6
Implementing a Population-Based Policy and Systems Approach to the Prevention and Control of Hypertension

Hypertension is highly prevalent in adults, endemic in the elderly, a major contributor to cardiovascular mortality and disability, costly to our society, and a substantial contributor to health disparities in the United States. Hypertension is also simple to diagnose, relatively inexpensive to treat, and more importantly, is highly preventable through lifestyle interventions.

Despite these facts, surprisingly and unfortunately, hypertension does not receive a level of attention and funding commensurate with its associated health burden and consequences, and the public health approach to addressing hypertension in this decade has suffered. The early national attention to hypertension of the 1970s (National High Blood Pressure Education Program) has diminished, and the focus on prevention and early detection has shifted toward pharmacologic treatment. This lack of attention is exacerbated, in part, because hypertension as a condition sits between more primary risk factors such as diet and physical activity and medical disease states such as cardiovascular and cerebrovascular disease, with consequent ambiguity in leadership and diffusion of responsibility between public health and medical care. From the perspective of those affected, hypertension is easy to neglect. It is not an apparent risk factor such as smoking or obesity, and, for the majority of individuals, it causes no symptoms. Thus there has been little “ownership” for the prevention of hypertension.

The Centers for Disease Control and Prevention (CDC), through the Division for Heart Disease and Stroke Prevention (DHDSP), has leveraged its broader cardiovascular disease prevention and control programmatic



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6 Implementing a Population-Based Policy  and Systems Approach to the Prevention  and Control of Hypertension H ypertension is highly prevalent in adults, endemic in the elderly, a major contributor to cardiovascular mortality and disability, costly to our society, and a substantial contributor to health disparities in the United States. Hypertension is also simple to diagnose, relatively inexpen- sive to treat, and more importantly, is highly preventable through lifestyle interventions. Despite these facts, surprisingly and unfortunately, hypertension does not receive a level of attention and funding commensurate with its associ- ated health burden and consequences, and the public health approach to addressing hypertension in this decade has suffered. The early national attention to hypertension of the 1970s (National High Blood Pressure Education Program) has diminished, and the focus on prevention and early detection has shifted toward pharmacologic treatment. This lack of attention is exacerbated, in part, because hypertension as a condition sits between more primary risk factors such as diet and physical activity and medical disease states such as cardiovascular and cerebrovascular disease, with consequent ambiguity in leadership and diffusion of responsibility between public health and medical care. From the perspective of those affected, hypertension is easy to neglect. It is not an apparent risk factor such as smoking or obesity, and, for the majority of individuals, it causes no symptoms. Thus there has been little “ownership” for the prevention of hypertension. The Centers for Disease Control and Prevention (CDC), through the Division for Heart Disease and Stroke Prevention (DHDSP), has leveraged its broader cardiovascular disease prevention and control programmatic 1

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION efforts to address hypertension primarily through its state heart disease and stroke prevention programs. Many of these efforts are described in Chap- ter 3 and throughout other chapters. Objectively, however, there are two 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 has more of a medical care rather than a population-based prevention focus. • 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. Despite the magnitude of hypertension-associated morbidity and mortality and costs to the health care system ($73 billion annually), the current resources available for hypertension prevention and control at the CDC are surprisingly limited ($54 million for all cardiovascular and stroke activities in 2009). This current economic reality limiting the absolute amount of re - sources available to the CDC must drive short-term programmatic pri- orities towards approaches that are not only cost-effective but also low in absolute cost. Compared with interventions directed toward individuals, interventions directed toward policy, systems, and environmental changes in populations are more likely to be realistic and effective in the current resource-constrained environment. The committee believes that the DHDSP should focus its priorities on approaches that cater to the strength of the public health system—population-based policy and systems approaches rather than individual health care-based approaches. Any investments in the health care sector should be policy- and systems-based and should leverage health care system resources. The committee has recommended a number of high-priority strategies to prevent and control hypertension to the DHDSP throughout Chapters 4 and 5. The recommendations embody a population-based policy and sys- tems approach grounded in the principles of measurement, system change, and accountability. In brief, the recommendations seek to: • hift the balance of the DHDSP’s hypertension priorities from in- S dividual-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

