Will the 2021 USPSTF Hypertension Screening Recommendation Decrease or Worsen Racial/Ethnic Disparities in Blood Pressure Control? | Cardiology | JAMA Network Open | JAMA Network
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Editorial
April 27, 2021

Will the 2021 USPSTF Hypertension Screening Recommendation Decrease or Worsen Racial/Ethnic Disparities in Blood Pressure Control?

Author Affiliations
  • 1Tulane Heart and Vascular Institute, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
  • 2Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
JAMA Netw Open. 2021;4(4):e213718. doi:10.1001/jamanetworkopen.2021.3718

Hypertension, defined as systolic blood pressure (BP) greater than or equal to 130 mm Hg or diastolic BP greater than or equal to 80 mm Hg, or currently using medication to lower BP, is a potent cardiovascular disease (CVD) risk factor affecting 45.4% of the adult US population.1 The highest prevalence is among non-Hispanic/Latinx Black adults (57.1%), for whom earlier age of onset and treatment resistance confer greater hypertension-related CVD, including coronary artery disease, congestive heart failure, cerebrovascular accident, and end-stage renal disease. Although the overall prevalence in Hispanic/Latinx adults is similar to non-Hispanic/Latinx White adults (43.7% vs 43.6%), there are considerable variations in prevalence and control among racial/ethnic subgroups resulting in less favorable hypertension-related outcomes.1,2 Similarly, recent national trends in BP control rates show worse hypertension control in all minoritized populations, including Black, Hispanic/Latinx, Asian or Pacific Islander, and Native American or Alaska Native individuals, compared with White individuals.3 Appropriate screening for diagnosis, treatment, and control of hypertension is necessary to decrease racial/ethnic disparities associated with hypertension-related morbidity and mortality.

The US Preventive Services Task Force (USPSTF) has issued a reaffirmation4,5 of their 2015 A recommendation for screening for hypertension in adults aged 18 years or older with office BP measurements. In addition, based on the literature review by Guirguis-Blake et al,5 the USPSTF recommendation statement by Krist et al4 recommended that BP readings be obtained outside the clinical setting for diagnostic confirmation before starting treatment. Ambulatory BP monitoring (ABPM) or home-based BP monitoring (HBPM) are 2 methods to measure BP outside of a clinic. The USPSTF recommends4,5 all adults be screened. However, annual screening is recommended for individuals aged greater than 40 years or those with increased risk, including Black individuals, those with high normal BP, or persons who are overweight or obese.4,5

Although we applaud the increased recognition of the significant impact of undiagnosed or untreated hypertension on CVD, it is necessary to question whether the recommended 2-stage screening method will further worsen or will decrease racial/ethnic disparities in BP control.4,5 To decrease racial/ethnic disparities, contemporary recommendations must be culturally tailored to mitigate any barriers to implementation.6 Therefore, the new USPSTF hypertension in adults screening recommendations4,5 are a unique approach with the potential to have a positive impact on hypertension control and outcomes in Black, Hispanic/Latinx, and other minority populations. Nevertheless, issues related to access to and implementation of effective BP recognition and control measures among various populations must be addressed.

Are There Benefits to the 2021 USPSTF Hypertension Screening Recommendations?

Accurate measurement of BP is essential to estimating CVD risk and guiding BP management. Despite the well-documented benefits of hypertension control in decreasing CVD, the diagnosis of hypertension is often done haphazardly, based solely on office BP measurements. Significant variance may occur between office BP measurements and out-of-office readings, thus underestimating white coat hypertension as sustained hypertension and misdiagnosing masked hypertension as sustained normotension. The American Heart Association7 estimates that up to 30% of patients with nonhypertensive office BP measurements have increased BPs when measured outside of the office (ie, masked hypertension) and up to 35% of people with elevated office BP measurements may have BP within reference range when measured outside of the office (ie, white coat hypertension). This is an important distinction, given that CVD risk and mortality are lower with white coat hypertension compared with sustained hypertension and higher with masked hypertension compared with sustained normotension.8 The Jackson Heart Study9 reported that masked hypertension was more common in non-Hispanic Black individuals, as was nocturnal hypertension, both conferring increased CVD and end-stage renal disease risk. Distinguishing these phenotypes can only be done by using both office BP measurements and out-of-office readings obtained by ABPM or HBPM.8

According to Target: BP, a national initiative formed by the American Heart Association and the American Medical Association,7 out-of-office BP measurements are recommended for titration of antihypertensive medications, in conjunction with telehealth counseling or clinical interventions. While there are limited data on whether using self-measured BP alone in individuals with hypertension improves BP control compared with usual care, there is strong evidence that self-measured BP, in conjunction with additional clinical support, is more effective than usual care in lowering BP and improving control among patients with hypertension.7

Data from the Hyperlink trial,10 conducted in a primary care setting, demonstrated that CVD could be decreased for patients using a home BP telemonitoring and pharmacist management strategy for BP management compared with usual care. The subsequent decrease in CVD also resulted in lower estimated health care costs over a 5-year period.10

An unintended benefit of the COVID-19 pandemic has been the importance of and reliance on self-measured BP in clinical decision-making. The use of self-measured BP supported through telemedicine by health care practitioners will likely become increasingly important for hypertension control as the pandemic continues and in future care models, thus potentially facilitating patient-centric care as patients become more aware of their disease process.11,12

What Are the Limitations of 2021 USPSTF Hypertension Screening Recommendations?

