Summary

In today’s public health world, the term “neglected disease” conjures up obscure tropical illnesses of little relevance to contemporary practice in the United States. Yet, when one considers the actual meaning of the words, the time may be right to add hypertension to this list. Despite the magnitude of hypertension-associated morbidity and mortality and the $73 billion in annual costs to the health care system, hypertension prevention and control is only one of a number of programs competing for a total of only $54 million (2009) in the Centers for Disease Control and Prevention’s (CDC’s) entire Heart Disease and Stroke Prevention portfolio.

The lack of attention to hypertension goes against the objective facts. Hypertension is one of the leading causes of preventable death in the United States. In 2005, high blood pressure was responsible for about one in six deaths of U.S. adults and was the single largest risk factor for cardiovascular mortality accounting for about 45 percent of all cardiovascular deaths. Based on data from the CDC and the National Heart, Lung, and Blood Institute (NHLBI) from 1995 to 2005, the death rate from high blood pressure increased by 25 percent and the actual number of deaths rose by 56 percent (Lloyd-Jones et al., 2009).

Hypertension, defined for adults as a systolic pressure of 140 mm Hg or greater or a diastolic pressure of 90 mm Hg or higher, is highly prevalent (Chobanian et al., 2003). Approximately 73 million Americans or nearly one in three U.S. adults has hypertension (Fields et al., 2004; Lloyd-Jones et al., 2009). An additional 59 million have prehypertension, which is defined as blood pressure ranging from 120-139 mm Hg systolic and/or 80-89 mm Hg diastolic (Chobanian et al., 2003).



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Summary I n today’s public health world, the term “neglected disease” conjures up obscure tropical illnesses of little relevance to contemporary practice in the United States. Yet, when one considers the actual meaning of the words, the time may be right to add hypertension to this list. Despite the magnitude of hypertension-associated morbidity and mortality and the $73 billion in annual costs to the health care system, hypertension prevention and control is only one of a number of programs competing for a total of only $54 million (2009) in the Centers for Disease Control and Prevention’s (CDC’s) entire Heart Disease and Stroke Prevention portfolio. The lack of attention to hypertension goes against the objective facts. Hypertension is one of the leading causes of preventable death in the United States. In 2005, high blood pressure was responsible for about one in six deaths of U.S. adults and was the single largest risk factor for cardiovascu- lar mortality accounting for about 45 percent of all cardiovascular deaths. Based on data from the CDC and the National Heart, Lung, and Blood Institute (NHLBI) from 1995 to 2005, the death rate from high blood pres- sure increased by 25 percent and the actual number of deaths rose by 56 percent (Lloyd-Jones et al., 2009). Hypertension, defined for adults as a systolic pressure of 140 mm Hg or greater or a diastolic pressure of 90 mm Hg or higher, is highly prevalent (Chobanian et al., 2003). Approximately 73 million Americans or nearly one in three U.S. adults has hypertension (Fields et al., 2004; Lloyd-Jones et al., 2009). An additional 59 million have prehypertension, which is defined as blood pressure ranging from 120-139 mm Hg systolic and/or 80-89 mm Hg diastolic (Chobanian et al., 2003). 1

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2 APPROACH TO PREVENT AND CONTROL HYPERTENSION The risk of developing hypertension increases with age, and in older age groups it is more common than not. Based on data from the Framingham study, the lifetime risk of hypertension is estimated to be 90 percent for people with normal blood pressure at ages 55 or 65 who live to be ages 80 to 85, respectively (Cutler et al., 2007; Vasan et al., 2002). Hypertension is costly to the health care system. It is the most common primary diagnosis in America (Chobanian et al., 2003), and it contributes to the costs of cardiovascular disease (coronary heart disease, myocardial infarction) and stroke. The American Heart Association (AHA) recently reported the direct and indirect costs of high blood pressure as a primary diagnosis as $73.4 billion for 2009 (Lloyd-Jones et al., 2009). With respect to the cost of treating hypertension, an analysis by DeVol and Bedroussian (2007) estimated that the total expenditure for the population reporting hy- pertension as a condition in the Medical Expenditure Panel Survey (MEPS) was $32.5 billion in 2003 (DeVol and Bedroussian, 2007). Another study estimated the total incremental annual direct expenditures for treating hy- pertension (the excess expenditure of treating patients with hypertension compared to patients without hypertension) to be about $55 billion in 2001 (Balu and Thomas, 2006). Much is known about the health consequences and costs associated with hypertension (Chapters 1 and 2). Robust clinical and public health research efforts have developed safe and cost-effective nonpharmacologi- cal and pharmacological interventions (Chapters 4 and 5) to prevent, treat, and control hypertension. Nonetheless, millions of Americans continue to develop, live with, and die from hypertension because we are failing to translate our public health and clinical knowledge into effective prevention, treatment, and control programs. In the committee’s view this current state is one of neglect, defined by Merriam-Webster as “giving insufficient atten- tion to something that merits attention.” The recommendations offered in this report outline a population-based policy and systems change approach to addressing hypertension that can be applied at the federal, state, and local level. It is time to give full attention and take concerted actions to prevent and control hypertension. THE CHARGE TO THE COMMITTEE The CDC Division for Heart Disease and Stroke Prevention (DHDSP) provides national leadership to reduce the burden of disease, disability, and death from heart disease and stroke. The DHDSP is co-lead, along with the NHLBI, for the Healthy People 2010 objectives related to heart disease and stroke including four objectives specific to hypertension (Table S-1). Findings from the Healthy People 2010 Midcourse Review (CDC, 2006) indicated that the nation was moving away from making progress in