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1 A POPULATION-BASED POLICY AND SYSTEMS APPROACH 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 committee, through these recommendations, underscores the im- portance of policy, systems, and environmental change interventions as fun- damental to preventing and controlling hypertension. Clearly, this approach cannot be limited to the CDC DHDSP but must also extend to state and local health departments and other partners responsible for implementing these interventions. 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 outcomes are achieved. In the next section the committee makes recommendations for state and local health jurisdictions, including neces- sary resources and accountability measures to support the recommended population-based policy and systems approach to preventing and control- ling hypertension. RECOMMENDATIONS FOR STATE AND LOCAL HEALTH JuRISDICTIONS State and local governments have specific roles and responsibilities for protecting, preserving, and promoting the public’s health. They fulfill their responsibility through many activities including monitoring injury and disease in the population through surveillance systems; providing a broad array of population-wide prevention services; and helping to assure access to high-quality health care services for poor and vulnerable populations. They also engage in a broad array of regulatory activities, and they oversee

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION the quality of health care provided in the public and private sectors (IOM, 2002). State and local public health agencies can act on the most upstream level of determinants of health. Action at this level may help to shift norms and values and lead to policies that promote health (for example, state and local tobacco policies). Thus, as with federal public health agencies, state and local public health agencies are uniquely skilled in population-based interventions and in general have more experience in these interventions than in interventions that directly provide health care to individuals. The committee views population-based approaches to prevent and con- trol hypertension at the state and local level to be consistent with the broad mandates of state and local public health jurisdictions (SLHJs). 6.1 The Committee recommends that state and local public health juris- dictions give priority to population-based approaches over individual- based approaches to prevent and control hypertension. Population-based policy and systems interventions for hypertension prevention and control are arguably the most important and relevant com- ponent of hypertension programming for SLHJs. By their nature, many elements of hypertension prevention fit neatly into current SLHJs’ programs for healthy eating, active living, and obesity prevention (IOM, 2007, 2009). As such, population approaches to hypertension should be integrated into these existing efforts rather than re-created as separate, stand alone pro- grams. At the same time, these existing programs may need adjustment and expansion. For example, the high prevalence of hypertension in older populations and other population subgroups (African Americans) should lead SLHJs to assess and, if necessary, modify these programs to assure they are relevant and accessible to older and higher-risk populations. 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. A major risk factor for hypertension—excess sodium consumption in the diet—currently is not targeted by most SLHJs and is a new, important target for public health action. Strategies for sodium reduction will be further refined in an upcoming IOM report by the Committee on Strate-

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19 A POPULATION-BASED POLICY AND SYSTEMS APPROACH gies to Reduce Sodium Intake (slated to be released in early 2010) but may include: public education to increase awareness of the importance of reduced sodium in the diet and the salt content of foods; modifying sodium poli- cies in food programs under SLHJs jurisdiction; voluntary or regulatory measures to reduce sodium levels in processed foods and foods prepared in institutions such as schools and worksites. Actions to reduce sodium levels in food products have been initiated by other countries including the United Kingdom (UK) and are showing some impact. The UK Food Standards Agency published voluntary salt reduction targets in March 2006 to lower population salt intake from 9.5 g (baseline in 2000-2001) to 6 g per day. Since that time, the agency has been work- ing with health departments, directorates and stakeholders, and industry to reduce salt consumption in the UK. A recent progress review indicated that many companies that produce processed foods have programs in place to reduce salt and have met targets for specific categories. Urinary analysis results taken in January and May 2008 indicate that overall salt reduction initiatives (public awareness, industry activities, and others) have decreased average salt intake to 8.6 g based on dietary sodium in 24-hour urine samples (National Centre for Social Research, 2008). In the United States, cities, states, and national health organizations are taking steps to reduce population salt intake; the National Salt Reduc- tion Initiative (NSRI), coordinated by the New York City (NYC) Health Department, has led the way. The NSRI’s strategy includes working with the food industry to set sodium reduction targets for their products that are substantive, achievable, gradual, measurable, and voluntary, with the goal of reducing population sodium intake by 20 percent over 5 years. The process for implementing the strategy includes meeting with food industry leaders to discuss sodium reduction, working with packaged food manu- facturers and restaurants to set voluntary sodium targets by food category, implementing targets and timelines to reduce salt, and monitoring the salt reduction process through the creation of restaurant and packaged food nutrition databases. Across the country 26 state and local public health agencies and 17 professional associations and organizations have coalesced into the NSRI (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.

