Hypertension and its effects on the economy of the health system for patients and society: suggestions for developing countries

Association of work and hypertension among middle-aged adults and elderly Indians

PURPOSE

Over two-fifth of middle-aged adults and elderly (45 +) in India are hypertensive. Though studies examined prevalence, awareness and control of hypertension, little is known on the association of hypertension with work status in India. This study examines the variations of hypertension by types of work among middle-aged adults and the elderly in India.

METHODS

Data were drawn from the Longitudinal Aging Survey of India (LASI), Wave 1, 2017-18, and analysis was restricted to participants aged 45 and above with complete information on employment and blood pressure (N = 59,196).

RESULTS

We estimated the adjusted prevalence of hypertension at 49.2% (95% CI, 47.8-50.6) among the ever worked but not currently working and 44.5% (95% CI, 43.1-45.8) among currently working. Among eight broad categories of the currently working population, the adjusted estimates of hypertension were highest among legislators, senior officials and managers (71.5%; 95% CI, 41.9-101.0), followed by service and sales worker workers (44.7%; 95% CI, 41.2-48.2) and least among the professionals (37.1%; 95% CI, 27.1-47.2). Relative to never worked, legislators, senior officials and managers were twice more likely [adjusted OR (AOR) 2.00; 95% CI, 0.74-5.39] to be hypertensive, followed by plant and machine operators (AOR 1.33; 95% CI, 1.04-1.71). The odds of being hypertensive was least among those engaged in professional (engineering, health, education) activities. The other significant predictors are age, sex, residence, education level, household economic condition, family history of hypertension, chronic disease and depression.

CONCLUSION

The risk of hypertension varies with the types of work in which older Indians are engaged. Awareness and treatment of hypertension in high-risk occupation are recommended.

Understanding adherence of hypertensive patients in Mexico to an exercise-referral scheme for increasing physical activity

Among the strategies developed thus far for promoting physical activity (PA), exercise-referral schemes (ERs) have gained in popularity as an effective means of preventing secondary health conditions such as hypertension. However, information on the factors affecting adherence to these programs is limited. Using a mixed-methods approach, we undertook the present study to determine the factors associated with adherence to a specific ER aimed at increasing PA among the hypertensive patients in a Social Security institution in Mexico. Data were obtained through semi-structured questionnaires and interviews as well as from the clinical records of participants. For the quantitative component, multinomial regression analysis estimated the factors behind the varying levels of adherence. For the qualitative component, we performed a content analysis based on the health belief model. According to our findings, 80% of participants who began the ER exhibited high levels of adherence. Older age and being female were the key demographic characteristics of those showing increased adherence. Meanwhile, financial issues, the investment of time required, low perception of the benefits of PA, lack of confidence in being able to achieve changes in lifestyle, and a reluctance to acknowledge the seriousness of their health condition were the principal factors among those who did not join the program or exhibited low levels of adherence. Our findings can serve as a basis for designing PA interventions that take into account individual, cultural and administrative elements in their efforts to improve adherence to PA programs for those suffering from chronic conditions such as hypertension.

Recent trends for the management of hypertension in older adults in Latin America in the context of universal coverage: Evidence from Mexico

Taking the Mexican case as a tracer of what is happening in Latin America on public health, we estimate the recent changes and challenges for the management of hypertension in older adults in the context of universal health coverage. The population base was 200, and 308 reported cases of older adults with hypertension. The cost-evaluation method used was based on the instrumentation and consensus technique. Regarding epidemiological changes for 2016 versus 2018, there is an increase of 21% (CI: 95%, p < 0.001). Comparing the economic impact in 2016 versus 2018 (CI: 95%, p < 0.001), the increase is 33%. The total amount estimated for hypertension in 2018 (in US dollars) was $ 1,896,520,273. It includes $ 898,064,979 as direct costs and $ 998,455,294 as indirect costs. The recent trends show that the financial requirements for the coming years do not guarantee the effectiveness of the coverage rates required for the elderly. In terms of catastrophic expenditure, the challenge is not minor, the greatest economic burden is for the pocket of patients and their families.

