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The Influence of Health Systems on Hypertension Awareness, Treatment, and Control: A Systematic Literature Review

Author

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  • Will Maimaris
  • Jared Paty
  • Pablo Perel
  • Helena Legido-Quigley
  • Dina Balabanova
  • Robby Nieuwlaat
  • Martin Mckee

Abstract

: Will Maimaris and colleagues systematically review the evidence that national or regional health systems, including place of care and medication co-pays, influence hypertension awareness, treatment, and control. Background: Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control. Methods and Findings: Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care. Conclusions: This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs. Background: In 2008, one billion people, three-quarters of whom were living in low- and middle-income countries, had high blood pressure (hypertension). Worldwide, hypertension, which rarely has any symptoms, leads to about 7.5 million deaths annually from heart attacks, stroke, other cardiovascular diseases, and kidney disease. Hypertension, selected by the World Health Organization as the theme for World Health Day 2013, is diagnosed by measuring blood pressure, the force that blood circulating in the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is contracts to pump blood out (systolic blood pressure) and lowest when the heart relaxes and refills (diastolic blood pressure). Normal adult blood pressure is defined as a systolic blood pressure of less than 120 millimeters of mercury (mmHg) and a diastolic blood pressure of less than 80 mmHg (a blood pressure of less than 120/80 mmHg). A blood pressure reading of more than 140/90 mmHg indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat fatty or salty foods are at high risk of developing hypertension. Why Was This Study Done?: Most individuals can achieve good hypertension control, which reduces death and disability from cardiovascular and kidney disease, by making lifestyle changes (mild hypertension) and/or by taking antihypertensive drugs. Yet, in both developed and developing countries, many people with hypertension are not aware of their condition and are not adequately treated. As with other chronic diseases, weaknesses in health care systems probably contribute to the inadequate treatment of hypertension. A health care system comprises all the organizations, institutions, and resources whose primary purpose is to improve health. Weaknesses in health care systems can exist at the national, regional, district, community, and household level. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers investigate how national and regional health care system arrangements influence hypertension awareness, treatment, and control. Actions that might influence hypertension care at this level of health care systems include providing treatment for hypertension at no or reduced cost, the introduction of financial incentives to healthcare practitioners for the diagnosis and treatment of hypertension, and enhanced insurance coverage in countries such as the US where people pay for health care through insurance policies. What Did the Researchers Do and Find?: The researchers identified 53 studies that analyzed whether regional or national health care systems arrangements were associated with patient awareness of hypertension, treatment of hypertension, adherence to antihypertensive medication treatment, and control of hypertension. The researchers used an established conceptual framework for health care systems and an approach called narrative synthesis to analyze the results of these studies, most of which were conducted in the US (36 studies) and other high-income countries (eight studies). Nearly all the studies evaluated the effects of health system financing on hypertension outcomes, although several looked at the effects of delivery and governance of health systems on these outcomes. The researchers' analysis revealed an association between reduced medication co-payments (drug costs that are not covered by health insurance and that are paid by patients in countries without universal free healthcare) and improved hypertension control and treatment adherence, mainly in US settings. In addition, in US settings, health insurance coverage was associated with improved hypertension outcomes, as was having a routine physician or place of care. What Do These Findings Mean?: These findings suggest that minimizing co-payments for health care and expansion of health insurance coverage in countries without universal free health care may improve the awareness, treatment, and control of hypertension. Although these findings are based mainly on US studies, they are likely to apply more generally but, importantly, these findings indicate that additional, high-quality studies are needed to unravel the impact of health systems arrangements on the management of hypertension. In particular, they reveal few studies in low- and middle-income countries where most of the global burden of hypertension lies and where weaknesses in health systems often result in deficiencies in the care of chronic diseases. Moreover, they highlight a need for studies that evaluate how aspects of health care systems other than financing (for example, delivery and governance mechanisms) and interactions between health care system arrangements affect hypertension outcomes. Without the results of such studies, governments and national and international organizations will not know the best ways to deal effectively with the global public-health crisis posed by hypertension. Additional Information: Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001490.

