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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 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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A Population-Based Policy and Systems Change 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 Chapter 3 and throughout other chapters. Objectively, however, there are two significant problems with the current status and direction of hypertension prevention and control activities: Hypertension is only one component of a larger cardiovascular disease prevention program that has more of a medical care rather than a population-based prevention focus. The CDC’s cardiovascular disease program in general, and the 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 resources available to the CDC must drive short-term programmatic priorities 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 systems approach grounded in the principles of measurement, system change, and accountability. In brief, the recommendations seek to: Shift the balance of the DHDSP’s hypertension priorities from individual-based strategies to population-based strategies to: strengthen collaboration among CDC units (and their partners) to ensure that hypertension is included as a dimension of other population-based activities around healthy lifestyle improvement, particularly greater consumption of potassium-rich
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension fruits and vegetables, increased physical activity, and weight management strengthen CDC’s leadership in monitoring and reducing sodium intake in the American diet to meet current dietary guidelines 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: 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 remove economic barriers to effective antihypertensive medications provide community-based support for individuals with hypertension through community health workers who are trained in dietary and physical activity counseling. The committee, through these recommendations, underscores the importance of policy, systems, and environmental change interventions as fundamental 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 necessary resources and accountability measures to support the recommended population-based policy and systems approach to preventing and controlling 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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A Population-Based Policy and Systems Change 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 control 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 jurisdictions 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 component 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 programs. 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 programmatic 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 hypertension 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 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 policies 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 working 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 Reduction 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 manufacturers 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Reliable, ongoing measurement of a public health problem is essential 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 measurement, 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 interventions; this lack of data may contribute to the relative inattention to hypertension by SLHJs to date. Hypertension provides one of the most compelling conditions justifying the creation of a state and local NHANES-like survey providing representative 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 localities 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 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, linkages are strong and the SLHJ could play a valuable role in convening and advocating for improved treatment and care for persons with hypertension. 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 measures of health care quality. Assuring complementary lifestyle interventions (physical activity, weight management, healthy diet) in health care treatment 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 uncontrolled 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 effectiveness 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 improvement 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 business coalitions and purchasing coalitions to remove economic barriers to effective antihypertensive medications for individuals who have difficulty accessing them.
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A Population-Based Policy and Systems Change 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 prevention 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 preventable 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 presented 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 treatment 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 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. Reporting 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 prioritization 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 assure adequate resources are devoted to the highest-priority areas. Attendant to current funding and potential future funding for hypertension 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 appropriately 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 systems 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 designing and executing hypertension prevention and control efforts that focus on population-based policy and system change. These experts
