52.6–57.6)
Usual source of care, %84.4 (80.4–88.3)73.5 (67.5–79.5)0.00292.0 (89.9–94.1)89.4 (86.2–92.5)0.1497.2 (96.5–97.9)95.6 (94.6–96.7)0.01
Access to care, %63.5 (58.4–68.7)54.2 (46.4–62.0)0.0476.6 (73.1–80.1)77.9 (74.0–81.8)0.6190.7 (89.2–92.2)90.9 (89.0–92.8)0.86
Education, <high school, %15.5 (10.8–20.2)12.4 (8.2–16.5)0.3717.8 (15.1–20.4)13.0 (10.3–15.8)0.1022.8 (20.0–25.6)15.7 (13.4–18.0)<0.0001
 High school, %21.1 (17.0–25.2)25.8 (18.3–33.4)24.9 (22.0–27.8)25.9 (21.0–30.9)24.2 (21.6–26.8)28.3 (25.8–30.8)
 ≥Some college63.4 (57.8–69.0)61.8 (54.5–69.1)57.3 (53.6–61.1)61.0 (55.3–66.8)53.1 (50.1–56.0)56.0 (52.8–59.1)
Income FPL, %2.6 (2.4–2.8)2.7 (2.4–3.1)0.543.0 (2.9–3.2)3.2 (3.0–3.4)0.302.9 (2.8–3)3.0 (2.8–3.2)0.44
Diabetes, %7.2 (5.0–9.5)7.2 (3.6–10.8)0.9820.5 (17.4–23.6)20.1 (16.7–23.6)0.8725.5 (24.0–27.0)30.2 (27.9–32.4)0.0002
CKD, %3.2 (1.7–4.7)3.3 (1.1–5.5)0.917.0 (5.1–8.9)6.5 (4.2–8.7)0.7529.0 (27.2–30.8)25.6 (23.1–28.1)0.03
CVD, %5.0 (2.6–7.3)5.2 (3.0–7.5)0.8710.1 (8.2–12.0)11.5 (8.7–14.2)0.4127.1 (24.9–29.3)25.8 (23.2–28.4)0.44
Data presented as mean and 95% CL except as indicated. Access indicates access to care=health care insurance, usual source of care, and ≥1 health care visit past year; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; Health Ins, health care insurance; Health Vsis, health care visits/y; HS, high school; Income FPL, incomes as % of federal poverty level; NHANES, The National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.
Among adults 18 to 39 years, the percentage with a usual care source declined, whereas the other variables reported did not change significantly. Among adults 40 to 59 years, the percentage reporting health care insurance rose. Adults ≥60 years had an increase in BMI, obesity, and diabetes, an increase in education level, and a decline in CKD. The percentage reporting a usual care source declined. Comparing age groups, health care insurance, health care visits, and having a regular source of care generally rose with advancing age as did prevalent diabetes, CVD, and CKD, while BMI and obesity fell possibly reflecting adverse selection.
Race-ethnicity groups 2015 to 2018 versus 2009 to 2014 (Table 3). SBP rose across race-ethnicity groups, whereas diastolic BP increased only in NHW adults. Hypertension control to <140/<90 and <130/<80 fell in NHW and NHB adults, whereas the decline in Hispanic adults was marginally significant (P=0.06). Among NHW adults, hypertension treatment and treatment effectiveness declined, whereas among NHB adults, hypertension awareness and treatment effectiveness fell. Among Hispanic adults, awareness declined, whereas the fall in treatment effectiveness was marginally significant (P=0.06).
Table 3. Selected Characteristics of Adults With Hypertension by Race-Ethnicity Group in NHANES 2009–2014 and 2015–2018
Age groupNon-Hispanic WhiteP valueNon-Hispanic BlackP valueHispanicP value
NHANES*2009–20142015–20182009–20142015–20182009–20142015–2018
Subjects, n25841404 16421149 1132944 
SBP, mm Hg133.6 (132.3–134.9)136.6 (135.2–138.0)0.001137.1 (135.6–138.7)141.9 (140.6–143.2)<0.0001138.0 (136.6–139.4)140.4 (138.4–142.3)0.05
DBP, mm Hg72.0 (71.0–72.9)74.2 (73.1–75.4)0.0275.7 (74.4–76.9)78.0 (76.3–79.6)0.0774.7 (73.5–75.9)76.5 (74.9–78.0)0.14
<130/<80, %37.3 (34.5–40.1)29.9 (26.2–33.6)0.00230.0 (26.5–33.4)24.9 (22.5–27.2)0.0228.8 (26.0–31.5)24.4 (20.5–28.3)0.09
Age, y61.2 (60.9–61.5)61.4 (61.0–61.8)0.2455.8 (55.6–56.1)56.1 (55.5–56.6)0.1557.1 (56.7–57.5)57.2 (56.9–57.6)0.93