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10 APPROACH TO PREVENT AND CONTROL HYPERTENSION Reliable, ongoing measurement of a public health problem is essen- tial to its effective control. Blood pressure is relatively simple to measure, however, access to and use of hypertension measures at the SLHJs level has proven difficult. The primary national data source for population estimates of hypertension—National Health and Nutrition Examination Survey (NHANES)—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. The primary risk factor surveillance system used by SLHJs, the Behavioral Risk Factor Surveillance System, is limited because it relies on self-report rather than objective mea- surement, and it provides no information on the extent and characteristics of undiagnosed hypertension. In short, SLHJs do not have the basic data that would be most useful in assessing need and driving local policy in- terventions; this lack of data may contribute to the relative inattention to hypertension by SLHJs to date. Hypertension provides one of the most compelling conditions justify- ing the creation of a state and local NHANES-like survey providing repre- sentative population-based objective clinical information. Some states and localities are moving in this direction. Currently four states receive funding from the DHDSP through the State Cardiovascular Health Examination Survey program to initiate state HANES-like surveys, but data are not yet available. NYC currently conducts a local version of the HANES that is a population-based, cross-sectional survey of noninstitutionalized NYC adult residents 20 years of age and older (Angell et al., 2008). The survey has allowed the NYC Department of Health and Mental Hygiene to monitor the health of NYC residents including the prevalence, awareness, treatment, and control of hypertension. SLHJs without the resources to implement a state-level HANES may need to identify other reliable population-based data sets, for example, health care quality reporting data, that could be used to monitor local hypertension trends. 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

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11 A POPULATION-BASED POLICY AND SYSTEMS APPROACH may want to actively seek other reliable and available population-based data sets as a way to monitor local hypertension trends. As a primary strategy, interventions in which public health dollars are used to directly deliver high-quality hypertension detection and treatment services are unlikely because of the cost of these interventions. Furthermore, direct interventions providing direct health care to individuals are most distant from the unique skills and value-added of state and local health agencies. But, because hypertension is treatable, SLHJs should consider how to use their limited resources to best leverage health care dollars for improved treatment and control of hypertension. Public health agencies vary widely in their working relations and links with the health care providers in their jurisdictions. In some areas, link- ages are strong and the SLHJ could play a valuable role in convening and advocating for improved treatment and care for persons with hyperten- sion. But such activity will not be equally productive everywhere and will require a case-by-case assessment. Alternatively, SLHJs may be able to play an effective leadership and convening and brokering role in influencing community-wide health care practices, for example, through advocacy for incorporating measures of hypertension control in local or regional mea- sures of health care quality. Assuring complementary lifestyle interventions (physical activity, weight management, healthy diet) in health care treat- ment protocols and linking these activities to community-based strategies through community health workers may be another important element of a local hypertension control program. Systolic hypertension in the elderly is the most common form of uncon- trolled hypertension in the United States. One area of special SLHJs activity relative to the hypertension health care delivery system may be to increase provider awareness of both prevalence and evidence of treatment effective- ness for moderate systolic hypertension in older patients and monitoring of provider performance in meeting Joint National Commission (JNC) treatment guidelines. 6.5 The committee recommends that state and local public health jurisdictions serve as conveners of health care system representatives, physician groups, purchasers of health care services, quality improve- ment organizations, and employers (and others) to develop a plan to engage and leverage skills and resources for improving the medical treatment of hypertension. 6.6 State and local public health jurisdictions should work with busi- ness coalitions and purchasing coalitions to remove economic barriers to effective antihypertensive medications for individuals who have dif- ficulty accessing them.

