As Hypertension Sweeps China, Awareness, Treatment, and Control Remain Poor

Hypertension remains a pervasive problem among Chinese adults, but fewer than half of those affected even know they have high blood pressure, according to a screening study of more than 1.7 million people.

Worse yet, only 30.1% of hypertensive individuals were taking prescribed medications for the condition, with blood pressure control achieved in just 7.2%, lead authors Jiapeng Lu, PhD (Fuwai Hospital, Beijing, China), and Yuan Lu, ScD (Yale New Haven Hospital, CT), and colleagues report in a paper published online October 25, 2017, ahead of print in the Lancet.

Problems stemming from the availability, cost, and prescription of antihypertensive medications seem to be a major cause of the dismal situation in China, according to a second paper by lead authors Meng Su, PhD, and Qiuli Zhang, PhD (Fuwai Hospital), and colleagues.

“We conclude that hypertension is a major public health challenge in China,” Lu et al write. “The low number of people in control is ubiquitous in all subgroups of the Chinese population and warrants [a] broad-based, global strategy, such as greater efforts in prevention, as well as better screening and more effective and affordable treatment.”

Paul Whelton, MD (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), who was not involved in the study, said that “alarm bells should be going off” based on the results of the two papers.

“The central theme that they report is one that we’ve seen consistently in China and other economically developing countries—that is, poor awareness, poor treatment, and very poor control,” Whelton told TCTMD.

He pointed out, however, that the United States was once in a similar position and has gradually made progress through focused efforts. He attributed the improvements to the availability of the federal government’s National Health and Nutrition Examination Survey (NHANES), which has provided a consistent way to monitor changes in hypertension prevalence, awareness, treatment, and control over time, to the use of high-quality guidelines, and to efforts to educate practitioners and the general public. Reported control rates are now around 90% within certain integrated healthcare systems and slightly over 50% in the general population, Whelton said.

Although those rates might be a bit rosy, there certainly has been substantial improvement over time, he said, adding that it is imperative that China follows a similar path.

As in most countries, the leading cause of death in China is cardiovascular disease, with risk factors similar to those seen in the United States, including smoking, poor diet, and low physical activity, Whelton noted.

“We know a lot about the general problems in China and why cardiovascular disease is so common there and is increasing, and you just have to try to tackle it,” Whelton said. “At some level the government has to have a will to do that and there has to be a more organized approach to awareness, treatment, and control of high blood pressure.”

Control Consistently Low Across Subgroups

Both Lancet papers came out of the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project, a government-funded, population-based screening study that enrolled about 1.74 million adults ages 35 to 75 living in the 31 provinces of mainland China. Information on the participants was collected at 141 sites—88 rural and 53 urban.

The analysis by Lu, Lu, and colleagues examined the scope of the hypertension problem. They found that 44.7% of participants had hypertension defined by recorded blood pressure or self-reported use of antihypertensive medication, but that only 44.7% of that group were aware that they had high blood pressure. Rates standardized for age and sex were 37.2% and 36.0%, respectively.

Whelton said that the prevalence figure cannot be considered representative of the general population in China because of the sampling method used in the study, noting that prior studies have shown relatively consistent rates about 10 percentage points lower.

Because of the large number of participants, the investigators explore 264,475 population subgroups defined using combinations of 11 demographic and clinical factors. They found wide variation across subpopulations in terms of prevalence, awareness, and treatment, although the control rate was consistently low (less than 30%).

“There is no evidence of any population subgroup excelling in hypertension control and no evidence that a particular biological or societal factor is associated with achieving high control,” the authors write. “This suggests a fundamental structural change is needed to address hypertension in China, and education and screening will not be sufficient without parallel efforts to improve treatments.”

‘Marked Deficiencies’ in Treatment

Su et al delved deeper into the treatment issue by looking at the China PEACE Million Persons Project’s primary healthcare survey, which included about 1 million participants. The investigators examined the availability, cost, and prescription of antihypertensives at 3,362 primary care sites (82% rural).

Overall, 8.1% of sites didn’t stock any antihypertensives and only 33.8% stocked all four major classes (ACE inhibitors/angiotensin receptor blockers, beta-blockers, calcium channel blockers, and diuretics). Availability was poorest at village clinics and sites in western China.

Only about one-third of sites (32.7%) stocked high-value medications, defined as those that are recommended by guidelines and are available at low cost. But those drugs accounted for just 11.2% of all prescriptions, with higher-cost, guideline-recommended drugs taking up the largest share (81.1%).

“China has marked deficiencies in the availability, cost, and prescription of antihypertensive medications. High-value medications are not preferentially used,” the researchers conclude. “Future efforts to reduce the burden of hypertension, particularly through the work of primary healthcare providers, will need to improve access to, and use of, antihypertensive medications, paying particular attention to those with high value.”

In 2009, China implemented a zero mark-up policy for essential medications aimed at improving availability and affordability for residents.

That policy, however, introduced “perverse incentives,” Therese Hesketh, MD, PhD (UCL Institute for Global Health, London, England), and Xudong Zhou, PhD (Zhejiang University School of Public Health, Hangzhou, China), say in an accompanying editorial.

The 2009 reforms “introduced a zero-profit drugs policy, designed to reduce financial incentives for doctors to prescribe specific drugs, which had in the past led to massive overprescribing of those drugs. But the zero-profit policy applies only to drugs on the Essential Drug List, with other drugs still liable to mark-up,” they explain. “Therefore, doctors are incentivized to prescribe more expensive drugs.”

Low figures for hypertension treatment and control can thus be attributed to that issue, as well as to deficiencies in screening processes and the failure of primary prevention measures, Hesketh and Zhou say. “This situation is worrying, not least because prevention and control of hypertension have been a high priority in China for more than 2 decades, and the two studies illustrate well the gap between policy and practice in this area.”

Despite some limitations related to sampling and questions surrounding the quality of measurements performed in such a large study, Whelton said, “these sorts of surveys are pretty shocking and they have to be taken seriously. When you have control rates this poor and your principal causes of disease are related to high blood pressure, it’s incumbent [on you] to try to tackle that problem in a more urgent fashion than seems to be happening.”