Female, %50.5 (48.1–52.9)49.6 (46.5–52.7)0.7756.3 (53.9–58.7)56.7 (54.4–59.0)0.7351.5 (48.5–54.4)49.2 (44.5–54.0)0.38
BMI≥30, %48.4 (46.0–50.7)54.4 (50.6–58.2)0.0157.9 (55.1–60.7)59.3 (56.6–61.9)0.7156.7 (53.6–59.9)56.2 (51.5–60.9)0.74
Health Ins, %92.8 (91.5–94.0)94.1 (91.6–96.5)0.3183.0 (80.3–85.7)88.3 (85.8–90.8)0.00374.7 (71.0–78.5)80.9 (77.3–84.6)0.04
Health Vis, 0, %5.7 (4.6–6.7)5.9 (4.5–7.3)0.248.6 (7.3–9.9)8.5 (6.8–10.3)0.5112.8 (9.7–15.9)15.0 (12.0–18.1)0.50
 1, %10.1 (8.5–11.7)11.5 (8.9–14.1)10.7 (9.0–12.4)12.0 (10.2–13.7)11.6 (9.8–13.5)13.4 (10.4–16.5)
 2–3, %29.4 (26.6–32.3)32.3 (29.5–35.2)29.0 (26.4–31.7)30.9 (27.6–34.2)28.9 (24.5–33.2)27.8 (23.6–32.0)
 ≥4, %54.7 (51.2–58.3)50.1 (47.5–52.8)51.7 (48.4–55.1)48.4 (44.7–52.1)46.7 (43.1–50.3)43.5 (38.3–48.7)
Source, %96.0 (94.9–97.1)92.8 (91.1–94.6)0.00393.0 (91.7–94.3)90.4 (88.0–92.7)0.0585.6 (82.5–88.7)84.4 (81.4–87.4)0.51
Access, %87.0 (85.1–88.9)86.0 (83.3–88.8)0.7177.4 (74.7–80.2)78.1 (75.4–80.9)0.5566.9 (62.5–71.4)69.1 (64.7–73.5)0.64
Education, <HS14.4 (11.6–17.2)8.7 (7.3–10.1)0.000627.4 (23.7–31.1)18.5 (15.1–22.0)0.000350.5 (45.8–55.2)41.7 (35.8–47.6)0.04
High school, %24.8 (22.0–27.6)28.2 (24.6–31.8)27.3 (25.0–29.7)27.8 (24.9–30.7)19.2 (16.6–21.9)22.3 (18.5–26.1)
≥Some college60.7 (56.9–64.5)63.0 (59.1–67.0)45.2 (41.3–49.0)53.6 (48.8–58.3)30.1 (25.7–34.5)35.8 (30.4–41.2)
Income FPL, %3.2 (3.1–3.3)3.3 (3.2–3.5)0.232.2 (2.1–2.4)2.4 (2.3–2.6)0.162.0 (1.8–2.1)2.2 (2.0–2.4)0.15
Diabetes, %19.2 (17.4–21.0)22.7 (20.8–24.5)0.00227.4 (25.0–29.8)24.8 (21.7–28.0)0.3831.1 (27.7–34.6)29.1 (24.5–33.6)0.45
CKD, %19.6 (18.1–21.1)17.8 (15.5–20.1)0.3715.5 (13.6–17.5)14.5 (12.4–16.6)0.7715.0 (12.4–17.5)12.7 (9.9–15.4)0.22
CVD, %19.2 (17.6–20.8)19.1 (16.9–21.4)0.8517.7 (15.7–19.7)17.7 (15.0–20.4)0.7616.6 (14.3–18.8)14.4 (11.7–17.2)0.22
Access indicates access to care=health care insurance, usual source of care, and ≥1 health care visit past year; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; Health Ins, health care insurance; Health Vsis, health care visits/y; HS, high school; Income FPL, incomes as % of federal poverty level; NHANES, The National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.
*
Data are presented as mean and 95% CL.
Age and percentages of females did not change in any race-ethnicity group. BMI, prevalent obesity, and diabetes increased in NHW adults. Percentages with health care insurance increased for NHB and Hispanic adults. The proportion with a usual source of care fell for NHW and NHB adults. Visit frequency was unchanged in any group. Education increased for all 3 race-ethnicity groups. Prevalent CKD and CVD were unchanged for all 3 groups.
Health care insurance, having a regular source of care, health care access, and education were generally the highest in NHW, intermediate in NHB, and lowest in Hispanic adults. Prevalent diabetes was the highest in Hispanic, intermediate in NHB, and lowest in NHW adults. Prevalent CKD and CVD were greater in NHW than NHB and Hispanic adults, although NHW adults were the oldest group.
Antihypertensive medications confirmed by examining pill bottles among adults who reported taking prescribed medication to lower BP in the prior 30 days (Table 4). The percentage reportedly taking BP medication was lower in 2015 to 2018 than 2009 to 2014; 97% provided bottles for pills taken in the previous 30 days that mapped to antihypertensive medications. Renin-angiotensin system blocker and ARB increased, whereas ACE inhibitor, α1-antagonists, and K+-sparing diuretics declined. Among all adults reportedly taking BP medication, the proportion that provided pill bottles confirming a single BP medication (monotherapy) increased 37.1% to 41.3%, P=0.04. Among the subset with uncontrolled BP, monotherapy did not change (41.1%–41.7%, P=0.86).