Effectiveness of Levoamlodipine Maleate for Hypertension Compared with Amlodipine Besylate: a Pragmatic Comparative Effectiveness Study

PURPOSE

Antihypertensive treatment is the most important method to reduce the risk of cardiovascular events in hypertensive patients. However, there is scant evidence of the benefits of levoamlodipine maleate for antihypertensive treatment using a head-to-head comparison in the real-world. This study aims to examine the effectiveness of levoamlodipine maleate used to treat outpatients with primary hypertension compared with amlodipine besylate in a real-world setting.

METHODS

This was a pragmatic comparative effectiveness study carried out at 110 centers across China in outpatients with primary hypertension treated with levoamlodipine maleate or amlodipine besylate, with 24 months of follow-up. The primary outcomes used for evaluating the effectiveness were composite major cardiovascular and cerebrovascular events (MACCE), adverse reactions, and cost-effectiveness.

RESULTS

Among the included 10,031 patients, there were 482 MACCE, 223 (4.4%) in the levoamlodipine maleate group (n = 5018) and 259 (5.2%) in the amlodipine besylate group (n = 5013) (adjusted hazard ratio = 0.90, 95%CI: 0.75-1.08, P = 0.252). The levoamlodipine maleate group had lower overall incidences of any adverse reactions (6.0% vs. 8.4%, P < 0.001), lower extremity edema (1.1% vs. 3.0%, P < 0.001) and headache (0.7% vs. 1.1%, P = 0.045). There was a nearly 100% chance of the levoamlodipine maleate being cost-effective at a willingness to pay threshold of 150,000 Yuan per quality-adjusted life years (QALYs) gained, resulting in more QALYs (incremental QALYs: 0.00392) and cost savings (saving 2725 Yuan or 28.8% reduction in overall costs) per patient.

CONCLUSION

In conclusion, levoamlodipine maleate could reduce cost by 29% with a similar MACCE incidence rate and lower occurrence of adverse reactions (especially edema and headache) compared with amlodipine besylate.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01844570 registered at May 1, 2013.

The global epidemiology of hypertension

Hypertension is the leading cause of cardiovascular disease and premature death worldwide. Owing to the widespread use of antihypertensive medications, global mean blood pressure (BP) has remained constant or has decreased slightly over the past four decades. By contrast, the prevalence of hypertension has increased, especially in low- and middle-income countries (LMICs). Estimates suggest that 31.1% of adults (1.39 billion) worldwide had hypertension in 2010. The prevalence of hypertension among adults was higher in LMICs (31.5%, 1.04 billion people) than in high-income countries (28.5%, 349 million people). Variations in the levels of risk factors for hypertension, such as high sodium intake, low potassium intake, obesity, alcohol consumption, physical inactivity and unhealthy diet, may explain some of the regional heterogeneity in hypertension prevalence. Despite the increasing prevalence, the proportions of hypertension awareness, treatment and BP control are low, particularly in LMICs, and few comprehensive assessments of the economic impact of hypertension exist. Future studies are warranted to test implementation strategies for hypertension prevention and control, especially in low-income populations, and to accurately assess the prevalence and financial burden of hypertension worldwide.

Identifying critical windows of prenatal particulate matter (PM2.5) exposure and early childhood blood pressure

BACKGROUND

Exposure to air pollution is associated with increased blood pressure (BP) in adults and children. Some evidence suggests that air pollution exposure during the prenatal period may contribute to adverse cardiorenal health later in life. Here we apply a distributed lag model (DLM) approach to identify critical windows that may underlie the association between prenatal particulate matter ≤ 2.5 μm in diameter (PM_2.5) exposure and children's BP at ages 4-6 years.

METHODS

Participants included 537 mother-child dyads enrolled in the Programming Research in Obesity, GRowth Environment, and Social Stress (PROGRESS) longitudinal birth cohort study based in Mexico City. Prenatal daily PM_2.5 exposure was estimated using a validated satellite-based spatio-temporal model and BP was measured using the automated Spacelabs system with a sized cuff. We used distributed lag models (DLMs) to examine associations between daily PM_2.5 exposure and systolic and diastolic BP (SBP and DBP), adjusting for child's age, sex and BMI, as well as maternal education, preeclampsia and indoor smoking report during the second and third trimester, seasonality and average postnatal year 1 PM_2.5 exposure.

