Long-term Blood Pressure Trajectories, Hypertension Burden, and Treatment Among Young Women and Men Veterans
Date of Award
Spring 2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Public Health
First Advisor
Lichtman, Judith
Abstract
Background: Young post-9/11 women and men Veterans in the United States are an understudied and growing subgroup of Veterans with unique clinical and social risk factors for hypertension. The goal of this dissertation was to understand if there are potential differences in longitudinal blood pressure (BP) patterns and hypertension burden and pharmacologic treatment that systematically impact subgroups of the young Veteran population, including women, racial and ethnic minorities, rural residents, and individuals experiencing homelessness. Specifically, the objectives were to describe longitudinal sex-specific BP trajectories over time after Veterans complete military service (Study 1), assess the sex-specific relationship between rurality of residence and hypertension measures (prevalence, identification, and treatment) (Study 2), and estimate the association between homelessness and hypertension measures and determine if this differs by sex and military-service related factors (Study 3). Methods: Using national Department of Veterans Affairs (VA) electronic health record data from 2001-2017, this retrospective cohort study included U.S. Veterans who served in support of conflicts in Afghanistan and Iraq (i.e., post-9/11 Veterans). Vital sign, pharmacy, and coded diagnostic and procedural data from inpatient and outpatient VA health care encounters were linked to form longitudinal patient records. • Study 1: Linear mixed effects models were used to examine longitudinal BP patterns and determine if there are sex, racial, or ethnic differences in BP trajectories (i.e., changes over time) over an average follow-up of 6.0+/-3.8 years. • Study 2: Using Chi-square tests, we tested for sex differences in the proportion of Veterans meeting criteria for clinical hypertension (diagnosis code, antihypertensive medication fill, or elevated BP), identified as having hypertension (diagnosis code or antihypertensive medication fill), and receiving pharmacologic treatment (antihypertensive medication fill). Next, multivariable logistic regression models were used to assess if rurality of residence (rural vs urban) was an independent predictor of hypertension prevalence, identification, and treatment. To determine if this association differed between women vs men and by 4 U.S. Census regions (Northeast, South, Midwest, West), sex*rurality and region*rurality interaction terms were included in the models. • Study 3: Multivariable logistic regression models were used to assess the association between homelessness (defined as any reported instance of homelessness during study follow-up) and hypertension prevalence, identification, and treatment, and determine if this relationship differed between women vs men, and those with vs without military service-related factors (posttraumatic stress disorder [PTSD], military sexual trauma [MST] history). Results: The study cohort included 750,502 young Veterans (13% women) with 14,788,864 outpatient BP measurements, and who were on average 32.5+/-9.2 years old when first accessing care at the VA. • Study 1: Longitudinal BP patterns revealed that young Veterans generally experienced systolic (SBP) and diastolic (DBP) blood pressure increases over an average 6-year follow-up period. At baseline, women vs men had lower SBP (114.4 vs 121.7 mmHg) and DBP (70.3 vs 73.8 mmHg), but rates of increase were greater for women vs men over time (SBP annual rate of increase=0.35 vs 0.09 mmHg/year; DBP=0.45 vs 0.30). Baseline BP varied across racial and ethnic groups, with Black women (SBP=0.44; DBP=0.49) and Asian women (SBP=0.44; DBP=0.49) having the most rapid increases over time. • Study 2: Approximately 51.2% of Veterans met criteria for clinical hypertension, of whom 44.5% were not identified as having hypertension and did not receive pharmacologic treatment. Although women had 58% lower odds of meeting criteria for clinical hypertension compared to men (adjusted odds ratio [AOR], 0.42; 95% confidence interval [CI], 0.41-0.43), women also had lower odds of adherence to antihypertensive medications (AOR, 0.83; 95% CI, 0.79-0.88). Rurality differences in clinical hypertension were the most pronounced in the South (rural South vs urban South AOR, 1.16; 95% CI, 1.12-1.17). • Study 3: Approximately 16.9% of young Veterans were identified as experiencing homelessness at least once during follow-up. Homeless Veterans had 9% increased odds of meeting clinical hypertension criteria (AOR, 1.09; 95% CI, 1.07-1.11), compared to those who were never identified as experiencing homelessness. The association between homelessness and hypertension was consistent between women and men, but homelessness was a stronger predictor of hypertension for those with a PTSD diagnosis vs those without, and those with MST history vs those without. Discussion: Approximately 51.2% (n=384,576) of young post-9/11 Veterans met criteria for hypertension, and 44.5% (n=171,195) of hypertensive Veterans were not identified and untreated. As this population ages, hypertension may contribute to future burden and disparities in cardiovascular disease, which may be particularly salient among higher-risk subgroups identified in this dissertation, including Veterans residing in the rural South and homeless Veterans with PTSD and MST. While women showed lower odds of hypertension, it is also notable that their rates of BP increase over time were 3 times faster than that of men, suggesting that this is also a critical group for targeted interventions.
Recommended Citation
Chang, Tiffany Elizabeth, "Long-term Blood Pressure Trajectories, Hypertension Burden, and Treatment Among Young Women and Men Veterans" (2024). Yale Graduate School of Arts and Sciences Dissertations. 1321.
https://elischolar.library.yale.edu/gsas_dissertations/1321
