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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population Board on Population Health and Public Health Practice INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2005-13434, TO 18 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population. A population-based policy and systems change approach to prevent and control hypertension / Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Board on Population Health and Public Health Practice. p. ; cm. Includes bibliographical references. ISBN 978-0-309-14809-2 (pbk.) — ISBN 978-0-309-14810-8 (pdf) 1. Hypertension—Prevention—Government policy—United States. 2. Centers for Disease Control and Prevention (U.S.) Division for Heart Disease and Stroke Prevention. I. Title. [DNLM: 1. Centers for Disease Control and Prevention (U.S.) Division for Heart Disease and Stroke Prevention. 2. Hypertension—prevention & control—United States. 3. Community Health Planning—United States. 4. Health Policy—United States. 5. United States Government Agencies—United States. WG 340 N279907p 2010] RA645.H9N38 2010 362.196’132—dc22 2010014536 Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academies Press.
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension COMMITTEE ON PUBLIC HEALTH PRIORITIES TO REDUCE AND CONTROL HYPERTENSION IN THE U.S. POPULATION DAVID W. FLEMING (Chair, March 2009-February 2010), Director and Health Officer, Public Health-Seattle & King County, Seattle, WA HOWARD KOH (Chair, January-March 2009), Professor of the Practice of Public Health, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA ANA V. DIEZ ROUX, Professor of Epidemiology and Director, Center for Integrative Approaches to Health Disparities, and Associate Director, Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI JIANG HE, Joseph S. Copes Chair and Professor, Department of Epidemiology, Tulane University, New Orleans, LA KATHY HEBERT, Associate Professor of Medicine, Division of Cardiology and Director, Disease Management and Outcomes Research, Miller School of Medicine, University of Miami, Miami, FL CORINNE HUSTEN, Executive Vice President for Program and Policy, Partnership for Prevention (January-October 2009) and Senior Medical Advisor, Center for Tobacco Products, Food and Drug Administration (October 2009-February 2010), Washington DC SHERMAN A. JAMES, Susan B. King Professor of Public Policy Studies, Professor of Family and Community Medicine, Sociology and African and African-American Studies, Duke University, Durham, NC THOMAS G. PICKERING (deceased), Director of the Behavior Cardiovascular Health and Hypertension Program, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY GEOFFRY ROSENTHAL, Department of Pediatrics, Cardiology Division, University of Maryland Medical Center, Baltimore, MD WALTER C. WILLETT, Fredrick John Stare Professor of Epidemiology and Nutrition, Chair, Department of Nutrition, Harvard School of Public Health, Boston, MA IOM Staff ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice RITA DENG, Associate Program Officer NORA HENNESSY, Associate Program Officer RAINA SHARMA, Senior Program Assistant FLORENCE POILLON, Senior Editor
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of the report: Lawrence J. Appel, Johns Hopkins Bloomberg School of Public Health Valentin Fuster, Mount Sinai School of Medicine Maxine Hayes, State of Washington, Department of Health Christine Johnson, New York City Department of Health and Mental Hygiene Michael Klag, Johns Hopkins Bloomberg School of Public Health M.A. “Tonette” Krousel-Wood, Tulane University Claude Lenfant, National Heart, Lung, and Blood Institute Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Kristine M. Gebbie,
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension City University of New York. Appointed by the National Research Council and the Institute of Medicine, she was responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests with the author committee and the institution.