RESULTS

We found that PM_2.5 exposure between weeks 11-32 of gestation (days 80-226) was significantly associated with children's increased SBP. Similarly, PM_2.5 exposure between weeks 9-25 of gestation (days 63-176) was significantly associated with increased DBP. To place this into context, a constant 10 μg/m³ increase in PM_2.5 sustained throughout this critical window would predict a cumulative increase of 2.6 mmHg (CI: 0.5, 4.6) in SBP and 0.88 mmHg (CI: 0.1, 1.6) in DBP at ages 4-6 years. In a stratified analysis by sex, this association persisted in boys but not in girls.

CONCLUSIONS

Second and third trimester PM_2.5 exposure may increase children's BP in early life. Further work investigating PM_2.5 exposure with BP trajectories later in childhood will be important to understanding cardiorenal trajectories that may predict adult disease. Our results underscore the importance of reducing air pollution exposure among susceptible populations, including pregnant women.

[Adaptation and validation of the SMP-T2D questionnaire in Spanish for evaluating self-management of high blood pressure and type 2 diabetes: PAG-DT2+HTA]

BACKGROUND

High blood pressure is one of the most common chronic conditions worldwide. It affects one in every 3 adults over 40, while one in 10 suffers from diabetes. For both diseases, adherence to pharmacological treatment is over 30%, and self-management, which takes into account diet and physical activity, is still unknown, as there is no tool available to measure self-management. Therefore, the object of this study was to adapt and validate the Spanish version of the self-management profile for type 2 diabetes (SMP-T2D) questionnaire in patients with type 2 diabetes and high blood pressure among users of first level care in the social security institution of Mexico.

METHODS

The SMP-T2D was adapted to Spanish by translation into Spanish, and being used only in patients with high blood pressure and type 2 diabetes-hypertension. A convergent and discriminatory validation was performed. Patients over 50 years old with high blood pressure were include. Those that did not complete the questionnaire or give informed consent were rejected.

RESULTS

The Spanish version of the SMP-T2D was called PAG-DT2+HTA, and was applied to 145 people with hypertension: 54.4% with hypertension only, and 43.6% with hypertension and type 2 diabetes. Mean age was 66.14 years (SD=10.78), with 34.7% women and 65.3% men. Internal consistency by α-Cronbach for the questionnaire was 0.561 (P=.000). The correlation between the PAG-DT2+HTA and Morisky-Green was significant. The ability to discriminate between people with and without education and with and without economic means was obtained.

CONCLUSION

The Spanish version of SMP-T2D (PAG-DT2+HTA) that measures self-management in type 2 diabetes, can be used to measure self-management in people with type 2 diabetes-hypertension.

Epidemiological and financial indicators of hypertension in older adults in Mexico: challenges for health planning and management in Latin America

This study estimated the epidemiological and financial indicators of hypertension in order to identify challenges in strategic planning and management for health systems in Latin America. This is a longitudinal study with a population base of 187 326 reported cases of older adults with hypertension, diagnosed at public health institutions in Mexico. The cost-evaluation method that was used was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2015-2017, time series analyses and probabilistic models were constructed according to the Box-Jenkins technique. Regarding epidemiological changes for 2015 versus 2017, an increase of 8-12% is expected (p < 0.001). Comparing the economic impact in 2015 versus 2017 (p < 0.001), there is a 22% increase in financial requirements. The total amount estimated for hypertension in 2015 (in US dollars) was $1 575 671 330. It included $747 527 259 as direct costs and $829 144 071 as indirect costs. If the risk factors and the different healthcare services for older adults remain as they are currently, the financial consequences of epidemiological changes in older adults will have a major impact on the users' pockets, following in order of importance, on social security providers and on public assistance providers. The challenges and implications of our findings in the context of universal coverage reforms in Latin America reinforce the urgent need to develop more and better strategic planning for the prevention of chronic diseases. Copyright © 2016 John Wiley & Sons, Ltd.

Challenges of the epidemiological and economic burdens associated with hypertension in middle income countries: evidence from Mexico

BACKGROUND

In order to identify the challenges resulting from hypertension in a middle income country, this study has developed probabilistic models to determine the epidemiological and economic burden of hypertension in Mexico.

METHODS

Considering a population base of 654,701 reported cases of adults with hypertension, we conducted a longitudinal analyses in order to identify the challenges of epidemiological changes and health care costs for hypertension in the Mexican health system. The cost-evaluation method used was based on the instrumentation technique. To estimate the epidemiological changes for 2015-2017, probabilistic models were constructed according to the Box-Jenkins technique.