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 SUMMARY TAbLE S-1 Healthy People 2010 Focus Area 12: Heart and Stroke, Blood Pressure Objectives Number Objective 12-9. Reduce the proportion of adults with high blood pressure. 12-10. Increase the proportion of adults with high blood pressure whose blood pressure is under control. 12-11. Increase the proportion of adults with high blood pressure who are taking action (for example, losing weight, increasing physical activity, or reducing sodium intake) to help control their blood pressure. 12-12. Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. SOURCE: CDC, 2006. the target objectives as reflected by increases in the prevalence of high blood pressure among adults and among children and adolescents. This moving away from Healthy People 2010 goals provided an increased emphasis for a DHDSP programmatic focus on hypertension. The DHDSP has developed a strategic plan to reduce and control hy- pertension that recognizes the urgent need to implement known effective practices and to develop new ones. The plan identifies a number of action areas and goals for the prevention and control of hypertension. The CDC requested assistance and guidance from the Institute of Medicine (IOM) to determine a small set of high-priority areas in which public health can fo- cus its efforts to accelerate progress in hypertension reduction and control. Specifically, the CDC requested that the IOM convene an expert committee to review available public health strategies for reducing and controlling hypertension in the U.S. population, including both science-based and practice-based knowledge. In conducting its work, the committee was asked to consider the following questions: What are the highest-priority action areas on which CDC’s Division for Heart Disease and Stroke Prevention and other partners should focus near-term efforts in hypertension? 1. Identify the particular role of CDC’s DHDSP in addressing the highest-priority areas. 2. Identify the role of state health departments in advancing progress in the priority action areas. 3. Identify the role of other public health partners.

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION 4. What visible impacts can be expected if DHDSP focuses its efforts in these priority areas? 5. What indicators should be monitored to assess the progress of DHDSP, state health departments, and partners in implementing the committee’s recommendations? 6. What are the potential positive and negative impacts on health disparities that could result if the committee’s recommendations are implemented? 7. What indicators should be monitored related to health disparities to ensure the intended impact of the DHDSP priority action areas identified? The committee was not expected to conduct a new, detailed review of peer-reviewed literature on hypertension because such literature reviews, meta-analyses, and syntheses already exist and have been used to inform existing guidelines and recommendations. FINDINGS AND RECOMMENDATIONS The CDC, through the Division for Heart Disease and Stroke Pre- vention, has leveraged its broader cardiovascular disease prevention and control programmatic efforts to address hypertension primarily through its state heart disease and stoke prevention programs. Many of these efforts are described in Chapter 3 and throughout other chapters. Objectively, however, there are several significant problems with the current status and direction of hypertension prevention and control activities: • ypertension is only one component of a larger cardiovascular H disease prevention program that, as a consequence, has more of a medical care rather than a population-based prevention focus based on system change. • he CDC’s cardiovascular disease program in general, and the T hypertension program in particular, are dramatically under funded relative to the preventable burden of disease and the strategy and action plan that have been developed. In light of the current situation, short-term programmatic priorities must be tempered by the economic reality that the absolute amount of prevention resources available to the CDC are limited, and thus cost- effectiveness and absolute costs must be considered. Compared with inter- ventions directed toward individuals, population-based interventions and interventions directed at system improvements and efficiencies are more

