As Elizabeth Warren Rises, Insurers Tighten Grip On Medicare

The health insurance industry is setting up new sales territories and blitzing seniors with television ads as they market private Medicare Advantage plans in more U.S. counties than ever despite the threat of Democrats to put them out of business.

In the last week, several pollsters showing the majority of Americans wanting Donald Trump to face an impeachment inquiry are also showing U.S. Sens. Elizabeth Warren and Bernie Sanders well ahead of the President should he face either in the general election next November 2020. A Fox News poll last week had Warren leading Trump 50% to 40% in a head-to-head general election matchup. Both Warren and Sanders favor a single payer version of expanded Medicare coverage for all Americans that would uproot the role of private insurers.
But Warren’s potential to challenge Trump should he be the Republican presidential nominee is becoming more real as some new polls of Democratic voters for their party’s nomination show her in a tight race with Joe Biden. The former Vice President is a supporter of privatized Medicare Advantage, which grew in the eight years of the Barack Obama White House thanks in part to new benefits under the Affordable Care Act. New regulations under Trump have allowed private insurers to flourish even more with the ability to sell more supplemental benefits.

Analysts say insurers are looking at the broader picture showing regulations favoring a private health plan’s participation in practically all areas of government-subsidized health benefit administration from Medicare and Medicaid to subsidized commercial coverage under the ACA.
“Aside from single payer, most health reform proposals revolve around broad eligibility for coverage in a regulated and subsidized direct-to-consumer market, so it makes sense that insurers are increasingly eager to participate in real-world opportunities like Medicare Advantage and the individual market,” says Kathy Hempstead, senior policy advisor at the Robert Wood Johnson Foundation. “There may be a sense that this is where the puck is going.”

This month, insurers are ramping up marketing and announcing their expansions in new regions ahead of the annual open enrollment period when seniors eligible for Medicare can choose new benefits or stay with their existing plans. Such changes can be made during Medicare’s open enrollment, which begins this Tuesday, Oct. 15 and runs through Dec. 7.
Already this month, major health insurers including Cigna and UnitedHealth Group have announced they are launching unprecedented expansions into new regions of the country to sell Medicare Advantage plans. Other insurers including CVS Health’s Aetna, Centene and Humana are also launching major expansions of Medicare Advantage products.
There will be about “1,200 more Medicare Advantage plans operating in 2020 than in 2018,” the Centers for Medicare & Medicaid Services said last month. “The average number of Medicare Advantage plan choices per county will increase from about 33 plans in 2019 to 39 plans in 2020. This represents an increase of 49% since 2017.”
Insurers are taking advantage of new rules that allow Medicare Advantage plans to offer more benefits to seniors. Medicare Advantage plans contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines with some also offering vision, dental care and wellness programs.
Enrollment in Medicare Advantage plans surpassed 22 million in 2018, which is 35% of total Medicare beneficiaries. Given the rule changes, one analyst — L.E.K. Consulting — has projected enrollment of seniors in private Medicare Advantage plans could reach 70% of those eligible for federal health benefits for the elderly between 2030 and 2040.
UnitedHealth Group, which has already clashed publicly with Sanders over single payer, said it will expand its Medicare Advantage health plan offerings to seniors in 100 new counties next year to reach an additional 1.2 million people. UnitedHealth will offer Medicare Advantage in 47 states in 2020, up from 45.
UnitedHealth, which is the nation’s largest insurer, currently sells individual Medicare Advantage plans in more than 1,700 counties but that will grow to more than 1,800, the insurer said. The insurer has new ads running across the country.
“In 2020, 90% of people eligible for Medicare will have a choice of UnitedHealthcare Medicare Advantage plans, nationwide,” the company said earlier this month.
Meanwhile, Anthem said its “affiliated health plans” will offer Medicare Advantage plans in 77 new counties for 2020. “These health plans currently sell Medicare Advantage plans in more than 850 counties and that will grow to nearly 950 counties in 2020, across 14 blue states and other affiliated plans,” Anthem said. And Cigna said its Medicare Advantage health maintenance organization plans in 2020 will be in 303 counties, 37 of which are new with the expansion,” a Cigna spokeswoman said. “We were in 266 counties before expansion.”
With the increased competition, premiums are expected to be lower in many areas of the country, the Trump administration has said.
“These dramatically lower costs in Medicare Advantage and Part D, thanks to President Trump’s leadership, means that we are putting dollars back into the pockets of our seniors,” CMS Administrator Seema Verma said last month. “On the contrast, proposals for more government through Medicare for All or a public option, would only harm the progress we have made to protect and strengthen the Medicare program for future generations.”
https://www.forbes.com/sites/brucejapsen/2019/10/13/as-elizabeth-warren-rises-insurers-tighten-grip-on-medicare/#529dcb0527f9