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12 APPROACH TO PREVENT AND CONTROL HYPERTENSION 6.7 State and local public health jurisdictions should promote and work with community health worker initiatives to ensure that preven- tion and control of hypertension is included in the array of services they provide and are appropriately linked to primary care services. RESOuRCES FOR HyPERTENSION PREVENTION AND CONTROL The DHDSP has developed a comprehensive strategic plan that is not implementable in full with the current resources available. Considering the limited available resources, the committee has provided recommendations on priorities among the many possible activities laid out by the DHDSP. These recommendations have centered on population-based policy and system interventions in which funding can leverage other public health, health care, and private sector funding for improved prevention, treatment, and control of hypertension. The committee notes, in fact, there are fewer public health resources for hypertension prevention than for any other pre- ventable risk factor underlying a disease burden of comparable magnitude. As an example, CDC funding for the Office on Smoking and Health is $106.2 million while funding for the Division for Heart Disease and Stroke Prevention is $54.1 million; this funding supports activities related to not only hypertension but also stroke and cardiovascular disease in general. Federal under funding of and insufficient attention to hypertension relative to the preventable burden of disease has played out at the state and local level as well. In general, states and localities have not invested in public health chronic disease prevention programs to the extent to which they have invested in communicable diseases (Frieden, 2004; Georgeson et al., 2005; Porterfield et al., 2009; Prentice and Flores, 2007). The evidence pre- sented in Chapter 4 indicates there is potential for a substantial preventive, nonpharmacologic, non-health care, population-based policy and system strategy to be implemented at the federal, state, and local levels. There is also room for substantial improvement in health care diagnosis and treat- ment as discussed in Chapter 5. Implementation of the strategy, however, will be hampered by limited resources. With the nation’s attention now focused on health care reform in general and specifically on the potential role of prevention, there is also the opportunity to advocate for increased financing for hypertension prevention and control. In an era of declining resources and conflicting priorities for public health, taking on any new challenges needs careful consideration. But given the disease and economic burden associated with hypertension, and in this climate of health care reform and increasing attention to prevention, there is great public health opportunity and no better time to rise to the challenge.

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1 A POPULATION-BASED POLICY AND SYSTEMS APPROACH 6.8 The committee recommends that Congress give priority to assuring adequate resources for implementing a broad suite of population-based policy and system approaches at the federal, state, and local levels that have the greatest promise to prevent, treat, and control hypertension. The committee notes that it was hampered in fully understanding how DHDSP funds were used for hypertension prevention and control activities at the state level insomuch as many of these activities were embedded in larger stroke or cardiovascular prevention and control activities. Report- ing of program activity and funding data was not sufficiently detailed to ascertain the degree of funding that was specifically related to hypertension prevention, treatment, and control. A vital component of DHDSP priori- tization of activities must be budget allocation. Rational decisions about where in a portfolio the next dollar should be spent can only be made with good information about where current dollars are being spent. A gap analysis comparing current resource use against priorities is critical to as- sure adequate resources are devoted to the highest-priority areas. Attendant to current funding and potential future funding for hyperten- sion prevention, treatment, and control, systems need to be in place to track and measure current and new programs activities at the federal, state, and local levels. Such a system would help ensure that resources are appropri- ately aligned and outcomes are achieved. 6.9 The committee recommends that the Division for Heart Disease and Stroke Prevention develop resource accountability systems to track and measure all current and new state programs for the prevention, treatment, and control of hypertension that would allow for resources to be assessed for alignment with the population-based policy and sys- tems strategy and for measuring the outcomes achieved. The committee acknowledges that the recommendations proffered, if adopted, would result in a significant programmatic change for the DHDSP. To effectively support the change and maintain a population-based focus, new expertise and guidance may be required beyond that which may be available through the DHDSP’s partnership with the National Forum for Heart Disease and Stroke Prevention. 6.10 The committee recommends that the Division for Heart Disease and Stroke Prevention identify and work with experts grounded in population-based approaches to provide guidance and assistance in de- signing and executing hypertension prevention and control efforts that focus on population-based policy and system change. These experts