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 SUMMARY likely to be more practical and realistic in the current resource-constrained environment. The committee believes that the reality of limited resources for hypertension prevention requires that DHDSP shift the weight of its focus to approaches that cater to the strength of the public health system—population-based and systems approaches rather than health care-based approaches. To that end, the committee has recommended a number of high-priority strategies to prevent and control hypertension to the CDC and DHDSP. The recommendations embody a population-based approach grounded in the principles of measurement, system change, and accountability and bridge public health and clinical care. The DHDSP can support the implementa- tion of these recommendations in collaboration with other CDC units. In brief, the recommendations seek to: • hift the balance of the DHDSP hypertension priorities from S individual-based strategies to population-based strategies to: o strengthen collaboration among CDC units (and their part- ners) to ensure that hypertension is included as a dimension of other population-based activities around healthy lifestyle im- provement, particularly greater consumption of potassium-rich fruits and vegetables, increased physical activity, and weight management o strengthen CDC’s leadership in monitoring and reducing sodium intake in the American diet to meet current dietary guidelines o improve the surveillance and reporting of hypertension to better characterize general trends and trends among subgroups of the population • Promote policy and system change approaches to: o improve the quality of care provided to individuals by assuring that individuals who should be in treatment are in treatment and receive care that is consistent with current treatment guidelines ♦ increase the importance of treating systolic hypertension, especially among the elderly o remove economic barriers to effective antihypertensive medications o provide community-based support for individuals with hyper- tension through community health workers who are trained in dietary and physical activity counseling. The population-based policy and systems approach recommended is not only limited to the CDC and DHDSP but also extends and applies to state and local health departments and to other partners. The high-priority recommendations directed to the DHDSP are discussed in Chapters 4 and 5

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION have been translated for action by state and local health jurisdictions in Chapter 6. Successfully implementing a population-based policy and systems approach at all levels will depend on the resources available and systems of accountability to ensure that resources are appropriately aligned and out- comes are achieved; those recommendations are also found in Chapter 6. For ease of presentation in this summary, the recommendations for the DHDSP and its most important partners, state and local health jurisdic- tions, have been integrated in this summary but are discussed separately in relevant chapters. Population-based Strategies Hypertension is highly preventable and manageable through lifestyle in- terventions. Given the co-occurrence or association with poor diet, physical inactivity, and obesity, which appear to be on the increase, lifestyle modifi- cations are of even greater importance. Government public health agencies are the only organizations with the mandate to provide population-wide services, and the CDC and state and local public health agencies are more experienced and skilled in population-based interventions than in interven- tions that provide health care directly to individuals. Through leadership and convening strategies, government public health agencies can galvanize political commitment, develop policy, prioritize funding, and coordinate programs (Baker and Porter, 2005). A stronger focus on primary prevention of hypertension is consistent with the DHDSP’s responsibility as co-lead of Healthy People 2010’s focus area on heart disease and stroke and in achieving progress in reducing the proportion of adults with high blood pressure. The committee acknowl- edges that within the CDC, the DHDSP is not the focal point for addressing dietary imbalances, physical inactivity, and other determinants to prevent the development of risk factors and progression of high blood pressure. It also acknowledges that the focus of DHDSP activities is primarily on adults, not children. The committee is also aware that the DHDSP, through the Cardiovascular Health Collaboration of the National Center for Chronic Disease Prevention and Health Promotion, collaborates with units across the CDC. The committee believes, however, that this collaboration can be strengthened and extended to leverage the efforts and resources of those programs to ensure proper attention to the prevention of hypertension and the reduction of hypertension risk factors. Based on the review of the literature there is strong evidence linking overweight and obesity, high sodium intake, low potassium intake, un- healthy diet, and decreased physical activity to hypertension. These risk factors contribute substantially to the burden of hypertension in the United

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 SUMMARY States; further, the prevalence of many of these risk factors is increasing. The observational and randomized clinical trial literature on interventions to reduce overweight and obesity, decrease sodium intake, support eating a healthy diet, increase potassium intake, and increase physical activity also indicate that these risk factors are modifiable and that they can help reduce blood pressure levels. The committee concludes in light of: (1) the high prevalence of these risk factors that contribute significantly to the de- velopment of high blood pressure, (2) existing interventions to reduce these risk factors, and (3) the potential to reduce the burden of hypertension if the interventions are implemented, that actions to reduce these risk factors merit a high priority. The committee recommendations follow; the number appearing before the recommendation refers to the chapter and number of the recommendation in that chapter. 4.1 The committee recommends that the Division for Heart Disease and Stroke Prevention integrate hypertension prevention and control in programmatic efforts to effect system, environmental, and policy changes through collaboration with other CDC units and their external partners, to ensure that population-based lifestyle or behavior change interventions where delivered, are delivered in a coordinated manner that includes a focus on the prevention of hypertension. High-priority programmatic activities on which to collaborate include interventions for: • reducing overweight and obesity; • promoting the consumption of a healthy diet that includes a higher intake of fruits, vegetables, whole grains, and unsatu- rated fats and reduced amounts of overall calories, sugar, sugary beverages, refined starches, and saturated and trans fats (for example, a diet that is consistent with the OmniHeart diet); • increasing potassium-rich fruits and vegetables in the diet; and • increasing physical activity. 4.2 The committee recommends that population-based interventions to improve physical activity and food environments (typically the focus of other CDC units) should include an evaluation of their feasibility and effectiveness, and their specific impact on hypertension prevalence and control. 4.3 To create a better balance between primary and secondary preven- tion of hypertension the committee recommends that the Division for Heart Disease and Stroke Prevention leverage its ability to shape state

