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Figure.  Coverage by Media, Journal Articles, and Press Releases of the Benefits and Harms of the 2017 Expanded Definition of Hypertension
Coverage by Media, Journal Articles, and Press Releases of the Benefits and Harms of the 2017 Expanded Definition of Hypertension

The Figure shows the focus of media stories, journal articles, and press releases.

aThe study did not measure coverage of conflicts of interest for journal articles and press releases.

Table.  Media Coverage of the Expanded Definition of Hypertension: Publication Dates and Secondary Outcomes, November 2017 to July 2018
Media Coverage of the Expanded Definition of Hypertension: Publication Dates and Secondary Outcomes, November 2017 to July 2018
1.
Pathirana  T, Clark  J, Moynihan  R.  Mapping the drivers of overdiagnosis to potential solutions.  BMJ. 2017;358:j3879. doi:10.1136/bmj.j3879PubMedGoogle ScholarCrossref
2.
Whelton  PK, Carey  RM, Aronow  WS,  et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.  Hypertension. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066PubMedGoogle ScholarCrossref
3.
Wilt  TJ, Kansagara  D, Qaseem  A; Clinical Guidelines Committee of the American College of Physicians.  Hypertension limbo: balancing benefits, harms, and patient preferences before we lower the bar on blood pressure.  Ann Intern Med. 2018;168(5):369-370. doi:10.7326/M17-3293PubMedGoogle ScholarCrossref
4.
Bell  KJL, Doust  J, Glasziou  P.  Incremental benefits and harms of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline.  JAMA Intern Med. 2018;178(6):755-757. doi:10.1001/jamainternmed.2018.0310PubMedGoogle ScholarCrossref
5.
Moynihan  R, Bero  L, Ross-Degnan  D,  et al.  Coverage by the news media of the benefits and risks of medications.  N Engl J Med. 2000;342(22):1645-1650. doi:10.1056/NEJM200006013422206PubMedGoogle ScholarCrossref
6.
Doust  J, Vandvik  PO, Qaseem  A,  et al; Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group.  Guidance for modifying the definition of diseases: a checklist.  JAMA Intern Med. 2017;177(7):1020-1025. doi:10.1001/jamainternmed.2017.1302PubMedGoogle ScholarCrossref
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    Research Letter
    December 28, 2018

    Media Coverage of the Benefits and Harms of the 2017 Expanded Definition of High Blood Pressure

    Author Affiliations
    • 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia, 4229
    JAMA Intern Med. 2019;179(2):272-273. doi:10.1001/jamainternmed.2018.6201

    Expanding disease definitions are one driver of overdiagnosis and related overtreatment.1 In November 2017, new guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) expanded the definition of hypertension, extending the label to 46% of adults in the United States.2 The expanded definition was welcomed by some as an important public health initiative; however, other national and international groups, including the American Academy of Family Physicians, did not endorse the expanded definition amid concerns about potential harms.3 Concerns raised included potential overtreatment; intellectual conflicts of interest held by some of the panel members involved with the new ACC/AHA guideline, including members who were connected to a major trial that strongly influenced the guideline; and uncertainty regarding blood pressure measurement methods. A checklist-based analysis found that most people newly classified as hypertensive were unlikely to benefit, but instead could experience harms from being unnecessarily labeled as having hypertension, and some people could experience adverse effects from unnecessary medication.4 We investigated how the media covered the potential benefits and harms of the expanded definition of hypertension.

    Methods

    We conducted a cross-sectional analysis of media coverage of the expanded definition of hypertension between November 1, 2017, and July 13, 2018. Using explicit terms about guidelines and hypertension, we conducted a broad search of English language stories in the ProQuest database. We also searched ProQuest for press releases and PubMed for journal articles responding to the change. Records were independently screened and were included in the study if they covered the new guidelines or responses to them. Records were excluded if they were duplicates, repeats of news stories syndicated across different outlets, or did not cover the guidelines. A coding tool was developed based on previous media analysis5 and tools used by organizations, including Health News Review (http://www.healthnewsreview.org), and it was used independently by 2 of us (R.N.M. and L.A.). Discrepancies in screening and coding were resolved by discussion among all authors. Primary outcomes were the proportion of stories covering the expanded definition’s potential benefits, potential harms, a balance of benefits and harms, and potential conflicts of interest of members of the ACC/AHA panel. Secondary outcomes included the proportion of stories covering specific evidence supporting the changes, changes to prevalence, costs relating to the changes, uncertainty about blood pressure measurement, and any criticism of the new guideline.