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A Population-Based Policy and Systems Change 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 overall 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 Disease 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, improve 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 approaches 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 population 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 antihypertensive 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 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 committee’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 Recommendations 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. Recommendations 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 measurement. 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 measure 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 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. 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Recommendations to Strengthen Leadership in Reducing Sodium Intake and Increasing Potassium Intake Priority Recommendation Short-Term Outcomes(or process input or outputs) Short-Term Indicator Intermediate Outcomes Intermediate Indicators 4.4 The DHDSP should take active leadership in convening other partners 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. Aggressive actions at the federal, state, and local levels to reduce sodium consumption and sodium content in the diet Proportion of states and localities with a strategic plan to reduce sodium intake and sodium content in food Reduction of salt consumption by the American population Mean population urinary sodium excretion level Reduction of salt content in food Proportion of individuals who consume five or more fruits and vegetables per day Development and implementation of federal, state, land ocal programs to reduce sodium intake Federal, state, and local budgets and plans for programs to reduce sodium intake Reduced prevalence of hypertension
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 6.3 SLHJs should immediately begin to consider developing a portfolio of dietary sodium reduction strategies that make the most sense for early action in their jurisdictions. Number of states implementing new or expanded programs to increase potassium rich fruit and vegetable consumption Mean population urinary potassium excretion level 4.5 DHDSP should 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. Development and implementation of programs to increase potassium intake Budget and plans for programs for increasing potassium consumption Increase in potassium rich fruit and vegetable consumption Mean and median blood pressure levels Reduction of hypertension risk factors in the population
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Recommendations to Improve the Surveillance and Reporting of Hypertension and Risk Factors Priority Recommendation Short-Term Outcomes(or process input or outputs) Short-Term Indicator Intermediate Outcomes Intermediate Indicators 2.1 The DHDSP should identify methods to better use (analyze and report) existing data on the monitoring and surveillance of hypertension over time and 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 elderly, and socioeconomic groups. Guidance on methods for analyzing and reporting existing data for monitoring and surveillance of hypertension and future data collection methods and analyses Improved estimates of hypertension prevalence, awareness, treatment, and control for the population as a whole and subgroups of the population (children, racial and ethnic minorities, the elderly, and socioeconomic groups) at the national, state, and local levels Improved capacity for assessing and monitoring progress in hypertension prevention and control Improved program design and implementation as a result of better data 6.4 SLHJs should 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 localities have relevant data that will assist them in addressing hypertension in their communities. Increased number of state and localities with a NHANES-like survey Number of states and localities with data systems that provide estimates of the prevalence, awareness, treatment, and control of hypertension for their jurisdictions Access to local data on hypertension trends Number of states and localities that are implementing program changes based on local surveillance and reporting information
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 4.6 The DHDSP and other CDC units, should explore methods to develop and implement data- gathering strategies that will allow for more accurate assessment and tracking of specific foods that are important contributors to dietary sodium intake by the American people. Improved systems for measuring or estimating sodium content in food are designed and implemented Availability of dataon specific foods that are important contributors to dietary sodium intake by the American people Data on high-sodium- containing foods are tracked and used to develop strategies for reduction Percent of high content sodium products that have reduced their sodium content 4.7 The DHDSP and other CDC units should explore methods to develop and implement data- gathering strategies that will allow for more accurate assessment and the tracking of population-level dietary sodium and potassium intake including the monitoring of 24-hour urinary sodium and potassium excretion. Improved systems for measuring or estimating dietary sodium and potassium intake are designed and implemented Availability of mean population dietary sodium and potassium intake at the national, state, and local levels Data on dietary sodium consumption are available and used to target dietary sodium reduction programs Reduction in mean dietary sodium intake
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension System Change Recommendations Directed at Individuals with Hypertension Recommendations to Improve the Quality of Care Provided to Individuals with Hypertension Priority Recommendation Short-Term Outcomes(or process input or outputs) Short-Term Indicator Intermediate Outcomes Intermediate Indicators 5.1 The DHDSP should give high priority to conducting research to better understand the reasons behind poor physician adherence to current JNC guidelines. Once these factors are better understood, strategies should be developed to increase the likelihood that primary providers will screen for and treat hypertension appropriately, especially in elderly patients. Better understanding of reasons behind poor physician adherence to JNC guidelines Proportion of providers who measure and classify blood pressure according to JNC guidelines Improved rates of diagnosed, treated, and controlled patients, especially systolic blood pressure control among the elderly Proportion of individuals with hypertension who have achieved blood pressure control Targeted strategies to improve provider awareness, understanding, acceptance, and adherence to JNC treatment guidelines Proportion of providers who follow JNC pharmacologic therapies for treatment of hypertension