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 APPROACH TO PREVENT AND CONTROL HYPERTENSION activities, through its grant making and cooperative agreements, to encourage state activities to shift toward population-based prevention of hypertension. The committee views a population-based policy and systems ap- proach to prevent and control hypertension at the state and local level to be consistent with the broad mandates of state and local public health jurisdictions. 6.1 The committee recommends that state and local public health ju- risdictions give priority to population-wide approaches over individual- based approaches to prevent and control hypertension. 6.2 The committee recommends that state and local public health jurisdictions integrate hypertension prevention and control in pro- grammatic efforts to effect system, environmental, and policy changes that will support healthy eating, active living, and obesity prevention. Existing and new programmatic efforts should be assessed to ensure they are aligned with populations most likely to be affected by hyper- tension such as older populations, which are often not the target of these programs. Based upon 2004 statistics using calculated intakes of sodium, 87 percent of U.S. adults consumed what is considered excess sodium based on the Dietary Guidelines for Americans (>100 mmol of sodium ≅ >2,400 mg sodium ≅ >6,000 mg of salt [sodium chloride per day]) (NCHS, 2008). Further, the Dietary Guidelines for Americans (HHS and USDA, 2005) and the AHA recommend that African Americans and persons who are middle aged or older or who have hypertension should consume less than 1,500 mg of sodium daily. Calculated sodium intake may not be accurate because the large majority of sodium in the U.S. food supply is added in processing and manufacturing of foods, and a large and increasing amount is used in the fast food industry. The amounts added can vary widely by brand and with time, making calculations difficult, and the smaller amounts added at home can also be challenging to quantify. Unfortunately, 24-hour urinary sodium excretion, which provides the best measure of sodium intake, has never been assessed in a nationally representative sample of the U.S. population, so that the true distribution of intakes in the United States is not known. The committee finds the evidence base to support policies to reduce dietary sodium as a means to shift the population distribution of blood pressure levels in the population convincing. The newly reported analysis of the substantial health benefits (reduced number of individuals with hy-

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9 SUMMARY pertension) and the equally substantial health care cost savings and quality adjusted life years (QALYs) saved by reducing sodium intake to or below the recommended levels, provide resounding support to place a high prior- ity on policies to reduce sodium intake (Palar and Sturm, 2009). The committee is aware of the Congressional directive to the CDC to engage in activities to reduce sodium intake and the DHDSP’s role in these activities. The DHDSP’s sponsorship of an IOM study to identify a range of interventions to reduce dietary sodium intake is an important step. The committee believes that the DHDSP is well positioned to take greater leadership in this area through it role as co-leader of Healthy People 2010 Focus Area 12: Heart Disease and Stroke, co-leader of the National Forum for Heart Disease and Stroke Prevention, and as the sponsor of grants to state health departments and other entities. 4.4 The committee recommends that the Division for Heart Disease and Stroke Prevention take active leadership in convening other part- ners in federal, state, and local government and industry to advocate for and implement strategies to reduce sodium in the American diet to meet dietary guidelines, which are currently less than 2,300 mg/day (equivalent to 100 mmol/day) for the general population and 1,500 mg/day (equivalent to 70 mmol/day) for blacks, middle-aged and older adults, and individuals with hypertension. The committee recognizes other work in progress by the IOM Com- mittee on Strategies to Reduce Sodium Intake; therefore, it did not develop specific recommendations or specific intervention strategies. Of all of the modifiable risk factors for hypertension, an inadequate consumption of potassium based on the current Dietary Reference Intake (DRI) criteria (IOM, 2004) is among the most prevalent. In a recent report from the CDC (NCHS, 2008), approximately 2 percent of U.S. adults met the current guidelines for dietary potassium intake (≥4.7 grams per day or 4,700 mg), but insufficient potassium intake is most prevalent in blacks and Hispanics, among whom the proportion consuming an adequate amount of potassium was close to 0 percent. Of note, the primary basis of the DRI of 4.7 grams per day for potassium is its beneficial effect on blood pressure (IOM, 2004). 4.5 The committee recommends that the Division for Heart Disease and Stroke Prevention specifically consider as a strategy advocating for the greater use of potassium/sodium chloride combinations as a means of simultaneously reducing sodium intake and increasing potassium intake.