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1 APPROACH TO PREVENT AND CONTROL HYPERTENSION could augment an existing advisory body or be drawn from an existing body with this expertise. ENSuRING SySTEM ACCOuNTAbILITy The committee considered the results that could be expected if the population-based policy and systems approach to prevent and control hypertension were implemented, including the potential effect on the over- all prevalence of hypertension in the population and on racial and ethnic disparities. This section outlines the committee’s consideration of those issues and identifies potential outcomes and indicators. The committee’s consideration of potential indictors was informed by the division’s draft document on Policy and System Outcome Indicators for State Heart Dis- ease and Stroke Prevention, Priority Area: High Blood Pressure Control (DHDSP, 2008). The committee believes that attention to the high-priority areas it has identified would lead to a reduction in the prevalence of hypertension, im- prove the quality of care provided to individuals with hypertension and in the long term, and ultimately, reduce mortality and morbidity due to heart disease and stroke. In the short term, one visible impact would be strong federal, state, and local public health agency leadership that gives priority to reducing the prevalence of hypertension through population-based ap- proaches integrated throughout agency activities, particularly those that target hypertension risk factors by reducing obesity, promoting health diets, and increasing physical activity. Active engagement and efforts by federal, state, and local jurisdictions to reduce sodium consumption, an area not typically addressed by parts of the governmental public health system, would be another short-term visible impact. Improved estimates of hypertension prevalence, awareness, treatment, and control for the popula- tion as a whole and subgroups of the population at the national, state, and local levels would be important results of efforts to improve surveillance and monitoring of hypertension trends. Similarly, through improved data collection, public health officials would have better estimates to monitor their progress in reducing dietary sodium consumption and the sodium content in food. Improved blood pressure control, especially systolic blood pressure among the elderly, would be the result of strategies designed to address the factors contributing to poor physician adherence to JNC treatment guidelines. The effect of removing economic barriers to effective antihyper- tensive medications and employing the use of community health workers to provide community-based support for individuals with hypertension would be improved access to medications and supportive hypertension care for vulnerable populations. Finally, essentially all of the proposed interventions

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1 A POPULATION-BASED POLICY AND SYSTEMS APPROACH have the potential to reduce health disparities if they are implemented with this goal in mind. However, this goal may not be in the forefront by all; thus, continued monitoring of health disparities will be necessary. Table 6-1 summarizes the committee’s recommendations for high- priority areas and related short-term and intermediate outcomes, and potential indicators to measure the progress made in advancing the com- mittee’s high-priority areas. Decreased mortality and morbidity from heart disease and stroke are understood as the ultimate long-term indicators; as such, they are not included in the table due to space consideration. The table is divided into broad sections (e.g., Population-Based Recommen- dations to the CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) and State and Local Jurisdictions (SLHJs), System Approaches Targeting Individuals with Hypertension Directed to the CDC and SLHJs, etc.) and includes subgroups of recommendations under those headings. Outcomes and indicators found in adjacent columns do not tract directly across but correspond to the subgroup of recommendations. Recommen- dations for resources and accountability (6.8-6.10) are not included in the table. HyPERTENSION AS A SENTINEL FOR SuCCESS OF THE PubLIC HEALTH SySTEM IN REDuCING HEALTH DISPARITIES Hypertension may provide an opportunity unique in public health chronic disease prevention for program evaluation through outcome mea- surement. In contrast to most chronic disease outcomes, measurement of hypertension has a combination of key ideal characteristics, including: (1) objectivity, (2) low cost, (3) ease and reproducibility, and (4) rapid response to intervention. In this context, it provides a single, reliable outcome mea- sure that can be linked to intervention process measures to rapidly inform program interventions. It is also an early objective outcome measure of multiple public health and medical interventions to increase healthy eating and physical exercise. Hypertension is prevalent, preventable, treatable, easily measured, and rapidly changeable. As such, it is a potential sentinel indicator for assessing and testing broader approaches to reduce health disparities. Hypertension is a condition strongly influenced by underlying individual and community risk factors related to healthy eating and active living—risk factors driven by race and class in most communities today. The prevalence of hyperten- sion 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. Thus, it is also a potentially very good marker for access to and continuity of health care in a community. The

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1 TAbLE 6-1 Continued Recommendations to Strengthen Leadership in Reducing Sodium Intake and Increasing Potassium Intake Short-Term Outcomes (or process input or Intermediate Priority Recommendation outputs) Short-Term Indicator Outcomes Intermediate Indicators 4.4 The DHDSP should take active Aggressive actions at Proportion of states Reduction of salt Mean population urinary leadership in convening other partners the federal, state, and and localities with consumption by the sodium excretion level in federal, state, and local government local levels to reduce a strategic plan to American population and industry to advocate for and sodium consumption reduce sodium intake Proportion of individuals implement strategies to reduce sodium and sodium content and sodium content Reduction of salt who consume five or in the American diet to meet dietary in the diet in food content in food more fruits and vegetables guidelines, which are currently less per day than 2,300 mg/day (equivalent to 100 Development and Federal, state, and Reduced prevalence mmol/day) for the general population implementation of local budgets and of hypertension and 1,500 mg/day (equivalent to 70 federal, state, land plans for programs to mmol/day) for blacks, middle-aged ocal programs to reduce sodium intake and older adults, and individuals with reduce sodium intake hypertension.

