Nikkil Sudharsanan1, Michaela Theilmann1, Tabea K Kirschbaum1, Jennifer Manne-Goehler2, Sina Azadnajafabad3, Pascal Bovet4, Simiao Chen1, Albertino Damasceno5, Jan-Walter De Neve1, Maria Dorobantu6, Cara Ebert7, Farshad Farzadfar3, Gladwell Gathecha8, Mongal Singh Gurung9, Kosar Jamshidi3, Jutta M A Jørgensen10, Demetre Labadarios11, Julia Lemp1, Nuno Lunet12, Joseph K Mwangi13, Sahar Saeedi Moghaddam3, Silver K Bahendeka14, Zhaxybay Zhumadilov15, Till Bärnighausen1, Sebastian Vollmer16, Rifat Atun17, Justine I Davies18, Pascal Geldsetzer19. 1. Heidelberg Institute of Global Health, Heidelberg University, Germany (N.S., M.T., T.K.K., S.C., J.-W.D.N., J.L., T.B.). 2. Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston (J.M.-G.). 3. Tehran University of Medical Sciences, Iran (S.A., F.F., K.J., S.S.M.). 4. Institute of Social and Preventive Medicine, Bern, Switzerland (P.B.). 5. Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.). 6. Cardiology Department, Emergency Hospital of Bucharest, Romania (M.D.). 7. RWI-Leibniz Institute for Economic Research, Essen, Germany (C.E.). 8. Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya (G.G.). 9. Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan (M.S.G.). 10. D-Tree International, Norwell, MA (J.M.A.J.). 11. Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa (D.L.). 12. Department of Public and Forensic Health Sciences and Medical Education, Faculty of Medicine, University of Porto, Portugal (N.L.). 13. Department of Strategic National Public Health Programs, Ministry of Health, Nairobi, Kenya (J.K.M.). 14. Saint Francis Hospital, Kampala, Uganda (S.K.B.). 15. National Laboratory Astana, University Medical Centre, Nazarbayev University, Kazakhstan (Z.Z.). 16. Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Germany (S.V.). 17. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (R.A.). 18. Institute of Applied Health Research, University of Birmingham, United Kingdom (J.I.D.). 19. Division of Primary Care and Population Health, Department of Medicine, Stanford University, CA (P.G.).
Abstract
BACKGROUND: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries. METHODS: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline. RESULTS: The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest. CONCLUSIONS: There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.
BACKGROUND: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries. METHODS: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline. RESULTS: The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest. CONCLUSIONS: There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.
Entities:
Keywords:
health policy; hypertension; therapeutics
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