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10 APPROACH TO PREVENT AND CONTROL HYPERTENSION State and local health jurisdictions can also play a strong role in for- mulating policies and other activities to reduce sodium in the diet. Across the country, 26 state and local public health agencies and 17 professional associations and organizations have coalesced to work toward the goal of reducing salt intake through the National Salt Reduction Initiative (The City of New York, 2009). 6.3 The committee recommends that all state and local public health jurisdictions immediately begin to consider developing a portfolio of dietary sodium reduction strategies that make the most sense for early action in their jurisdictions. Surveillance Data collection is fundamental to addressing any public health problem. Data are critical for determining the burden of hypertension, characterizing the patterns among subgroups of the population, assessing changes in the problem over time, and evaluating the success of interventions. Repeated independent cross-sectional surveys in the same populations over time can provide important information about secular trends in blood pressure. In the general U.S. population, government surveys (NHES I [National Health Examination Survey]; NHANES I, II, and III [National Health and Nutrition Examination Survey]; HHANES [Hispanic Health and Nutrition Examination Survey]) may provide the best data to examine secular trends in hypertension. However, there are marked, not easily explainable changes in the temporal trends for hypertension based on the NHANES data. In particular, there was a dramatic reduction in age-adjusted hypertension prevalence between the NHANES II (1976-1980) from 31.8 to 20 percent in the NHANES III (1988-1991). At the same time, there have been signifi- cant modifications in the protocol for blood pressure measurement, sample sizes, and other factors that may increase the potential for measurement error (Burt et al., 1995). As a consequence, there is ongoing uncertainty about the validity and therefore usefulness of long-term temporal data for U.S. trends in hypertension. Effective monitoring and surveillance systems need to be in place to monitor progress in reducing the prevalence of hypertension and increasing the awareness, treatment, and control of hypertension. Given the challenges posed by the changing methodologies used to collect blood pressure mea- surements, the committee believes that efforts to strengthen hypertension surveillance and monitoring are critical.

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11 SUMMARY 2.1 The committee recommends that the Division for Heart Disease and Stroke Prevention • Identify methods to better use (analyze and report) existing data on the monitoring and surveillance of hypertension over time. • Develop norms for data collection, analysis, and reporting of future surveillance of blood pressure levels and hypertension. In developing better data collection methods and analyses, the DHDSP should increase and improve analysis and reporting of understudied populations including: children, racial and ethnic minorities, the el- derly, and socioeconomic groups. Access to and use of hypertension measures at the state and local public health jurisdictions (SLHJs) level has proven especially difficult. The primary national data source for population estimates of hypertension— National Health and Nutrition Examination Survey—is not designed to produce accurate state or local estimates. This shortcoming is a major one, as there is likely substantial variation across regions not only in prevalence but also in the proportions of the hypertensive population not diagnosed, diagnosed but not under treatment, and under treatment but not controlled. Some state and localities have begun to develop local level HANES to better monitor hypertension. 6.4 The committee recommends that state and local public health jurisdictions assess their capacity to develop local HANES as a means to obtain local estimates of the prevalence, awareness, treatment, and control of hypertension. Further, if a program to reduce hypertension is a national goal, funding should be made available to assure that locali- ties have relevant data that will assist them in addressing hypertension in their communities. The committee recognizes that local financial constraints may not allow many SLHJs to move forward in this regard in the short term; thus, SLHJs may want to actively seek other reliable and available population-based data sets as a way to monitor local hypertension trends. Accurate information on sodium intake or the content of sodium in specific foods that presently contribute importantly to sodium intake is nec- essary for monitoring its reduction. These data are not currently available in a systematic or timely fashion. The lack of data presents a significant gap

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TAbLE S-2 Continued 22 Recommendations to Improve the Surveillance and Reporting of Hypertension and Risk Factors Short-Term Outcomes (or process input or Intermediate Priority Recommendation outputs) Short-Term Indicator Outcomes Intermediate Indicators 2.1 The DHDSP should identify Guidance on methods Improved estimates Improved capacity Improved program design methods to better use (analyze for analyzing and of hypertension for assessing and and implementation as a and report) existing data on the reporting existing prevalence, monitoring progress result of better data monitoring and surveillance of data for monitoring awareness, treatment, in hypertension hypertension over time and develop and surveillance of and control for the prevention and norms for data collection, analysis, hypertension and population as a whole control and reporting of future surveillance future data collection and subgroups of the of blood pressure levels and methods and analyses population (children, hypertension. In developing better racial and ethnic data collection methods and analyses, minorities, the elderly, the DHDSP should increase and and socioeconomic improve analysis and reporting of groups) at the understudied populations including: national, state, and children, racial and ethnic minorities, local levels the elderly, and socioeconomic groups. 6.4 SLHJs should assess their Increased number of Number of states Access to local data Number of states capacity to develop local HANES as state and localities and localities with on hypertension and localities that are a means to obtain local estimates of with a NHANES-like data systems that trends implementing program the prevalence, awareness, treatment, survey provide estimates changes based on local and control of hypertension. Further, of the prevalence, surveillance and reporting if a program to reduce hypertension awareness, treatment, information is a national goal, funding should and control of be made available to assure that hypertension for their localities have relevant data that jurisdictions will assist them in addressing hypertension in their communities.

