The Rising Prevalence of Multiple Chronic Conditions Among US Adults With Hypertension

The National Health and Nutrition Examination Survey (NHANES), initiated in 1960, is a program of the National Center for Health Statistics (NCHS) focused on different population groups and health topics.1 NHANES is responsible for producing vital health statistics to assess the health and nutritional status of adults and children in the United States. The survey combines interviews, physical examinations, and bio-specimen tests of a representative sample of noninstitutionalized civilians from 15 US counties. Medical examinations and laboratory tests follow standardized protocols to ensure comparability across sites and providers. From 1960 to 1994, 7 national examination surveys were conducted. Since 1999, the survey has been administered continuously; however, because of the COVID-19 pandemic, data collection was suspended for over a year but resumed in 2021.2 The NHANES Interview is conducted in the homes of participants and includes demographic, socioeconomic, dietary, and health-related questions. All participants also visit a physician, and the examination component consists of medical, dental, physiological measurements, and laboratory tests. Health measurements are performed in specially equipped mobile examination centers, which travel to chosen locations throughout the country. The study teams consist of physicians, medical and health technicians, and dietary and health interviewers. The sample for the survey is selected to represent the US population of all ages. Different groups, such as low-income persons, teens, older persons, and selected racial/ethnic populations have been over sampled during specific survey cycles to produce reliable statistics.3 In this issue of the American Journal of Hypertension, Muntner et al. estimate changes in the age-adjusted prevalence of multiple (≥3) chronic conditions in US adults using data from NHANES, from 1999–2000 to 2017–2020, among US adults with and without high blood pressure (HBP).4 The authors defined HBP as systolic blood pressure (BP) ≥130 mm Hg, diastolic BP ≥80 mm Hg, or self-reported and antihypertensive medication use. Fourteen common chronic conditions were studied. The authors demonstrated an increase in the number of chronic conditions among US adults with hypertension and concluded that between 2017 and 2020, more than half of US adults with hypertension had ≥3 additional chronic conditions—a substantial increase from 20 years ago. Many US health systems provide comprehensive acute care services to patients with major adverse cardiovascular events (MACE), including well-staffed medical and surgical intensive care units, sophisticated state-of-the-art technologies and procedure rooms for advanced imaging for revascularization interventions, and specialist physicians, nurses, pharmacists, and other healthcare professionals with advanced training. Health system service line executives juggle day-to-day operations, complex supply chains, ever-evolving information technologies, challenging workforce requirements, managed care negotiations, and increasing capital demands while simultaneously maintaining access, decreasing cost, and promoting clinical excellence. Chief Executive Officers and their governing boards prioritize the “strategic” intention of these service lines to achieve substantial future revenue growth through increased market share, as well as gaining a competitive advantage for being recognized as “cutting edge and ahead of the curve.” In contrast, HBP, the dominant risk factor for MACE, results in billions of dollars of waste from reduced worker productivity as well as increased per capita healthcare costs.5,6 Reducing the risk of MACE by controlling HBP, and thereby improving health-related quality of life, can significantly lower healthcare costs. High-quality scientific evidence from large-scale population-based studies published in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA HBP Clinical Practice Guidelines endorsed by 11 multidisciplinary clinical specialty societies (ACC = American College of Cardiology; AHA = American Heart Association; AAPA = American Association of Physician Assistants; ABC = Association of Black Cardiologists; ACPM = American College of Preventive Medicine; AGS = American Geriatrics Society; APhA = American Pharmacists Association; ASPC = American Association for Preventive Cardiologists; ASH = American Society of Hypertension; NMA = National Medical Association; PCNA = Preventive Cardiology Nurses Association) documents the significant BP lowering effects from 6 specific critically important lifestyle modifications: tobacco cessation, regular physical exercise, restriction of dietary sodium, dietary intake of potassium, moderate alcohol consumption and a “healthy heart” diet.7,8 Assessments of Social Determinants of Health (SDoH), Shared Decision Making (SDM) conversations between patients and their physicians, and Team-Based Care (TBC) delivered by nurses, pharmacists, and other health professionals can result in significant improvement in BP control and other health risk reduction targets through effective, evidence-based lifestyle modifications.9 Nevertheless, current data estimate that 122.4 million Americans have HBP, and as few as 30% are adequately controlled to current guideline-based BP targets (i.e., systolic BP less than 130 mm Hg).10,11 BP is most always measured incorrectly, resulting in innumerable inaccurate readings obtained in both healthcare settings and at home.12,13 Inadequately controlled HBP is one of many major unmet public health challenges directly traced to diffuse health system inertia that is at the heart of this matter. No doubt, the healthcare delivery infrastructure and economic resources that support the care of major acute and chronic cardiovascular diseases (CVDs) are vastly different than what is needed to achieve health promotion, maintenance, and prevention necessary to reduce MACE, but it is nonetheless imperative to devote more effort to successful HBP control efforts. We recently asked some health system senior managers, governing board members, and primary care physicians to informally describe the barriers to achieving optimal HBP control. Their comments were remarkably consistent and focused on time and resource constraints, process limitations, and a general lack of urgency regarding HBP as a top organizational priority. Not surprisingly, control of HBP for patients and employees as a key performance indicator on any governance or managerial accountability “dashboards” was severely lacking. The clinicians described control of HBP as “just another metric” within constantly expanding externally imposed quality, cost, and patient experience requirements. Furthermore, understaffed and overworked “primary care” practices do not ensure consistent and accurate BP measurement techniques with validated and certified devices in accordance with standardized guideline-based scientific methods. Increased administrative demands remain overly burdensome, leading to too many “clicks” to manually add accurately obtained home BP readings to the electronic health record and document quality measure requirements. Hypertensive patients, especially those with multiple chronic conditions, often have other pressing concerns, which can lead to deferment of BP control until the next office visit, sometimes delaying needed treatment changes, which further complicates and compromises positive health outcomes. Of course, it is certainly much easier to describe “wicked” problems like control of HBP than to implement cogently clear pathways to solving them. CVDs are the leading causes of death, not only in the United States, but for the entire world.10,14 CVDs, when combined with other adverse HBP-related outcomes (including stroke, chronic kidney disease, and dementia) account for a very large number of often preventable expensive conditions. These new findings from NHANES presented by Muntner et al.4 confirm that additional attention is needed, including the deployment of multidisciplinary TBC designed to achieve adequate control of HBP, while also effectively co-managing other chronic conditions. The stark reality is that the historical decline in CVD mortality among US adults with hypertension has stalled.15,16 Hence, stronger health system accountability must congruently align with insurers, employers, public health, community health safety net organizations, large and small bio-pharmaceutical and device firms, digital health and information technology companies, and governmental health agencies17,18 and that accountability must cascade throughout healthcare provider organizations and appear as an imperative priority on the myriad of dashboards that guide modern healthcare operations. This must especially include data and action that eliminate disparities by aggressively addressing social determinants as root causes of inequities in providing consistent guideline-based BP control treatment, especially to those who need it most.19 The 8 “Blueprint for Change for Adults with HBP” recommendations highlighted in Figure 1 provide a comprehensive evidence-based road map for senior leaders from health systems, payers, clinicians, public health practitioners, and government to work collaboratively to improve guideline-based care delivery for more than 100 million Americans with HBP.20 “Moving the Big Needle” of the improved health status of the US population cannot be glibly relegated only to “primary care,” and now requires a major re-prioritization of both capital and human resource allocation by all of these stakeholders. The Blueprint for Change for Control of High Blood Pressure.20 The authors declared no conflict of interest.