Medical Publishing House; 1996:94â101. 14. Kaplan GA, Keil JE. ..... Johnson CL, Rifkind BM, Sempos CT, et al. De- clining serum total cholesterol levels ...
RESEARCH AND PRACTICE
Guangdong Provincial Cardiovascular Institute, Guangzhou, People’s Republic of China.
Human Participant Protection No institutional review board approval was needed for this study.
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Undiagnosed Hypertension and Hypercholesterolemia Among Uninsured and Insured Adults in the Third National Health and Nutrition Examination Survey | John Z. Ayanian, MD, MPP, Alan M. Zaslavsky, PhD, Joel S. Weissman, PhD, Eric C. Schneider, MD, MSc, and Jack A. Ginsburg, MPE
Uninsured adults are much less likely than insured adults to receive routine checkups or preventive services, including screening for hypertension and hypercholesterolemia.1 To obtain nationally representative estimates of undiagnosed hypertension and hypercholesterolemia by insurance status, we analyzed the Third National Health and Nutrition Examination Survey (NHANES III).2,3
METHODS The NHANES III was conducted during 1988 through 1994 by the National Center for Health Statistics in a probability sample of the civilian, noninstitutionalized US population. Of the 39 695 people sampled, 33 994 (85.6%) completed a standardized
December 2003, Vol 93, No. 12 | American Journal of Public Health
English or Spanish interview, and 30 818 (77.6%) underwent clinical testing at an examination center.4 Participants reported their health insurance during the prior month, sociodemographic characteristics (age, gender, race/ethnicity, income, education, region), access to care (regular site of care, regular provider, last contact with health professional), previous diagnoses of hypertension and hypercholesterolemia, and current use of prescribed medicines for these conditions. Blood pressure and serum cholesterol were measured with standardized protocols.5,6 We defined hypertension as average systolic blood pressure readings greater than 140 mm Hg or diastolic blood pressure readings greater than 90 mm Hg or taking antihypertensive medicine, and we defined hypercholesterolemia as a serum cholesterol level greater than 240 mg/dL or taking lipid-lowering medicine.3,5,7–10 We studied 10 998 adults aged 25 to 64 years who reported their insurance status. In descriptive analyses, we assessed the proportions of adults with undiagnosed hypertension and hypercholesterolemia by insurance status, sociodemographic characteristics, and access to care. We used logistic regression to assess the adjusted relative odds of undiagnosed hypertension and hypercholesterolemia by insurance status, and we controlled for the sociodemographic characteristics listed in the previous paragraph. We then added the 3 access measures mentioned earlier as potential mechanisms of insurance effects. We used CAT statistical software to obtain multiple imputed values for respondents with missing data on income (6.2%) and education (0.5%).11 We used SUDAAN software to calculate accurate standard errors and statistical tests under the complex survey design.12,13
RESULTS Among the 10 998 adults aged 25 to 64 years who reported their insurance status, 10 946 (99.5%) had their blood pressure recorded, and 10 387 (94.4%) underwent serum cholesterol testing. In each of these groups, 13.2% of the adults were uninsured. Uninsured adults had a lower prevalence of hypercholesterolemia than did insured adults
Ayanian et al. | Peer Reviewed | Research and Practice | 2051
RESEARCH AND PRACTICE
TABLE 1—Characteristics of Uninsured and Insured Adults Aged 25–64 Years With Hypertension and Hypercholesterolemia Adults With Hypertensiona Characteristic Age, y 25–34 35–44 45–54 55–64 Female Race/Ethnicity White Black Hispanic Other Annual family income, $ < 15 000 15 000–24 999 25 000–34 999 35 000–49 999 ≥ 50 000 Education < High school graduate High school graduate College graduate Region Northeast Midwest South West Regular site of care Regular health care provider Last contact with a health professional, mo < 11 12–23 24–59 ≥ 60
Uninsured, %
Insured, %
(n = 343)
(n = 2031)
14.6 23.9 29.1 32.4 52.7
9.4 24.6 27.3 38.8 43.9
60.6 19.6 17.7 2.1
74.6 17.1 6.0 2.3
51.6 23.1 8.8 9.9 6.6
16.7 17.8 17.2 20.0 26.2
40.1 53.6 6.3
26.8 55.5 17.7
Adults With Hypercholesterolemiaa Pb
Uninsured, %
Insured, %
(n = 322)
(n = 1630)
24.9 34.1 22.4 18.6 53.8
15.5 24.3 28.6 31.6 49.8
57.0 11.6 30.8 0.8
80.9 8.5 7.7 2.9
50.3 23.3 14.5 6.9 5.0
11.4 17.6 16.9 24.5 29.6
47.9 38.9 13.3
21.6 58.0 20.4
.22
.02 .03
.12
