Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change

Recent analyses of data from the National Health and Nutrition Examination Survey (NHANES) estimate that 115 million adults (46%) in the United States have hypertension (also referred to as High Blood Pressure or “HBP”) as defined by systolic blood pressure BP ≥130 mm Hg or diastolic BP ≥80 mm Hg. ¹ Atherosclerotic cardiovascular disease (ASCVD) and stroke, when combined, remain the leading causes of death in the United States with more than 1 million deaths annually, translating to a rate of 2754 deaths per day. ² In addition, individuals with HBP face, on average, nearly $2000 more in annual health care expenditures than those who do not have HBP. ³

In this issue of Population Health Management, researchers and health economists from the Centers for Disease Control and Prevention (CDC) summarize a literature review of peer-reviewed articles published 2000–2019 to determine the types and extent of hypertension-associated work-related productivity loss among adults in the United States. ⁴ Of the initial 411 relevant references screened, 27 articles met the selection criteria and were included in this review, which focused on hypertension-related productivity losses in the United States, paid work or unpaid home activities, and monetary or nonmonetary outcomes.

All monetary outcomes were standardized to 2019 US dollars using the Employment Cost Index for total compensation for civilian workers. Nearly half (12) of the 27 articles meeting inclusion criteria presented monetary outcomes of productivity loss. Work characteristics were considered in 9 studies and several studies focused on specific companies and industries, such as financial/insurance services, manufacturing, oil, and health care. There was heterogeneity in statistical methods and sources of dollar values assigned in each of these 12 studies.

The authors also note that there are different forms of productivity loss that can include short-term absences from work, reduced function while at work, the inability to work due to disability and premature mortality, and impairments to activities of daily living. In addition, multiple data sources were used to examine these categories of productivity loss, such as short-term disability claims or company personnel records of absenteeism, as well as data from several different commonly used standardized questionnaires.

Absenteeism (14 articles) and presenteeism (8 articles) were most frequently assessed. Annual absenteeism attributable to hypertension was estimated as more than $11 billion nationally controlling for sociodemographic characteristics. Annual excess per capita costs related to workers with hypertension were estimated at $63 for short-term disability, $72–$330 for absenteeism, $53–$156 for presenteeism, and may be as high as $2362 for absenteeism and presenteeism when studied in combination, controlling for participant characteristics.

Using Medical Expenditures Panel Survey (MEPS) data, the authors estimate that hypertension-associated productivity loss from absenteeism could be lowered by 15%–36% depending on the extent of controlling for sociodemographic characteristics, work characteristics, health risk factors (such as obesity, smoking, and physical inactivity), and common comorbidities related to HBP (such as diabetes, hyperlipidemia, cardiovascular disease, and stroke).

Also using MEPS, hypertension-associated productivity loss from absenteeism was lowered by 51% after controlling for hypertension comorbidities (specifically, heart disease, stroke, diabetes, and mood disorders) and health conditions unrelated to hypertension (eg, cancer and arthritis) from estimates that controlled for sociodemographic characteristics, body mass index, and smoking. None of the studies evaluated in this article were noted to address the “silent killer” in terms of treatment versus nontreatment, or work-related causative and associative factors contributing to the development and worsening of high blood pressure.

For the first time, we have a comprehensive summary of a structured evaluation of published peer-reviewed research on the monetary and nonmonetary impacts of productivity loss due to HBP for individual workers and their employers. For the first time, we are able to leverage a body of peer-reviewed research to better understand broader implications for effective control of HBP for larger populations (communities, regions, states, nationally, etc.). And through this literature review, 2 critical insights have emerged: (1) hypertension has a significant impact on workplace productivity on multiple levels and (2) economic estimates of these impacts vary widely in size and scope.

In other words, hypertension research has proven problematic for more generalized impact estimation. Pulling this disparate body of research together is the necessary first step to begin doing just that. We applaud the authors for the breadth of the information provided and feel the sheer variability of the reviewed studies merits a concrete conceptualization to fully grasp their collective implications. In this vein, and purely for demonstrative purposes, imagine a hypothetical company we will call HTN, Inc. Using rates and dollar amounts pulled from the CDC's review and other previously published research on hypertension and related outcomes (available upon request), we can make a “back of the envelope” estimate of the cost of productivity loss due to HBP for this population.

As the health care industry is well represented (cited in 4 of the 12 articles where specific industries are identified, more so than any other industry), we will make HTN a modest-sized health system in the nondescript suburban community of Anytown, USA. HTN's employee demographics are representative of the larger eligible US labor force (ie, adults 18 and older). Of HTN's 1000 employees, nearly half (470) have a diagnosis of hypertension. For more than a full third (390), it is uncontrolled hypertension. And the next 12 months will be precarious, both for this subgroup and HTN itself. From the employee perspective, 2 will have strokes, 3 will suffer acute myocardial infarction, 3 will require treatment for chronic kidney disease, and a dozen more will have chronic heart failure.