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4.6 The DHDSP and other CDC Improved systems Availability of data Data on high-sodium- Percent of high content units, should explore methods for measuring or on specific foods containing foods are sodium products that to develop and implement data- estimating sodium that are important tracked and used to have reduced their sodium gathering strategies that will allow content in food contributors to develop strategies for content for more accurate assessment and are designed and dietary sodium intake reduction tracking of specific foods that are implemented by the American important contributors to dietary people sodium intake by the American people. 4.7 The DHDSP and other CDC Improved systems Availability of Data on dietary Reduction in mean dietary units should explore methods for measuring or mean population sodium consumption sodium intake to develop and implement data- estimating dietary dietary sodium and are available and gathering strategies that will allow sodium and potassium intake at used to target dietary for more accurate assessment and potassium intake the national, state, sodium reduction the tracking of population-level are designed and and local levels programs dietary sodium and potassium intake implemented including the monitoring of 24-hour urinary sodium and potassium excretion. continued 2

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2 TAbLE S-2 Continued System Change Recommendations Directed at Individuals with Hypertension Recommendations to Improve the Quality of Care Provided to Individuals with Hypertension Short-Term Outcomes (or process input or Intermediate Priority Recommendation outputs) Short-Term Indicator Outcomes Intermediate Indicators 5.1 The DHDSP should give high Better understanding Proportion of Improved rates of Proportion of individuals priority to conducting research to of reasons behind providers who diagnosed, treated, with hypertension who better understand the reasons behind poor physician measure and classify and controlled have achieved blood poor physician adherence to current adherence to JNC blood pressure patients, especially pressure control JNC guidelines. Once these factors guidelines according to JNC systolic blood are better understood, strategies guidelines pressure control should be developed to increase the Targeted strategies among the elderly likelihood that primary providers to improve Proportion of will screen for and treat hypertension provider awareness, providers who follow appropriately, especially in elderly understanding, JNC pharmacologic patients. acceptance, and therapies for adherence to JNC treatment of treatment guidelines hypertension

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5.2 The DHDSP should work Partnerships with Proportion of patients Improvements in Proportion of older with The Joint Commission and health care quality who receive provider- state- or local-level individuals with systolic the health care quality community community focused initiated prescription provider performance hypertension who receive to improve provider performance on improving and follow-up of in quality measures appropriate treatment on measures focused on assessing provider performance therapeutic lifestyle associated with blood adherence to guidelines for screening on quality measure modifications pressure treatment for hypertension, the development of for hypertension and control a hypertension disease management Proportion of patients plan that is consistent with JNC with uncontrolled guidelines, and achievement of blood high blood pressure control. pressure who have documented provider initiated change in pharmaceutical intervention 6.5 SLHJs should serve as conveners Development of local- Development of local Improvement in state of health care system representatives, level partnerships collaborative plans to reported diagnosis, physician groups, purchasers between SLHJs address hypertension treatment, and control rates of health care services, quality and health care prevention, control, improvement organizations, and representatives, and treatment employers (and others) to develop physician groups, a plan to engage and leverage skills purchasers of and resources for improving the health care services, medical treatment of hypertension. quality improvement organizations, and employers around hypertension prevention and control continued 2

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2 TAbLE S-2 Continued Recommendations to Remove Economic Barriers to Effective Antihypertensive Medications Short-Term Outcomes (or process input or Intermediate Priority Recommendation outputs) Short-Term Indicator Outcomes Intermediate Indicators 5.3 The DHDSP should encourage Reduced cost Out-of-pocket costs Improved adherence Prevalence of controlled the Centers for Medicare & Medicaid for effective for antihypertensive to antihypertensive hypertension, especially Services to recommend the elimination antihypertensive medications by medications especially in the poor, elderly, and or reduction of deductibles for medication, especially insurance and in the poor, elderly, those without health antihypertensive medications among among the poor, economic status and those without insurance coverage plans participating under Medicare elderly, and those health insurance Part D, and work with state Medicaid without health coverage Proportion of programs and encourage them to insurance coverage patients who adhere eliminate deductibles and copayments Improved to antihypertensive for antihypertensive medications. hypertension control, medication regimens The DHDSP should work with the especially in the pharmaceutical industry and its trade poor, elderly, and Degree of disparity in organizations to standardize and simplify those without health blood pressure control applications for patient assistance insurance coverage between general and programs that provide reduced-cost or priority populations free antihypertensive medications for low-income, underinsured, or uninsured individuals.