    Results

    Our searches produced 2309 stories, 932 press releases, and 102 journal articles. After screening and excluding duplicates, syndicated copies, and material not covering the new guidelines, 100 unique stories, 15 press releases, and 37 journal articles were included in the study (a full list of the news stories, press releases, and journal articles is available from the authors). Media coverage was concentrated immediately after publication of the new guidelines in November 2017, with few stories covering subsequent journal articles responding to the changes (Table). Media coverage was largely positive about the expanded definition of hypertension. Of 100 included stories, 98 (98%; 95% CI, 95%-100%) covered the benefits of the expanded definition, 67 (67%; 95% CI, 58%-76%) did not mention any harms, 73 (73%; 95% CI, 64%-82%) favored benefits overall, and 98 (98%; 95% CI, 95%-100%) did not mention any conflicts of interest (Figure). Press releases similarly favored the benefits of the expanded definition, whereas journal articles had more balance, with only one-third (n = 14) favoring benefits overall (Figure). Results for secondary outcomes are reported in the Table.

    Discussion

    In this sample, most media coverage of the 2017 ACC/AHA expansion of the definition of hypertension did not mention important potential harms and did not cover information emerging from the peer-reviewed literature about conflict and controversy associated with the change among influential medical groups. Study limitations include use of the ProQuest database, which does not provide a comprehensive collection of news stories across all forms of media, and the use of English language records only. Strengths include a novel analysis of media coverage of the expanded definition of hypertension, a sensitive search to minimize missing stories, and supplementation with press releases and journal articles. In light of moves to reform disease definition processes,6 our findings suggest a need to improve media coverage of expanding disease definitions, particularly when those expanding definitions may cause many people harm.

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    Article Information

    Accepted for Publication: September 17, 2018.

    Corresponding Author: Raymond Noel Moynihan, PhD, Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia, 4229 (rmoyniha@bond.edu.au).

    Published Online: December 28, 2018. doi:10.1001/jamainternmed.2018.6201

    Author Contributions: Dr Moynihan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Albarqouni, Moynihan.

    Acquisition, analysis, or interpretation of data: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Albarqouni, Moynihan.

    Administrative, technical, or material support: Moynihan, Clark.

    Study supervision: Moynihan.

    Conflict of Interest Disclosures: Dr Moynihan reports support from the National Health and Medical Research Council grant #1124207, and serves as a member of the scientific committee for the Preventing Overdiagnosis conference. No other disclosures were reported.

    Funding/Support: National Health and Medical Research Council grant No. 1124207 provided funding support.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank Paul Glasziou, MD, FRACGP, PhD, Centre for Research in Evidence-Based Practice, Bond University, Australia, for comments on the manuscript. He did not receive compensation for this contribution.

    References
    1.
    Pathirana  T, Clark  J, Moynihan  R.  Mapping the drivers of overdiagnosis to potential solutions.  BMJ. 2017;358:j3879. doi:10.1136/bmj.j3879PubMedGoogle ScholarCrossref
    2.
    Whelton  PK, Carey  RM, Aronow  WS,  et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.  Hypertension. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066PubMedGoogle ScholarCrossref
    3.
    Wilt  TJ, Kansagara  D, Qaseem  A; Clinical Guidelines Committee of the American College of Physicians.  Hypertension limbo: balancing benefits, harms, and patient preferences before we lower the bar on blood pressure.  Ann Intern Med. 2018;168(5):369-370. doi:10.7326/M17-3293PubMedGoogle ScholarCrossref
    4.
    Bell  KJL, Doust  J, Glasziou  P.  Incremental benefits and harms of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline.  JAMA Intern Med. 2018;178(6):755-757. doi:10.1001/jamainternmed.2018.0310PubMedGoogle ScholarCrossref
    5.
    Moynihan  R, Bero  L, Ross-Degnan  D,  et al.  Coverage by the news media of the benefits and risks of medications.  N Engl J Med. 2000;342(22):1645-1650. doi:10.1056/NEJM200006013422206PubMedGoogle ScholarCrossref
    6.
    Doust  J, Vandvik  PO, Qaseem  A,  et al; Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group.  Guidance for modifying the definition of diseases: a checklist.  JAMA Intern Med. 2017;177(7):1020-1025. doi:10.1001/jamainternmed.2017.1302PubMedGoogle ScholarCrossref
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