Prevalence of Self-Reported Hypertension and Antihypertensive Medication Use Among Adults Aged ≥18 Years — United States, 2011–2015

Hypertension, which affects nearly one third of adults in the United States, is a major risk factor for heart disease and stroke (1), and only approximately half of those with hypertension have their hypertension under control (2). The prevalence of hypertension is highest among non-Hispanic blacks, whereas the prevalence of antihypertensive medication use is lowest among Hispanics (1). Geographic variations have also been identified: a recent report indicated that the Southern region of the United States had the highest prevalence of hypertension as well as the highest prevalence of medication use (3). Using data from the Behavioral Risk Factor Surveillance System (BRFSS), this study found minimal change in state-level prevalence of hypertension awareness and treatment among U.S. adults during the first half of the current decade. From 2011 to 2015, the age-standardized prevalence of self-reported hypertension decreased slightly, from 30.1% to 29.8% (p = 0.031); among those with hypertension, the age-standardized prevalence of medication use also decreased slightly, from 63.0% to 61.8% (p<0.001). Persistent differences were observed by age, sex, race/ethnicity, level of education, and state of residence. Increasing hypertension awareness, as well as increasing hypertension control through lifestyle changes and consistent antihypertensive medication use, requires diverse clinical and public health intervention.

for your high blood pressure?" Hypertension and treatment were assessed by age group (18-44 years, 45-64 years, and ≥65 years), sex, race/ethnicity (non-Hispanic whites [whites]; non-Hispanic blacks [blacks]; Hispanics; non-Hispanic Asians [Asians]; non-Hispanic Native Hawaiian/Pacific Islanders [NH/PIs]; non-Hispanic American Indian/Alaskan Natives [AI/ANs]); and non-Hispanic others [others]), highest level of education attained (less than high school graduate, high school graduate, some college, college graduate or higher), and state of residence. Estimates were directly age-standardized to the 2000 U.S. standard population. Changes over time were assessed using t-tests for the differences from 2011 to 2015. Because of a large difference in the age distribution between persons with hypertension and the general population, both age-standardized and crude estimates were calculated. All analyses were conducted using statistical software to account for the complex sampling design.
By state, the age-standardized prevalence of self-reported hypertension ranged from 24.2% in Minnesota to 40.1% in Mississippi in 2015 (Table 1). From 2011 to 2015, significant increases in the prevalence of hypertension were observed in five states (Arkansas, Georgia, Hawaii, North Carolina, and West Virginia) In 2015, hypertension prevalence was, in general, higher in the Southern states and lower in the Western states ( Figure). Among participants with self-reported hypertension, the age-standardized prevalences of antihypertensive medication use in 2011, 2013, and 2015 were 63.0%, 62.0%, and 61.8%, respectively (p<0.001, Table 2). In 2015, the prevalence of medication use was higher among women (66.8%), adults aged ≥65 years (93.1%), and blacks (60.7%), and lower among men (58.5%), adults aged 18-44 years (41.2%), and Hispanics (55.4%). From 2011 to 2015, significant decreases in antihypertensive medication use among persons with self-reported hypertension were observed among both men and women, persons aged ≥65 years, whites, and high school graduates, as well as those with any college education. By state, a significant decrease in the prevalence of medication use was observed in Connecticut, Hawaii, North Carolina, South Carolina, Texas, Utah, and West Virginia. In 2015, the prevalence of medication use among persons with self-reported hypertension was highest in Louisiana (73.8%) and lowest in Idaho (51.1%). In general, the prevalence of medication use was higher in the Southern states and lower in the Western states (Figure).
Age-standardized estimates were lower than unadjusted estimates for self-reported hypertension (Supplementary Table 1; https://stacks.cdc.gov/view/cdc/50226) and substantially lower for antihypertension medication use (Supplementary Table 2; https://stacks.cdc.gov/view/cdc/50226). In addition, statistically significant increases were observed in the unadjusted prevalence of both hypertension (0.6%), and antihypertension medication use from 2011 to 2015; however, the increase in medication use was small in magnitude (0.1%).