Table 4. Number and Class of BP Medications Verified in Adults With Hypertension Who Affirmed Taking Medication Confirmed by Review of Pill Bottles
NHANES, y2009–20142015–2018P value
Self-report BP MedsYes (confirmed by pill bottles)
Percent (95% CI)75.3 (73.1–77.5)70.7 (68.3–73.1)0.004
BP Meds confirmed, %*97.3 (96.7–97.9)97.3 (96.5–98.2)0.81
 1 BP Med, %37.1 (35.3–39)41.3 (38.4–44.1)0.04
 2 BP Meds, %34.5 (32.6–36.4)33.1 (30.7–35.5)0.45
 3 BP Meds, %17.0 (15.3–18.6)15.5 (14–17)0.30
 ≥4 BP Meds, %8.7 (7.3–10.1)7.5 (6.3–8.8)0.23
Med class confirmed, %*
 α1-blocker, %3.1 (2.4–3.9)2.2 (1.5–2.9)0.04
 RASB, %68.0 (65.7–70.2)71.4 (68.8–73.9)0.04
  ACE inhibitor, %65.3 (62.9–67.8)59.8 (55.7–64.0)0.01
  ARB, %35.4 (32.9–37.9)40.6 (36.5–44.7)0.01
 β-blocker, %32.3 (30.0–34.6)29.0 (26.5–31.5)0.09
 α,β-blocker, %5.9 (4.8–7.0)5.6 (4.2–7.0)0.76
 CCB, %27.5 (25.1–29.8)26.6 (24.1–29.1)0.75
  dCCB, %83.4 (80.7–86)87.3 (83.2–91.4)0.12
  ndCCB, %17.0 (14.3–19.6)12.9 (8.8–17.1)0.11
 Diuretic, %44.3 (42.2–46.3)40.4 (36.9–43.9)0.07
  Aldo Antag, %4.8 (3.4–6.2)6.6 (3.6–9.5)0.21
  K+-sparing, %9.2 (7.5–10.9)5.7 (3.4–7.9)0.03
  Loop, %19.5 (17.2–21.8)21.3 (18–24.7)0.20
  Thiazide, %79.5 (77.1–81.9)78.3 (75–81.6)0.43
 Sympatholytic, %2.7 (2.1–3.4)2.0 (1.5–2.5)0.08
 Vasodilator, %2.6 (2.1–3.0)2.6 (1.8–3.4)0.99
ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; NHANES, The National Health and Nutrition Examination Survey; and RASB, renin-angiotensin system blocker.
*
Medications taken in the past 30 d confirmed by active medications (pill bottles) provided and reviewed during mobile exam interview.
The prevalence of hypertension for all NHANES participants is shown in addition to the data depicted in Figure 1 for those with hypertension (Table S1). Among all adults, prevalent hypertension did not change. Among all adults with hypertension, awareness, treatment, and treatment effectiveness, that is, the proportion of treated adults controlled and hypertension control declined significantly.
Among the age, and race-ethnicity subgroups, prevalence increased significantly only among Hispanic adults from 2009 to 2014 to 2015 to 2018. Awareness declined among the subgroups who were 40 to 59 years, NHB, and Hispanic. Treatment fell in the subgroups who were 40 to 59 years and NHW. Treatment effectiveness and hypertension control declined among subgroups who were 40 to 59 years, ≥60 years, NHW and NHB.
Among those who denied taking prescription medication to lower BP, roughly 1 in 8 provided pill bottles mapping to antihypertensive medications (Table S2). Among this group, β-blockers rose marginally (P=0.05), whereas the percentage with α,β-blockers declined.
Based on unadjusted odds ratios, NHB and Hispanic adults were less likely to have controlled hypertension in 2009 to 2014 and 2015 to 2018 than NHW adults (Table S3). The racial and ethnic disparities in unadjusted odds ratios for hypertension control were marginally less in 2015 to 2018 than 2009 to 2014. Adjusting for modifiable variables attenuated racial and ethnic disparities in hypertension control, especially for Hispanics in 2015 to 2018. Adjusting for both modifiable and nonmodifiable variables did not alter the adjusted odds ratio for hypertension control in NHB or Hispanic adults compared with adjusting for modifiable variables only.

