Department of Nutrition, Gillings School of Global Public Health & School of Medicine, University of North Carolina at Chapel Hill, USA.
Carolina Population Center, UNC-Chapel Hill, USA.
Am J Hypertens. 2017 Dec 8;31(1):63-71. doi: 10.1093/ajh/hpx137.
It is unknown whether efforts to reduce hypertension burden in countries with very high prevalence, would be more effective if directed at hypertension diagnosis vs. treatment. Most analyses do not address bias and correlation across the sequence from elevated blood pressure (BP) to hypertension diagnosis and treatment, leading to potentially misleading findings.
Using data spanning 18 years of the China Health and Nutrition Survey (n = 18,926; ages 18-75 years), we used an innovative 3-step, integrated system of equations to predict the sequence from: (i) elevated BP (systolic/diastolic BP ≥ 140/90 mm Hg) to (ii) diagnosed hypertension conditional on elevated BP, and to (iii) treatment (medication use) conditional on diagnosis, accounting for measured and unmeasured individual- and community-level confounders at each of the 3 steps. We compared results to separate traditional logistic regression models without control for unmeasured confounding.
Using our 3-step model, elevated BP increased from 12.6% and 8.5% (1991) to 36.8% and 29% (2009) in men and women, respectively, but diagnosis remained under 50%. We found widening disparities in hypertension diagnosis (higher hypertension at lower vs. higher education (difference of 2% in 1991 that widened to 5% in 2009)) and narrowing disparities in education (difference of 6% in 1991 to 4% in 2009) and insurance status (difference of 7% in 1991 to 2% in 2009) for treatment.
Our 3-step model improved model fit over traditionally used models. Our findings highlight serious barriers to hypertension diagnosis in Chinese adults, particularly among men and individuals of low attained education.
在高血压患病率极高的国家，降低高血压负担的努力如果针对高血压诊断而不是治疗，是否会更有效，目前尚不清楚。大多数分析并未解决从血压升高（BP）到高血压诊断和治疗的序列中存在的偏倚和相关性，这可能导致有误导性的发现。
利用中国健康与营养调查（n=18926；年龄 18-75 岁）18 年的数据，我们使用了一种创新的三步骤综合方程组方法，来预测从以下序列：（i）血压升高（收缩压/舒张压≥140/90mmHg）到（ii）在血压升高的情况下诊断出高血压，以及（iii）在诊断出高血压的情况下进行治疗（使用药物），该方法考虑了每一步的个体和社区层面的可测量和不可测量的混杂因素。我们将结果与不控制不可测量混杂因素的单独传统逻辑回归模型进行了比较。
使用我们的三步骤模型，男性和女性的血压升高率分别从 1991 年的 12.6%和 8.5%上升到 2009 年的 36.8%和 29%，但诊断率仍低于 50%。我们发现高血压诊断方面的差距不断扩大（较低教育水平的高血压发生率高于较高教育水平的高血压发生率，差异从 1991 年的 2%扩大到 2009 年的 5%），而在教育程度（1991 年的差异为 6%，2009 年的差异为 4%）和保险状况（1991 年的差异为 7%，2009 年的差异为 2%）方面，治疗的差距在缩小。
我们的三步骤模型比传统使用的模型提高了模型拟合度。我们的研究结果强调了中国成年人高血压诊断方面存在严重障碍，特别是在男性和受教育程度较低的人群中。