Discussion
Among U.S. adults, the age-standardized prevalence of selfreported hypertension and antihypertension medication use changed little from 2011 to 2015. Differences were observed by age, sex, race/ethnicity, and state of residence.
A recent report using National Health and Nutrition Examination Survey data found no change in the prevalence of hypertension among U.S. adults, from 1999-2000 (28.4%) to 2011-2012 (28.7%) and 2015-2016 (29.0%) (4). Because of the large number of participants in BRFSS each year, the statistically significant decline in hypertension prevalence from 30.1% to 29.8% likely does not represent a meaningful change. However, at the state level, both the age-standardized and unadjusted prevalences of hypertension declined significantly in Alaska, Michigan, Nevada, New Hampshire, and Texas and increased in Arkansas, Georgia, Hawaii, and West Virginia, which suggests that there might be notable changes in hypertension prevalence in these states.
The finding that the age-standardized prevalence of antihypertensive medication use declined slightly from 2011 (63.1%) to 2015 (61.8%) was unexpected, although the trend in unadjusted prevalence had no meaningful change (from 77.5% to 77.6%).

TABLE 1. (Continued) Age-standardized prevalence of self-reported hypertension among adults aged ≥18 years by sociodemographic characteristics and state* -Behavioral Risk Factor Surveillance System, United States 2011-2015
A previous study found that hypertension medication prescriptions provided during U.S. physician office visits increased from 69.2% to 78. prescription sales data also indicated that prescription fill counts for antihypertensive medication increased from 2009 to 2014 (6). Data from the National Health and Nutrition Examination   (7). Reduction targets in the prevalence of hypertension and improvements in its management are included in many national initiatives. Healthy People 2020 heart disease and stroke objectives include reducing the proportion of persons in the population with hypertension (target = 26.9%) and increasing the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure (target = 69.5%). § § https://www.healthypeople.gov/2020/topics-objectives/topic/ heart-disease-and-stroke.

Summary
What is already known about this topic?
Hypertension is a major risk factor for heart disease and stroke. Hypertension prevalence and treatment among the U.S. population varies by demographic characteristics and by state.
What is added by this report?
During 2011-2015, overall, the age-standardized prevalence of hypertension (30.1% in 2011 to 29.8% in 2015), as well as the use of antihypertensive medication among persons with self-reported hypertension (63.0% in 2011 to 61.8% in 2015), decreased slightly among U.S. adults. However, it is unclear whether these small changes are clinically meaningful.
What are the implications for public health practice?
Aggressive public health actions to expand existing, effective interventions could enhance improvement in hypertension prevention and management in order to achieve Healthy People 2020 goals.
Although improvements have been seen in hypertension management, Healthy People 2020 hypertension targets have yet to be realized. Whereas Healthy People 2020 objectives and targets are set for the United States, data from this report highlighting sociodemographic and geographic differences in the prevalence and treatment of hypertension can be used by state partners to target interventions to improve hypertension management within their populations and communities. Complementary to Healthy People 2020 and other programs, the U.S. Department of Health and Human Services Million Hearts initiative ¶ seeks to improve hypertension control through diverse, multifaceted interventions (8). CDC has been working with state and local public health communities to improve hypertension awareness, treatment, and control through multiple strategies within the CDC State Heart Disease and Stroke Prevention programs (9). In addition to effective, replicable interventions available through these programs, data from this report could be used by public health practitioners to inform hypertension awareness initiatives and management strategies with clinical partners. The findings in this report are subject to at least three limitations. First, BRFSS data are based on self-report; the lack of direct blood pressure measurement makes it impossible to fully assess hypertension prevalence or control according to current guidelines. Based on data from the National Health and Nutrition Examination Survey, the prevalence of awareness among adults with hypertension was 83.3% during 2011-2014 (10). Therefore, nearly 20% of adults with hypertension are unaware of their condition. Second, the representativeness of the BRFSS sample might be affected by median response rates of <50% across the states. Finally, because hypertension is related to age, the slight decline in the age-standardized prevalence of medication use during the analysis period could be caused by the mathematical distortion of standardizing to a general population age distribution, or could reflect reporting bias. This report provides the most current self-reported state-level hypertension surveillance data. Hypertension remains a significant public health problem. Public health and health system interventions might help to improve hypertension awareness and management. A substantial evidence base is available to inform programs at multiple levels and across diverse settings to support improvements in hypertension management.** , † †