Health Coverage for Hypertension Management

With the introduction of the Patient Protection and Affordable Care Act (ACA), the debate on universal healthcare has become heated. Cross-country analysis can examine health system structures and outcomes, providing information on how beneficial the ACA will be in improving health outcomes and reducing coverage disparities.

Hypertension management is a significant quality measure in determining cross-country disparities due to population, healthcare provider, and health system characteristics. A recent study compared quality and disparities in hypertension management by socioeconomic position in the United States and England [PLoS One. 2014;9(1):e83705]. England already had universal healthcare in place, prior to the ACA.

The researchers sought to compare the United States and England because the 2 systems have 4 differences that may influence hypertension management: (1) in the United States, there is a higher ratio of specialists to general practitioners and more ambulatory care is delivered by specialists, while England’s system, the National Health Service (NHS), provides more services through general primary care; (2) the NHS is a single payer system, with potentially clearer lines of accountability and centralized coordination of quality improvement; (3) the United States has higher healthcare spending that England; and (4) England offers universal health coverage with care free at the point of delivery.

Dalton and colleagues used data from 2 national longitudinal surveys: the English Longitudinal Study of Aging (ELSA) from England and the Health Retirement Survey (HRS) from the United States. Both surveys included non-Hispanic white respondents aged ≥50 years with diagnosed hypertension. Two age groups were analyzed separately: 50 to 64 years of age and ≥65 years of age.

The ELSA data used was from 2008 to 2009, including 4910 respondents fitting inclusion criteria. The HRS data used was from 2008 with 4920 respondents meeting the study requirements.

Blood pressure (BP) control was compared to clinical guideline and adult targets (140/90 mm Hg and 150/90 mm Hg, respectively). Mean systolic and diastolic BP, antihypertensive therapy prescribing, and disparities in the United States and England systems in terms of educational attainment, income and wealth, and use of regression models were assessed.

In England, the unadjusted prevalence of hypertension in the 50 to 64 years of age cohort was 38.2% compared to 45.1% in the United States. In England, the unadjusted prevalence of hypertension in the ≥65 years of age cohort was 52.9% compared to 63.6% in the United States.

The study found that there was significantly higher aggregate BP control in the US respondents aged ≥65 years using clinical targets (P=.043) but not audit targets (P=.388). Mean systolic BP was significantly lower in the United States compared with England but mean diastolic BP, was significantly higher in the United States (P<.001 for both). Prescribing of ≥1 antihypertensive medication was significantly more common in the United States (P<.001). See Table for more details.

England had no significant socioeconomic disparity regarding BP control in the ≥65 years of age cohort. In the wealthier cohort, 60.9% achieved BP control, while 63.5% of the lower wealth cohort achieved BP control (P=.588). The United States had socioeconomic differences in the 50 to 64 years of age cohort. In the wealthier cohort, 71.7% achieved BP control, while 55.2% of the lower wealth cohort achieved BP control (P=.003).

According to the researchers, moving toward universal health coverage may reduce the US disparity in hypertension management. Seemingly, universal coverage of adults ≥65 years of age is not enough for hypertension management.