Discussion

Hypertension control in the United States to a target of <140/<90 mm Hg was significantly lower in 2015 to 2018 than 2009 to 2014 among all adults with the condition. The decline in hypertension control during 2015 to 2018 was of similar magnitude across age- and race-ethnicity groups and did not exacerbate previously documented disparities.
Hypertension carries a greater population attributable risk for cardiovascular events than any other modifiable risk factor. Of concern, cardiovascular deaths, which had fallen consistently from 2000 to 2014 have increased since.23,24 Elucidation of factors responsible for worsening hypertension control could be helpful in informing health care policy, payment, and delivery initiatives to reverse the rapid decline in hypertension control and accelerate progress.
The sequential cascade of hypertension awareness, treatment, and treatment effectiveness is the principal pathway to hypertension control. Unfortunately, awareness, treatment, and treatment effectiveness fell in all adults with hypertension and in the age- and race-ethnicity groups evaluated, albeit not statistically significant in all subgroups. These observations suggest that attention to all 3 variables in the cascade is required to reverse broad-based, population-wide decline in hypertension control.
Access to care, defined as health care insurance, a regular source of health care, and one or more health care visits in the past year, is an important mediator of success in the cascade to hypertension control.9 In this report, access to care was unchanged in all adults with hypertension combined and all demographic groups evaluated except those 18 to 39 years old. Thus, changes in access to care do not explain the fall in hypertension control during 2015 to 2018.
Since access to care was unchanged and hypertension awareness, treatment, and treatment effectiveness declined, the quality of care in diagnosing and managing hypertension fell. The percentage of adults taking a single antihypertensive medication (monotherapy) increased, although the change was not significant in those with uncontrolled hypertension. Yet, most adults with hypertension require a combination antihypertensive therapy to attain control.13 Prevalent obesity and diabetes, which are associated with treatment resistant hypertension,25 increased, that is, the need for combination pharmacotherapy increased but did not occur.
The increase in prevalent obesity and diabetes reflect unhealthy, decades long trends in the United States. These trends attest to the relative ineffectiveness of both public health measures and the health care system to promote healthy lifestyles, which is a departure from successes documented in the 1960s and early 1970s.26 The increase of BMI, obesity, and diabetes achieved statistical significance in all adults combined and the subgroups ≥60 years or NHW. The prevalence of obesity and diabetes remained higher in NHB and Hispanic than NHW adults. Thus, programs, for example, Life’s Simple 7 with attention to structural inequities, are a logical approach to addressing the broad-based decline in hypertension control and related health disparities.27
While access to care did not change between 2009 to 2014 and 2015 to 2018, changes in components of access may reveal opportunities to improve hypertension control. Health care insurance, which is strongly related to hypertension control,17 did not decline for any group and increased for adults who were 40 to 59 years, NHB, or Hispanic. Yet, percentages reporting a usual source of care declined for all adults with hypertension, and those who were 18 to 39 years, ≥60 years, NHB, or NHW. Health care insurance does not always translate into an established source of care. Initiatives to ensure equitable distribution of primary care services and policies to facilitate access may help close the gap between insurance and a regular source of care.
Additional findings are consistent with a decline in quality of care. In adults 40 to 59 years, the fall in hypertension control coincided with decreased awareness and treatment of hypertension, which suggests but does not prove that primary care clinicians were less likely to diagnose and treat hypertension among middle-aged adults in 2015 to 2018 than previously. Among adults ≥60 years, the decline in hypertension control was accompanied by a fall in treatment effectiveness. This observation could indicate reluctance to intensify pharmacotherapy for older adults with uncontrolled hypertension, possibly reflecting the dispute on target BP.19–21
With regard to race-ethnicity, hypertension control and treatment effectiveness fell in all 3 race-ethnicity groups. The decline in treatment effectiveness in all 3 race-ethnicity groups magnifies concerns of clinician reluctance to intensify pharmacotherapy for uncontrolled hypertension. Our logistic regression confirms reported disparities in hypertension control. The findings further suggest that attention to modifiable variables including education, obesity, and access to care could attenuate racial and especially Hispanic ethnicity disparities in hypertension control. The observations also indirectly support a potentially greater role for structural inequities in health disparities among NHB individuals.27
Programs are needed to support physicians and care teams and their patients in improving care for the diagnosis and management of hypertension. MAP:BP is an evidence-based approach for improving hypertension control, which focuses on 3 critical processes.28,29 Measuring accurately, including self-measured BP, is important for identifying adults with hypertension, which is a key to raising awareness, and in assessing control. Acting rapidly, calls for prompt implementation of an effective management plan including adequate, algorithm-guided pharmacotherapy. Partnering with patients in self-management, is essential to realizing the benefits of an effective management plan. All 3 processes are critical to treatment effectiveness. Quality improvement programs including MAP BP29 and Kaiser Permanente30 can facilitate rapid and sustained gains in hypertension control.
This study has notable limitations. NHANES represents repeated cross-sectional evaluations of the US civilian population and not a longitudinal cohort. Thus, temporal changes are implied from cross-sectional observations. While BP is rigorously measured in NHANES, values during a single examination may not reflect usual values for all individuals. Important details of antihypertensive pharmacotherapy including medication adherence and dose intensity are unavailable. Hypertension controlled by lifestyle only was not assessed. Despite limitations, NHANES have served as a valued resource for longitudinally assessing the clinical epidemiology of hypertension in the US population for over 40 years.

