Longitudinal evidence on treatment discontinuation, adherence, and loss of hypertension control in four middle-income countries

Abstract

Managing hypertension is a highly dynamic process, yet current evidence on hypertension control in middle-income countries (MICs) is largely based on cross-sectional data. Using multiple waves of population-based cohort data from four MICs (China, Indonesia, Mexico, and South Africa), we undertook a longitudinal investigation into how individuals with hypertension move through care over time. We classified adults aged 40 years and over ( N = 8527) into care stages at both baseline and follow-up waves and estimated the probability of transitioning between stages using Poisson regression models. Over a 5- to 9-year follow-up period, only around 30% of undiagnosed individuals became diagnosed [Mexico, 27% (95% confidence interval: 23%, 31%); China, 30% (26%, 33%); Indonesia, 30% (28%, 32%); and South Africa, 36% (31%, 41%)], and one in four untreated individuals became treated [Indonesia, 11% (10%, 12%); Mexico, 24% (20%, 28%); China, 26% (23%, 29%); and South Africa, 33% (29%, 38%)]. The probability of reaching blood pressure (BP) control was lower [Indonesia, 2% (1%, 2%); China, 9% (7%, 11%); Mexico, 12% (9%, 14%); and South Africa, 24% (20%, 28%)] regardless of treatment status. A substantial proportion of individuals discontinued treatment [Indonesia, 70% (67%, 73%); China, 36% (32%, 40%); Mexico, 34% (29%, 39%); and South Africa, 20% (15%, 25%)], and most individuals lost BP control by follow-up [Indonesia, 92% (89%, 96%); Mexico, 77% (71%, 83%); China, 76% (69%, 83%); and South Africa 45% (36%, 54%)]. Our results highlight that policies solely aimed at improving diagnosis or initiating treatment may not lead to long-term hypertension control improvements in MICs.

Hypertension Diagnosis, Treatment, and Control in India

“…Our study also has some limitations. First, while the hypertension care continuum is an invaluable tool to visualize gaps at 1 time point, these data hide the dynamic nature of hypertension treatment and control, which argues for systems of ongoing surveillance . Second, hypertension among those who did not self-report a physician diagnosis was based on blood pressure measurements at a single time point .…”

Hypertension diagnosis, treatment, and control in India: nationally representative results from 1.69 million adults, 2019-2021

“…First, while the hypertension care continuum is an invaluable tool to visualize gaps at one time-point, these data hide the dynamic nature of hypertension treatment and control, and argues for systems of ongoing surveillance. 35,36 Second, hypertension, among those who did not self-report a physician diagnosis, was based on blood pressure measurements at a single time point. 37 The ICMR guidelines for diagnosis of hypertension requires a minimum of 2 sets of readings on 2 different occasions, which are at least 1-4 weeks apart.…”

“…18 Third, diagnosis and treatment were based on self-report, and not validated through medical records. 35,38 Finally, we did not have data on older adults living by themselves or institutionalized and non-civilian adults. 16 In India, nationally, more than 1 in 4 people have hypertension, and cumulatively, over 90% of adults with hypertension were either undiagnosed, untreated, or treated and uncontrolled.…”

National Estimates of the Adult Diabetes Care Continuum in India, 2019-2021

“…Using recent nationally representative data, we characterized the diabetes care continuum (diagnosis, treatment, and control) for India by state, district, and sociodemographic subgroups (sex, urban/rural residence, age, attained schooling, and household wealth) . We developed a dashboard for easy visualization of these data at the district level.…”