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Acknowledgements The committee acknowledges the valuable contributions made by the many persons who shared their experience and knowledge with the committee. First the committee wishes to thank Howard Koh, who chaired the committee before assuming responsibility as Assistant Secretary for Health. The committee appreciates the time and insight of the presenters during the public sessions: Kathryn Gallagher, Yuling Hong, Darwin Labarthe, and Michael Schooley, Centers for Disease Control and Prevention; Aram Chobanian, Boston University; Eduardo Ortiz, National Heart, Lung, and Blood Institute; Ed Rocella, retired National Heart, Lung, and Blood Institute; Sonia Angell, New York City Department of Health and Mental Hygiene; Susan Cooper, Tennessee Department of Health; Barry Davis, University of Texas School of Public Health; Richard Cooper, Loyola University; Russell Luepker, University of Minnesota; Stephen Lim, University of Washington; David Goff, Wake Forest University; and Frank Sacks, Harvard University. The committee also thanks John Forman, Brigham and Women’s Hospital, for the background paper on modifiable risk factors and population attributable fractions that informed the committee’s deliberations. This report would not have been possible without the diligent assistance of technical monitors Diane Dunet and Rashon Lane, and statistician Cathleen Gillespie, Centers for Disease Control and Prevention. The committee thanks the staff members of the Institute of Medicine, the National Research Council, and the National Academies Press who contributed to the development, production, and dissemination of this report. The com-
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension mittee thanks Rose Marie Martinez, study director, Rita Deng, associate program officer, and Nora Hennessy, associate program officer, for their work in navigating this complex topic with the committee, Raina Sharma for her diligent management of the committee logistics, and Hope Hare for her attention to report production. This report was made possible by the support of the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention.
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension Contents SUMMARY 1 The Charge to the Committee, 2 Findings and Recommendations, 4 References, 29 1 INTRODUCTION 33 CDC Efforts to Reduce and Control Hypertension, 36 Study Process, 39 Study Approach, 40 References, 46 2 PUBLIC HEALTH IMPORTANCE OF HYPERTENSION 49 Prevalence of Hypertension in the U.S. Population, 50 International Comparison, 60 Awareness, Treatment, and Control of Hypertension in the Community, 60 Hypertension Data Quality and Monitoring Concerns, 63 Trends in Associated Risk Factors, 68 Recommendations, 70 References, 71
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 3 THE ROLE OF THE DIVISION FOR HEART DISEASE AND STROKE PREVENTION IN THE PREVENTION AND CONTROL OF HYPERTENSION 75 Programmatic Funding, 76 National Heart Disease and Stroke Prevention Program, 76 Wisewoman (Well-Integrated Screening and Evaluation for Women Across the Nation), 79 The Paul Coverdell National Acute Stroke Registry, 80 State Cardiovascular Health Examination Survey, 81 Activities to Reduce Sodium Intake, 81 Other Programmatic Activities, 82 Division for Heart Disease and Stroke Prevention Strategic Plan, 87 DHDSP Collaboration with Other CDC Units, 87 References, 90 4 INTERVENTIONS DIRECTED AT THE GENERAL POPULATION 91 Methodology, 92 Promote Weight Loss Among Overweight Persons, 93 Decrease Sodium Intake, 95 Increase Potassium and Intake of Fruits and Vegetables, 99 Consume a Healthy Diet, 102 Reduce Excessive Alcohol Intake, 105 Increase Physical Activity, 107 Multiple Dietary Interventions, 108 Other Potential Interventions, 110 Community and Environmental Interventions, 112 Relative Costs of Population-Based Interventions, 117 Population-Based Interventions and Health Disparities, 119 Conclusions, 122 References, 126 5 INTERVENTIONS DIRECTED AT INDIVIDUALS WITH HYPERTENSION 135 Access to Care and Control of Hypertension, 135 Employer Initiatives to Address Hypertension, 159 Community Health Workers and Hypertension, 161 Conclusions, 163 References, 167