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5.4 The DHDSP should collaborate Partnerships between Out-of-pocket costs Improved adherence Proportion of with leaders in the business community the DHDSP and for antihypertensive to antihypertensive employees who adhere to educate them about the impact of business community medications for medications among to antihypertensive reduced patient costs on antihypertensive focused on reducing worksite employees employees medication regimens medication adherence and work with out-of-pocket costs them to encourage employers to leverage for antihypertensive Degree of disparity in their health care purchasing power medications blood pressure control to advocate for reduced deductibles between general and and copayments for antihypertensive priority employee medications in their health insurance populations benefits packages. 6.6 SLHJs should work with business Partnerships between coalitions and purchasing coalitions to SLHJs and business remove economic barriers to effective community focused antihypertensive medications for on reducing out- individuals who have difficulty accessing of-pocket costs for them. antihypertensive medications continued 2

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2 TAbLE S-2 Continued Recommendations to Provide Community Support for Individuals with Hypertension Short-Term Outcomes (or process input or Intermediate Priority Recommendation outputs) Short-Term Indicator Outcomes Intermediate Indicators 5.5 The DHDSP should work Design and Budget allocated Improved Prevalence of uncontrolled with state partners to leverage implementation of to development or hypertension control hypertension in opportunities to ensure that existing new or enhanced enhancement of in communities served communities served by community health worker programs community health community health by community health community health workers include a focus on the prevention worker programs worker programs worker programs and control of hypertension. In targeting hypertension Degree of reduction in the absence of such programs, the control Number of disparities in blood pressure DHDSP should work with state community health control between general partners to develop programs of worker programs population and populations community health workers who targeting hypertension served by community would be deployed in high-risk health workers communities to help support healthy living strategies that include a focus on hypertension. 6.7 SLHJs should promote and work with community health worker initiatives to ensure that prevention and control of hypertension is included in the array of services they provide and are appropriately linked to primary care services.

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29 SUMMARY Hypertension as a Sentinel Indicator for Health Disparities Hypertension is a disease for which there are major inequities across racial groups and economic groups—along the entire spectrum from risk factors to delivery of medical care. Interventions directed toward general population groups historically do not correct these inequities and can even worsen them. Care must be taken to assure that any portfolio of interven- tions implemented will minimize existing inequities in prevention, detec- tion, treatment, and control of hypertension. Hypertension is a condition strongly influenced by underlying indi- vidual and community risk factors related to healthy eating and active living—risk factors driven by race and class in most communities today. As such, it is a potential sentinel indicator for assessing and testing broader approaches to reduce health disparities. The prevalence of hypertension may provide a relatively quick and objective measure of programs directed at these risk factors as well as underlying social determinants of health. Hypertension, while treatable, requires ongoing access to primary care for maximum effectiveness. As such, it is also a potentially very good marker for lack of access to or continuity of health care in a community. SLHJs should consider hypertension as a sentinel measure for evaluation of the effectiveness of a range of disparity-reducing activities, including impor- tant place-based strategies tackling conditions through community policy interventions. REFERENCES Austvoll-Dahlgren, A., M. Aaserud, G. Vist, C. Ramsay, A. D. Oxman, H. Sturm, J. P. Kosters, and A. Vernby. 2008. Pharmaceutical policies: Effects of cap and co-payment on rational drug use. Cochrane Database of Systematic Reviews (1). Baker, E. L., and J. Porter. 2005. Practicing management and leadership: Creating the infor- mation network for public health officials. Journal of Public Health Management and Practice 11(5):469-473. Balu, S., and J. Thomas, 3rd. 2006. Incremental expenditure of treating hypertension in the United States. American Journal of Hypertension 19(8):810-816. Berlowitz, D. R., A. S. Ash, E. C. Hickey, R. H. Friedman, M. Glickman, B. Kader, and M. A. Moskowitz. 1998. Inadequate management of blood pressure in a hypertensive popula- tion. New England Journal of Medicine 339(27):1957-1963. Bosworth, H. B., M. K. Olsen, P. Gentry, M. Orr, T. Dudley, F. McCant, and E. Z. Oddone. 2005. Nurse administered telephone intervention for blood pressure control: A patient- tailored multifactorial intervention. Patient Education and Counseling 57(1):5-14. Burt, V. L., J. A. Cutler, M. Higgins, M. J. Horan, D. Labarthe, P. Whelton, C. Brown, and E. J. Roccella. 1995. Trends in the prevalence, awareness, treatment, and control of hy- pertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension 26(1):60-69. CDC (Centers for Disease Control and Prevention). 2006. Healthy People 2010 Midcourse Review: Section 12: Heart disease and stroke. http://www.healthypeople.gov/data/mid- course/pdf/fa12.pdf (accessed February 4, 2010).