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 5.2 The DHDSP should work with The Joint Commission and the health care quality community to improve provider performance on measures focused on assessing adherence to guidelines for screening for hypertension, the development of a hypertension disease management plan that is consistent with JNC guidelines, and achievement of blood pressure control. Partnerships with health care quality community focused on improving provider performance on quality measure for hypertension Proportion of patients who receive provider-initiated prescription and follow-up of therapeutic lifestyle modifications Improvements in state- or local-level provider performance in quality measures associated with blood pressure treatment and control Proportion of older individuals with systolic hypertension who receive appropriate treatment Proportion of patients with uncontrolled high blood pressure who have documented provider initiated change in pharmaceutical intervention 6.5 SLHJs should serve as conveners of health care system representatives, physician groups, purchasers of health care services, quality improvement organizations, and employers (and others) to develop a plan to engage and leverage skills and resources for improving the medical treatment of hypertension Development of local- level partnerships between SLHJs and health care representatives, physician groups, purchasers of health care services, quality improvement organizations, and employers around hypertension prevention and control Development of local collaborative plans to address hypertension prevention, control, and treatment Improvement in state reported diagnosis, treatment, and control rates
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Recommendations to Remove Economic Barriers to Effective Antihypertensive Medications Priority Recommendation Short-Term Outcomes(or process input or outputs) Short-Term Indicator Intermediate Outcomes Intermediate Indicators 5.3 The DHDSP should encourage the Centers for Medicare & Medicaid Services to recommend the elimination or reduction of deductibles for antihypertensive medications among plans participating under Medicare Part D, and work with state Medicaid programs and encourage them to eliminate deductibles and copayments for antihypertensive medications. The DHDSP should work with the pharmaceutical industry and its trade organizations to standardize and simplify applications for patient assistance programs that provide reduced-cost or free antihypertensive medications for low-income, underinsured, or uninsured individuals. Reduced cost for effective antihypertensive medication, especially among the poor, elderly, and those without health insurance coverage Out-of-pocket costs for antihypertensive medications by insurance and economic status Improved adherence to antihypertensive medications especially in the poor, elderly, and those without health insurance coverage Prevalence of controlled hypertension, especially in the poor, elderly, and those without health insurance coverage Improved hypertension control, especially in the poor, elderly, and those without health insurance coverage Proportion of patients who adhere to antihypertensive medication regimens Degree of disparity in blood pressure control between general and priority populations
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 5.4 The DHDSP should collaborate with leaders in the business community to educate them about the impact of reduced patient costs on antihypertensive medication adherence and work with them to encourage employers to leverage their health care purchasing power to advocate for reduced deductibles and copayments for antihypertensive medications in their health insurance benefits packages. Partnerships between the DHDSP and business community focused on reducing out-of-pocket costs for antihypertensive medications Out-of-pocket costs for antihypertensive medications for worksite employees Improved adherence to antihypertensive medications among employees Proportion of employees who adhere to antihypertensive medication regimens Degree of disparity in blood pressure control between general and priority employee populations 6.6 SLHJs should work with business coalitions and purchasing coalitions to remove economic barriers to effective antihypertensive medications for individuals who have difficulty accessing them. Partnerships between SLHJs and business community focused on reducing out- of-pocket costs for antihypertensive medications
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Recommendations to Provide Community Support for Individuals with Hypertension Priority Recommendation Short-Term Outcomes(or process input or outputs) Short-Term Indicator Intermediate Outcomes Intermediate Indicators 5.5 The DHDSP should work with state partners to leverage opportunities to ensure that existing community health worker programs include a focus on the prevention and control of hypertension. In the absence of such programs, the DHDSP should work with state partners to develop programs of community health workers who would be deployed in high-risk communities to help support healthy living strategies that include a focus on hypertension. Design and implementation of new or enhanced community health worker programs targeting hypertension control Budget allocated to development or enhancement of community health worker programs Improved hypertension control in communities served by community health worker programs Prevalence of uncontrolled hypertension in communities served by community health workers Number of community health worker programs targeting hypertension Degree of reduction in disparities in blood pressure control between general population and populations served by community health workers 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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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension combination of these two elements or drivers of hypertension potentially increases the likelihood that standard public health interventions may increase 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 community 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. Prevalence, 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 pressure 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 19-64) in the UK general population in 2008, based on analysis of dietary sodium in 24 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 department 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 disease: 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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