Unfortunately, despite known benefits, ABPM use is limited, monitors are not well covered by insurance, and reimbursement is low.11 Moreover, ABPM is not readily available outside of academic institutions and large private health systems and practices. Use of ABPM devices requires training of the clinician and the patient, as well as adherence to instructions for use. In addition, there are only modest data supporting better outcomes with the treatment of white coat or masked hypertension beyond standard treatment of existing CVD risk factors.11

On the other hand, HBPM offers a more practical alternative. With clinical support, it is a cost-effective strategy for reducing hypertension, augmenting patient knowledge, improving health system processes, and enhancing medication adherence. As recommended in all contemporary guidelines, HBPM or self-measured BP outside of the office is considered a necessary component to the appropriate diagnosis and eventual treatment and control of hypertension in the modern setting.2,4,5,11 These devices have been deemed reliable and accurate, but similar to ABPM, require use of validated devices, standardized procedures, and appropriate patient information and training.12 The Centers for Disease Control and Prevention found strong evidence that self-measured BP, with additional support, was more effective than usual care in lowering BP.13 In addition, the Million Hearts initiative13 supports out-of-office BP monitoring and associated strategies, according to the best evidence. However, implementation of these tools may remain unrealistic for often understaffed community health centers, including Federally Qualified Health Centers, to achieve, since they rely on federal and state funds to serve underinsured and uninsured populations. Until reimbursement improves, self-measured BP remains a luxury that may contribute to the already persistent, longstanding, and unacceptable disparities in hypertension outcomes, specifically among racial/ethnic minority groups, such as Black and Hispanic/Latinx individuals, and disadvantaged populations.

Despite the strong evidence for self-measured BP and endorsement from national health care leaders, uptake of self-measured BP in the US remains low, with limited third-party reimbursement cited as a primary barrier to use.13 A detailed analysis of self-measured BP monitoring coverage and reimbursement among selected public and private payers or insurers by researchers at George Washington University14 revealed a general lack of coverage for HBPM for the diagnosis and management of hypertension. Medicaid coverage varied from state to state, often requiring beneficiaries to have conditions in addition to the diagnosis of hypertension. Only 2 of 20 private payers analyzed offered coverage for BP screening. Both public and private coverage of self-measured BP clinical support services were rarely explicit, but support could occur through disease management benefits that included health education and self-management instruction. Similarly across all payers, remote patient BP monitoring, if available, appeared limited to beneficiaries with serious chronic conditions, not just a diagnosis or potential diagnosis of hypertension.

What Is the Association of Race/Ethnicity With Utilization of Self-measured BP?

Decreasing and eventually eliminating racial/ethnic disparities in hypertension control and CVD outcomes will require a multilevel approach consisting of patients, clinicians, health systems, public health officials, and policy makers to better address cultural, socioeconomic, environmental, and structural contributing factors.6 If the underlying social determinants of health are not properly recognized and reversed, the use of ABPM and self-measured BP has the potential unintended consequence of increasing the disparities in racial/ethnic minority patients at high risk, who often have the least access to these devices.

Potential recommendations to enhance the effective utilization of the new USPSTF hypertension screening recommendations4,5 include viewing structural racism and social determinants of health as public health concerns with a direct impact on hypertension disparities and outcome; understanding each patient’s health status based on social determinants of health, including preferences for engagement and treatment based on individuals’ culture and beliefs; increasing clinician self-awareness of biases, clinical uncertainty and inertia, and stereotypes that affect treatment recommendations, particularly related to lifestyle, medication choices, and testing; ensuring employers select and shape insurance policies that include reimbursement for self-measured BP equipment, clinical support, and training; expanding coverage through health care flexible spending accounts; improving health care systems’ utilization of self-measured BP implementation and guidance from Million Hearts13 and Target: BP,7 a community-based implementation initiative formed by the American Heart Association and American Medical Association that helps health care organizations and care teams, at no cost, improve BP control rates through an evidence-based quality improvement program; creating clinician-specific data dashboard for hypertension quality improvement metrics; promulgating national and community-based organization collaborations for resource sharing around public education and best practices; supporting public health advocacy for Medicaid coverage of HBPM; and incorporating validated self-measured BP devices in clinical care.15 This list of medical approaches to identify, decrease, and potentially eliminate disparities in hypertension-related outcomes should serve as guidance for initiatives that go beyond simply disseminating various scientific reports.

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Article Information

Published: April 27, 2021. doi:10.1001/jamanetworkopen.2021.3718

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ferdinand KC et al. JAMA Network Open.

Corresponding Author: Keith C. Ferdinand, MD, Tulane Heart and Vascular Institute, John W. Deming Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, #8548, New Orleans, LA 70112 (kferdina@tulane.edu).

Conflict of Interest Disclosures: Dr Ferdinand reported serving as a consultant for Medtronic, Amgen, and Novartis outside the submitted work. Dr Brown reported receiving grants from the National Institutes of Health and Medtronic (paid to Washington University School of Medicine in St Louis) outside the submitted work.

References
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