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0 APPROACH TO PREVENT AND CONTROL HYPERTENSION Chiong, J. R. 2008. Controlling hypertension from a public health perspective. International Journal of Cardiology 127(2):151-156. Chobanian, A. V., G. L. Bakris, H. R. Black, W. C. Cushman, L. A. Green, J. L. Izzo, Jr., D. W. Jones, B. J. Materson, S. Oparil, J. T. Wright, Jr., and E. J. Roccella. 2003. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. Journal of the American Medical Association 289(19):2560-2572. Cutler, D. M., G. Long, E. R. Berndt, J. Royer, A. A. Fournier, A. Sasser, and P. Cremieux. 2007. The value of antihypertensive drugs: A perspective on medical innovation. Health Affairs 26(1):97-110. DeVol, R., and A. Bedroussian. 2007. An unhealthy America: The economic burden of chronic disease. Santa Monica, CA: Milken Institute. Fields, L. E., V. L. Burt, J. A. Cutler, J. Hughes, E. J. Roccella, and P. Sorlie. 2004. The burden of adult hypertension in the United States 1999 to 2000: A rising tide. Hypertension 44(4):398-404. Fihn, S. D., and J. B. Wicher. 1988. Withdrawing routine outpatient medical services: Effects on access and health. Journal of General Internal Medicine 3(4):356-362. Goldman, D. P., G. F. Joyce, and Y. Zheng. 2007. Prescription drug cost sharing: Associations with medication and medical utilization and spending and health. Journal of the Ameri- can Medical Association 298(1):61-69. HHS (U.S. Department of Health and Human Services) and USDA (U.S. Department of Ag- riculture). Dietary Guidelines for Americans, 2005. 6th Edition. Washington, DC: U.S. Government Printing Office. HRSA (Health Resources and Services Adminstration). 2007. Community health workers national workforce study. Washington, DC: U.S. Department of Health and Human Services. Hyman, D. J., and V. N. Pavlik. 2001. Characteristics of patients with uncontrolled hyperten- sion in the United States. [see comment] [erratum appears in 2002 New England Journal of Medicine 346(7):544]. New England Journal of Medicine 345(7):479-486. Hyman, D. J., V. N. Pavlik, and C. Vallbona. 2000. Physician role in lack of awareness and control of hypertension. Journal of Clinical Hypertension (Greenwich) 2(5):324-330. IOM (Institute of Medicine). 2003. Unequal treatment: Confronting racial and ethnic dispari- ties in health care. Washington, DC: The National Academies Press. ———. 2004. Dietary reference intakes: Water, potassium, sodium, chloride, and sulfate. Washington, DC: The National Academies Press. Izzo, J. L., Jr., D. Levy, and H. R. Black. 2000. Clinical advisory statement. Importance of systolic blood pressure in older Americans. Hypertension 35(5):1021-1024. Kilgore, M. L., and D. P. Goldman. 2008. Drug costs and out-of-pocket spending in cancer clinical trials. Contemporary Clinical Trials 29(1):1-8. Lloyd-Jones, D. M., J. C. Evans, M. G. Larson, and D. Levy. 2002. Treatment and control of hypertension in the community: A prospective analysis. Hypertension 40(5):640-646. Lloyd-Jones, D., R. Adams, M. Carnethon, G. De Simone, T. B. Ferguson, K. Flegal, E. Ford, K. Furie, A. Go, K. Greenlund, N. Haase, S. Hailpern, M. Ho, V. Howard, B. Kissela, S. Kittner, D. Lackland, L. Lisabeth, A. Marelli, M. McDermott, J. Meigs, D. Mozaffarian, G. Nichol, C. O’Donnell, V. Roger, W. Rosamond, R. Sacco, P. Sorlie, R. Stafford, J. Steinberger, T. Thom, S. Wasserthiel-Smoller, N. Wong, J. Wylie-Rosett, and Y. Hong. 2009. Heart disease and stroke statistics—2009 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 119(3):480-486.

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1 SUMMARY NCHS (National Center for Health Statistics). 2008. Healthy People 2010 progress re- view: Focus area 19: Nutrition and overweight presentation. http://www.cdc.gov/nchs/ ppt/hp2010/focus_areas/fa19_2_ppt/fa19_nutrition2_ppt. htm (accessed September 14, 2009). Palar, K., and R. Sturm. 2009. Potential societal savings from reduced sodium consumption in the U.S. adult population. American Journal of Health Promotion 24(1):49-57. Pavlik, V. N., D. J. Hyman, C. Vallbona, C. Toronjo, and K. Louis. 1997. Hypertension awareness and control in an inner-city African-American sample. Journal of Human Hypertension 11(5):277-283. Rogowski, J., L. A. Lillard, and R. Kington. 1997. The financial burden of prescription drug use among elderly persons. Gerontologist 37(4):475-482. The City of New York. 2009. Statement of commitment by health organizations and public agencies. http://www.nyc.gov/html/doh/html/cardio/cardio-salt-coalition.shtml (accessed December 18, 2009). Vasan, R. S., A. Beiser, S. Seshadri, M. G. Larson, W. B. Kannel, R. B. D’Agostino, and D. Levy. 2002. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. Journal of the American Medical Association 287(8):1003-1010.

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