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6.3 SLHJs should immediately begin Number of states Mean population urinary to consider developing a portfolio of implementing potassium excretion level dietary sodium reduction strategies new or expanded that make the most sense for early programs to increase action in their jurisdictions. potassium rich fruit and vegetable consumption 4.5 DHDSP should specifically Development and Budget and plans Increase in Mean and median blood consider as a strategy advocating for implementation of for programs for potassium rich pressure levels the greater use of potassium/sodium programs to increase increasing potassium fruit and vegetable chloride combinations as a means of potassium intake consumption consumption simultaneously reducing sodium intake and increasing potassium intake. Reduction of hypertension risk factors in the population continued 19

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TAbLE 6-1 Continued 190 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 191

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192 TAbLE 6-1 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 19

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19 TAbLE 6-1 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 19

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TAbLE 6-1 Continued 19 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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19 A POPULATION-BASED POLICY AND SYSTEMS APPROACH combination of these two elements or drivers of hypertension potentially increases the likelihood that standard public health interventions may in- crease rather than decrease disparities, as has often been the case in tobacco reduction interventions. SLHJs should consider hypertension as a sentinel measure for evaluation of the effectiveness of a range of disparity-reducing activities, especially place-based strategies tackling conditions through com- munity policy interventions. Hypertension is also a disease of aging, becoming increasingly prevalent as individuals grow older. From the perspectives of the proportion affected, attention must be directed toward groups with the highest prevalence. But from the perspective of the individual, hypertension in younger age groups has a greater potential for causing premature morbidity and mortality, and therefore so special attention needs to be paid to this risk population. REFERENCES Angell, S. Y., R. K. Garg, R. C. Gwynn, L. Bash, L. E. Thorpe, and T. R. Frieden. 2008. Preva- lence, awareness, treatment, and predictors of control of hypertension in New York City. Circulation: Cardiovascular Quality and Outcomes 1(1):46-53. DHDSP (Division for Heart Disease and Stroke Prevention). 2008. Policy and system outcome indicators for state heart disease and stroke prevention, priority area: High blood pres- sure control. Atlanta, GA: Centers for Disease Control and Prevention. Frieden, T. R. 2004. Asleep at the switch: Local public health and chronic disease. American Journal of Public Health 94(12):2059-2061. Georgeson, M., L. Thorpe, M. Merlino, T. Frieden, J. Fielding, and The Big Cities Health Coalition. 2005. Shortchanged? An assessment of chronic disease programming in major US city health departments. Journal of Urban Health 82(2):183-190. IOM (Institute of Medicine). 2002. The future of the public’s health in the 21st century. Washington, DC: The National Academies Press. ———. 2007. Progress in preventing childhood obesity: How do we measure up? Washington, DC: The National Academies Press. ———. 2009. Local government actions to prevent childhood obesity. Washington, DC: The National Academies Press. National Centre for Social Research. 2008. An assessment of dietary sodium levels among adults (aged 19-) in the UK general population in 200, based on analysis of di- etary sodium in 2 hour urine samples. http://www.food.gov.uk/multimedia/pdfs/sodium report08.pdf (accessed January 15, 2010). Porterfield, D. S., J. Reaves, T. R. Konrad, B. J. Weiner, J. M. Garrett, M. Davis, C. W. Dickson, M. Plescia, J. Alexander, and E. L. Baker, Jr. 2009. Assessing local health depart- ment performance in diabetes prevention and control—North Carolina, 2005. Preventing Chronic Disease 6(3):A87. Prentice, B., and G. Flores. 2007. Local health departments and the challenge of chronic dis- ease: Lessons from California. Preventing Chronic Disease 4(1):A15. The City of New York. 2009. Statement of health organiztions and public agencies. http:// www.nyc.gov/html//doh/html/cardio/cardio-salt-coalition.shtml (accessed December 18, 2009).

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