Suggested Citation

  • Will Maimaris & Jared Paty & Pablo Perel & Helena Legido-Quigley & Dina Balabanova & Robby Nieuwlaat & Martin Mckee, 2013. "The Influence of Health Systems on Hypertension Awareness, Treatment, and Control: A Systematic Literature Review," PLOS Medicine, Public Library of Science, vol. 10(7), pages 1-18, July.
  • Handle: RePEc:plo:pmed00:1001490
    DOI: 10.1371/journal.pmed.1001490
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    1. Hamid Najafipour & Hamid Nasri & Mahdi Afshari & Mansoor Moazenzadeh & Mostafa Shokoohi & Afsaneh Foroud & Koorosh Etemad & Behnam Sadeghi & Ali Mirzazadeh, 2014. "Hypertension: diagnosis, control status and its predictors in general population aged between 15 and 75 years: a community-based study in southeastern Iran," International Journal of Public Health, Springer;Swiss School of Public Health (SSPH+), vol. 59(6), pages 999-1009, December.
    2. John Tayu Lee & Fozia Hamid & Sanghamitra Pati & Rifat Atun & Christopher Millett, 2015. "Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis," PLOS ONE, Public Library of Science, vol. 10(7), pages 1-18, July.
    3. Hon Lon Tam & Eliza Mi Ling Wong & Kin Cheung, 2020. "Effectiveness of Educational Interventions on Adherence to Lifestyle Modifications Among Hypertensive Patients: An Integrative Review," IJERPH, MDPI, vol. 17(7), pages 1-15, April.
    4. Dóra Chor & Antonio Luiz Pinho Ribeiro & Marilia Sá Carvalho & Bruce Bartholow Duncan & Paulo Andrade Lotufo & Aline Araújo Nobre & Estela Mota Lima Leão de Aquino & Maria Inês Schmidt & Rosane Härter, 2015. "Prevalence, Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study," PLOS ONE, Public Library of Science, vol. 10(6), pages 1-14, June.
    5. Helena Legido-Quigley & Paul Anthony Camacho Lopez & Dina Balabanova & Pablo Perel & Patricio Lopez-Jaramillo & Robby Nieuwlaat & J-D Schwalm & Tara McCready & Salim Yusuf & Martin McKee, 2015. "Patients’ Knowledge, Attitudes, Behaviour and Health Care Experiences on the Prevention, Detection, Management and Control of Hypertension in Colombia: A Qualitative Study," PLOS ONE, Public Library of Science, vol. 10(4), pages 1-16, April.
    6. Patricia Ortiz & Yajaira Vásquez & Esperanza Arévalo & Patrick Van der Stuyft & Esteban Londoño Agudelo, 2022. "Gaps in Hypertension Management in a Middle-Income Community of Quito-Ecuador: A Population-Based Study," IJERPH, MDPI, vol. 19(10), pages 1-13, May.
    7. Juliet Iwelunmor & Jacob Plange-Rhule & Collins O Airhihenbuwa & Chizoba Ezepue & Olugbenga Ogedegbe, 2015. "A Narrative Synthesis of the Health Systems Factors Influencing Optimal Hypertension Control in Sub-Saharan Africa," PLOS ONE, Public Library of Science, vol. 10(7), pages 1-17, July.
    8. Cervero-Liceras, Francisco & McKee, Martin & Legido-Quigley, Helena, 2015. "The effects of the financial crisis and austerity measures on the Spanish health care system: A qualitative analysis of health professionals’ perceptions in the region of Valencia," Health Policy, Elsevier, vol. 119(1), pages 100-106.
    9. Turnbull, Eleanor & Priaulx, Jennifer & van Ravesteyn, Nicolien T. & Heinävaara, Sirpa & Siljander, Ilona & Senore, Carlo & Segnan, Nereo & Vokó, Zoltán & Hagymásy, Judit & Jarm, Katja & Veerus, Piret, 2018. "A health systems approach to identifying barriers to breast cancer screening programmes. Methodology and application in six European countries," Health Policy, Elsevier, vol. 122(11), pages 1198-1205.

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