RESULTS

Regarding changes in expected cases for 2015 vs. 2017, an increase of 12 % is expected (p < 0.001). Comparing the economic impact in 2015 versus 2017 (p < 0.001), there is a 23 % increase in financial requirements. The total amount for hypertension in 2016 (US dollars) will be $6306,685,320 Of these, $ 2990,109,035 will be as direct costs and $ 3316,576,285 as indirect costs.

CONCLUSIONS

If the risk factors and care models remain as they are currently in the health system, the financial consequences will have a major impact on the out-of-pocket users, following in order of importance, on social security providers and on public assistance providers.

An internet-based self-administered intervention for promoting healthy habits and weight loss in hypertensive people who are overweight or obese: a randomized controlled trial

BACKGROUND

The prevalence of overweight and obesity is on the rise worldwide with severe physical and psychosocial consequences. One of the most dangerous is hypertension. Lifestyle changes related to eating behaviour and physical activity are the critical components in the prevention and treatment of hypertension and obesity. Data indicates that the usual procedures to promote these healthy habits in health services are either insufficient or not efficient enough. Internet has been shown to be an effective tool for the implementation of lifestyle interventions based on this type of problem. This study aims to assess the efficacy of a totally self-administered online intervention programme versus the usual medical care for obese and overweight participants with hypertension (from the Spanish public health care system) to promote healthy lifestyles (eating behaviour and physical activity).

METHOD

A randomized controlled trial will be conducted with 100 patients recruited from the hypertension unit of a public hospital. Participants will be randomly assigned to one of two conditions: a) SII: a self-administered Internet-based intervention protocol; and b) MUC-medical usual care. The online intervention is an Internet-delivered, multimedia, interactive, self-administered programme, composed of nine modules designed to promote healthy eating habits and increase physical activity. The first five modules will be activated at a rate of one per week, and access for modules 5 to 9 will open every two weeks. Patients will be assessed at four points: before the intervention, after the intervention (3 months), and at 6 and 12 months (follow-up). The outcome variables will include blood pressure, and Body Mass Index, as primary outcome measures, and quality of life and other lifestyle and anthropometrical variables as secondary outcome measures.

DISCUSSION

The literature highlights the need for more studies on the benefits of using the Internet to promote lifestyle interventions. This study aims to investigate the efficiency of a totally self-administered Internet - +based programme for promoting healthy habits and improving the medical indicators of a hypertensive and overweight population.

TRIAL REGISTRATION

NCT02445833.

Costs and epidemiological changes of chronic diseases: implications and challenges for health systems

BACKGROUND

The need to integrate economic and epidemiological aspects in the clinical perspective leads to a proposal for the analysis of health disparities and to an evaluation of the health services and of the new challenges which are now being faced by health system reforms in middle income countries.

OBJECTIVE

To identify the epidemiological changes, the demand for health services and economic burden from chronic diseases (diabetes and hypertension) in a middle income county.

METHODS

We conducted longitudinal analyses of costs and epidemiological changes for diabetes and hypertension in the Mexican health system. The study population included both the insured and uninsured populations. The cost-evaluation method was used, based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2014-2016, six models were constructed according to the Box-Jenkins technique, using confidence intervals of 95%, and the Box-Pierce test.

RESULTS

Regarding epidemiological changes expected in both diseases for 2014 vs. 2016, an increase is expected, although results predict a greater increase for diabetes, 8-12% in all three studied institutions, (p < .05). Indeed, in the case of diabetes, the increase was 41469 cases for uninsured population (SSA) and 65737 for the insured population (IMSS and ISSSTE). On hypertension cases the increase was 38109 for uninsured vs 62895 for insured. Costs in US$ ranged from $699 to $748 for annual case management per patient in the case of diabetes, and from $485 to $622 in patients with hypertension. Comparing financial consequences of health services required by insured and uninsured populations, the greater increase (23%) will be for the insured population (p < .05). The financial requirements of both diseases will amount to 19.5% of the total budget for the uninsured and 12.5% for the insured population.

CONCLUSIONS

If the risk factors and the different health care models remain as they currently are, the economic impact of expected epidemiological changes on the social security system will be particularly strong. Another relevant challenge is the appearance of internal competition in the use and allocation of financial resources with programs for other chronic and infectious diseases.