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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 175 Recommendations for State and Local Health Jurisdictions, 177 Resources for Hypertension Prevention and Control, 182 Ensuring System Accountability, 184 Hypertension as a Sentinel for Success of the Public Health System in Reducing Health Disparities, 185 References, 197 APPENDIXES A Committee Member Biographies 199 B Agendas of Public Meetings Held by the Committee on Public Health Priorities to Reduce and Control Hypertension 203 C A Public Health Action Plan to Prevent Heart Disease and Stroke 209 D DHDSP Strategic Plan 215 TABLES AND FIGURES Tables S-1 Healthy People 2010 Focus Area 12: Heart and Stroke, Blood Pressure Objectives, 3 S-2 Priority Recommendations, 18 1-1 Healthy People 2010 Focus Area 12: Heart and Stroke, Blood Pressure Objectives, 37 1-2 Criteria Considered for Selecting Priority Areas for the Prevention and Control of Hypertension, 43 2-1 Age-Specific Prevalence (Standard Error) of Hypertension in the U.S. Adult Population: NHANES 1999-2004, 51 2-2 Prevalence (Standard Error) of Elevated Blood Pressure Among Children and Adolescents Ages 8 Through 17 Years: NHANES 2003-2006, 53 2-3 Hypertension Awareness, Treatment, and Control in the U.S. Adult Hypertensive Population: NHANES 1988-1994 and NHANES 1999-2004, 62 2-4 Median and Mean Systolic and Diastolic Blood Pressure and Prevalence of Hypertension for Adults and Children Based on First Blood Pressure Measurement—NHANES Data, 65
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 2-5 Prevalence of Hypertension (averaged measures), Overweight, Obesity, and Average Intake of Dietary Sodium per 1,000 Adults 1960-2006, 69 3-1 DHDSP Administrative and Program Budgets (FY 2008), 76 3-2 CDC Units or Programs, Funding and Program Description, 88 4-1 Risk Factor: Overweight and Obesity, 94 4-2 Risk Factor: High Salt Intake, 96 4-3 Risk Factor: Low Potassium Intake, 100 4-4 Risk Factor: Western-Style (Unhealthy Diet), 104 4-5 Risk Factor: Heavy Alcohol Intake, 106 4-6 Risk Factors: Physical Inactivity, 109 4-7 Risk Factors: Multiple Interventions, 111 4-8 Modifiable Risk Factors and Attributable Fractions Based on Interventional Studies, 111 5-1 Proportion of Cases of Uncontrolled Hypertension in Each Population Subgroup Attributable to Identified Risk Factors, 140 5-2 HEDIS® and Physician Consortium for Performance Improvement Hypertension Measures, 150 6-1 Priority Recommendations, 186 Figures 1-1 Increased risk of death from heart disease associated with blood pressure by decade of life, 35 1-2 Increased risk of death from stroke associated with blood pressure by decade of life, 35 1-3 Schematic framework of factors affecting blood pressure, 41 2-1 Age-specific prevalance of hypertension in U.S. adults ages 60 and older for men and women, NHANES: 1988-1994 and NHANES 1999-2004, 56 2-2 Prevalence of elevated blood pressure among children and adolescents ages 8 through 17 years: United States, NHANES: 1988-1994, 1999-2002, and 2003-2006, 57 2-3 Residual lifetime risk of hypertension in women and men aged 65 years, 60 2-4 Age- and sex-adjusted mean systolic blood pressure (upper panel) and diastolic blood pressure (lower panel) by race or ethnicity in adults ages 20 years or older: United States, NHANES: 1971-1975, 1976-1980, 1988-1994, 1999-2002, and 2003-2006, 66
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A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension 2-5 Age- and sex-adjusted mean systolic blood pressure and diastolic blood pressure by race or ethnicity in children ages 8-17 years, 67 2-6 Secular trends in hypertension, overweight, obesity and sodium intake in the United States, 70 3-1 Overall logic model for strategies and interventions to reduce high blood pressure (HBP), 78 3-2 Progress quotient chart for Healthy People 2010 Focus Area 12: Heart Disease and Stroke, 84 5-1 The proportion of patients over a 24-month period that was not diagnosed with hypertension, separated by average diastolic and systolic blood pressure, 142 5-2 The diastolic and systolic blood pressure ranges at which physicians would start drug treatment in patients with uncomplicated hypertension, 143 5-3 The systolic (A) and diastolic (B) blood pressures of 72 patients with no initiation or change in antihypertensive medication, 147 5-4 Frequency and distribution of untreated hypertensive individuals by age and hypertension subtype, 148
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