Over the next year, HTN, Inc.'s workforce with hypertension will miss an additional 1034 days of work more than their nonhypertension counterparts. Those with uncontrolled hypertension will accrue roughly $600,000 in medical expenses and cost HTN an additional $400,000 in work disability, absenteeism, presenteeism, and general work-productivity loss.

Is $1,000,000 per year in additional costs for a single business and its employees enough to grab your attention? If not, let us explore some additional implications. Estimates indicate an additional 20% of the population have undiagnosed hypertension due to lack of awareness, thereby further magnifying the costs for HTN, Inc. and its employees. Again, we acknowledge these estimates to be back of the envelope. They are nonetheless relatively conservative and reflective of the general adult population within the United States. Were we to slightly shift HTN, Inc.'s demographics toward an older population with more of its 1000-person work force >65 years of age or skewed toward certain comorbidities represented in the research, loss impacts could be far greater.

With these new findings in mind, what are future opportunities and challenges for population health professionals and the US population health industry? In essence, the staggering overall annual economic and noneconomic losses from almost 50% of the overall US population with HBP (when including all age ranges for adults) are currently in the hundreds of billions of dollars. Since 80% of those with hypertension are currently considered “uncontrolled,” ¹ the opportunities are many for employers to partner with health care delivery systems, health insurers, and digital health industries to effectively implement more effective evidence-based recommendations from the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) HBP Guidelines. ⁵

For example, the authors note that none of the economic evaluations used in their review explicitly assessed or documented the use of recommendations outlined in these guidelines, which include specific standards for obtaining accurate BP measurement, evaluating 10-year ASCVD Risk and appropriately classifying patients with HBP. Incorrect and hence inaccurate measurement of blood pressure has also now become a major challenge in terms of correct identification and treatment of people with high blood pressure, an issue that could be addressed and reinforced within the workplace through standardized self-monitoring programs such as the national AHA/American Medical Association Target BP program. ⁶

It has also become clear that effective and consistent ongoing assessment of social determinants of health through team-based care and shared decision making is important to help guide treatment options with nonpharmacological interventions, lifestyle modifications, and (when appropriate) medications provide excellent opportunities for improved BP control. ²

Extensive empiric evidence evaluations of so-called “workplace wellness” programs designed to improve blood pressure control in employees with hypertension have not demonstrated to be of any consistent positive impact, although recent data from China has shown promise that may have some relevance. ^7,8 Unfortunately, national initiatives (such as the Health and Human Services [HHS]-sponsored “Million Hearts” model) have also (so far) only made small marginal improvements on blood pressure control at the national level. ⁹

Hence, employers and their workers must work more closely with cardiovascular researchers, health economists, and public health officials to standardize measurement and monitoring of hypertension-associated productivity and nonproductivity costs, especially when implementing cost-effective national guideline-driven interventions designed to achieve better BP control. For example, employers could very easily provide and promote use of certified semiautomated oscillometric self-monitoring BP devices for home BP monitoring and patient/family digital educational resources on how to correctly measure BP in accordance with standard protocols espoused by Target BP, ⁷ perhaps in partnership/collaboration with their health insurers and/or local health systems.

Good quality scientific evidence now confirms that multilevel multicomponent strategies, including patient coaching and self-monitoring with home BP monitoring, provider training to address social determinants of health and lifestyle modification, clinical decision support within electronic health records, and multidisciplinary team-based care, when combined, are most effective for improving BP control in patients with hypertension. ¹⁰ Hence, it is no longer necessary to argue about “The What,” but instead, focus on successful implementation of “The How” and “By Who.”

This responsibility now lies simultaneously at the feet of not only employers, but health systems, insurers, and the digital health companies that provide so-called “solution” services to them. A group of nationally renowned health care and hypertension experts have recently published “The Blueprint for Change” model, which is a comprehensive evidence-based guideline-driven system of care for people with HBP, calling on managerial, clinical, and operational leaders of these organizations to actively collaborate at the local, regional, and national levels to create and support a coordinated system of guideline-based care delivery for adults with HBP. ²

The model is based on high-quality evidence-based guidelines and serves as the basis for (1) engaging and activating health system, payer, and employer leadership for organizational and financial support at every level; (2) continuously using transparent evidence-based standardized performance measurement and quality improvements to assess progress; and (3) insisting on effective shared accountability at all levels (including governance) of the US health system for ensuring access, infrastructure, and coverage (including proper and adequate payment).

Without this type of active collaboration, current unrealistic and unfortunate expectations that employers, providers, payers, and digital health companies will be able to achieve population levels of effective patient-centered BP control in the current siloed environment will continue to lead to failure of the population health industry for millions of Americans.