Perspectives

The progressive decline in hypertension control in consecutive 2-year cycles, that is, 2015 to 2016 and 2017 to 2018, is the first such occurrence in NHANES. Moreover, systolic BP and cardiovascular deaths are rising. The cascade of hypertension control including awareness, treatment, and treatment effectiveness declined in all adults combined and generally fell across age- and race-ethnicity groups during 2015 to 2018. As access to health care was unchanged, health care quality apparently fell. These observations indicate a broad-based and urgent need to improve the quality of health care for diagnosing, treating, and controlling hypertension. Until public, behavioral, and medical health programs reverse the obesity and diabetes epidemics, increasing antihypertensive treatment intensity will be key to improving treatment effectiveness, that is, the growing monotherapy trend is unacceptable. The recommendations do not diminish the continuing imperative to address persistent drivers of disparities in hypertension control, which include achieving equity in education, lifestyle patterns, and access to high-quality care.

Novelty and Significance

What Is New?

Hypertension control fell across age- and race-ethnicity groups during 2015 to 2018 and generally reflected declining awareness, treatment, and treatment effectiveness
Access to care was unchanged, which suggests the quality of care for diagnosing and managing hypertension fell

What Is Relevant?

Antihypertensive monotherapy increased, despite a rise in obesity and diabetes, which require more intensive pharmacotherapy for hypertension control
Racial and ethnic disparities in hypertension control declined after adjusting for modifiable variables including education, obesity, and access to care

Summary

Improving hypertension control and reducing disparities require greater and more equitable access to high quality health care and healthier lifestyles

Footnote

Nonstandard Abbreviations and Acronyms

ACE
angiotensin-converting enzyme
ARB
angiotensin receptor blocker
BP
blood pressure
CKD
chronic kidney disease
CVD
cardiovascular disease
NHANES
The National Health and Nutrition Examination Survey

Supplemental Material

File (hyp_hype-2020-16418-t_supp1.pdf)

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Pages: 578 - 587
PubMed: 34120453

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Received: 28 September 2020
Accepted: 8 April 2021
Published online: 14 June 2021
Published in print: September 2021

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Keywords

  1. age
  2. awareness
  3. control
  4. hypertension
  5. treatment

Subjects

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Affiliations

American Medical Association, Improving Health Outcomes, Greenville, SC (B.M.E., S.E.S.).
Jiexiang Li
Department of Mathematics, College of Charleston, SC (J.L.).
American Medical Association, Improving Health Outcomes, Greenville, SC (B.M.E., S.E.S.).
Michael K. Rakotz
American Medical Association, Improving Health Outcomes, Chicago, IL (M.K.R., G.D.W.).
Gregory D. Wozniak
American Medical Association, Improving Health Outcomes, Chicago, IL (M.K.R., G.D.W.).

Notes

The Data Supplement is available with this article at Supplemental Material.
For Sources of Funding and Disclosures, see page 586.
Correspondence to: Brent M. Egan, American Medical Association, The One Bldg, 2 Washington St, Suite 601, Greenville, SC 29601. Email [email protected]

Disclosures

Disclosures B.M. Egan received a lecture honorarium and travel expenses from Merck KGaA and royalties from UpToDate. The other authors report no conflicts. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the American Medical Association.

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Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups
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