Only 15% of trials could be replicated using real world data

A study published this week in JAMA Network Open finds that currently available real-world data (RWD) sources can only be used to feasibly replicate 15% of clinical trials.
The aim of the study was to determine whether RWD could be used to power observational studies that answer the same clinical questions as traditional clinical trials.
Randomized controlled trials (RCTs) are considered the gold standard for clinical evidence to support the safety and efficacy of medical products due to high levels of internal consistency and reduced bias.
However, as the authors of the study write, “Compared with RCTs, RWE [real-world evidence] better reflects the actual clinical environments in which medical interventions are used, including patient demographics, comorbidities, adherence, and concurrent treatments,” noting that RCTs are costly and time intensive compared to observational studies.
To conduct the study, the authors reviewed 220 clinical trials conducted in the US that were published in the top seven medical journals in 2017 and determined whether RWD obtained from insurance claims and electronic health records (EHRs) contained the information necessary to replicate the studies.
Of those trials, the authors were only able to identify 86 (39%) that “had an intervention that could be ascertained from insurance claims and/or EHR data.” From there, the authors narrowed the trials further to identify ones with an indication and inclusion/exclusion criteria that could be extracted from RWD.
From there the authors were able to identify just 33 (15%) trials with one or more primary endpoints that could be ascertained from available RWD sources.
“This finding suggests the potential for real-world evidence to complement clinical trials, both by examining the concordance between randomized experiments and observational studies and by comparing the generalizability of the trial population with the real-world population of interest,” the authors write.
However, the authors caution that for new products, RWE is unlikely to serve as a replacement for RCTs and point out that many of the trials they looked at could not be replicated because the data necessary to do so “are unlikely to appear in an EHR in structured form if at all.”
But the authors stress that RWE could be used to provide “critical insights” into product safety and efficacy in the postapproval setting and could allow the FDA to identify and act on safety issues more quickly.

Researchers find 15% of trials could be replicated using real world data

In-office gene therapy for wet age-related macular degeneration is coming

Gene therapy is showing promise for one of the most common causes of blindness. Data presented today shows that six patients with wet age-related macular degeneration (AMD) have, so far, gone at least six months without the need for continued injections to control a disease that typically requires treatment every four to six weeks. Researchers say the hope is that gene therapy will free patients from nearly monthly eye injections by offering a potential “one-and-done” treatment. It’s not just about convenience; a more consistent treatment may also help people keep more of their vision. The research will be presented today at AAO 2019, the 123rd Annual Meeting of the American Academy of Ophthalmology.

“This is potentially paradigm shifting,” said lead researcher, Szilárd Kiss, M.D., director of Clinical Research and chief of the Retina Service in the Department of Ophthalmology at Weill Cornell Medical College in New York City. “It’s the next revolutionary leap in treating AMD. When you think about what is science fiction and what is science reality; gene therapy for AMD is becoming a clinical reality.”
Dr. Kiss expects a gene therapy for wet AMD could be available within the next three to five years, depending upon the results of further clinical studies and regulatory approvals.
AMD is the most common cause of vision loss and blindness in Americans over age 50, affecting about 2.1 million people nationwide; a number that’s expected to explode as the population ages. AMD is a degenerative eye disease that happens when part of the retina is damaged. The damage happens when new, weak blood vessels form behind the retina at the back of the eye. These abnormal vessels leak, causing scaring and killing off the cells that allow us to see.
The first revolutionary leap in AMD treatment occurred a little over a decade ago, with the introduction of a new medication called anti-VEGF therapy. It was the first treatment to inhibit the formation of those damaging, new blood vessels, allowing more than 90 percent of patients to keep their vision, according to clinical trials.
However, in the real world, the actual percentage is closer to 50 percent. One main reason why is that patients are undertreated. This is because most people with AMD must go to the ophthalmologist’s office every four to eight weeks for an injection directly into their eye (oftentimes in both eyes). This can be a difficult schedule to maintain for many elderly patients struggling with other maladies and reliant on others to get them to their ophthalmologist visits. It’s also unsustainable for the health care system. Last year alone, ophthalmologists performed more than 8 million anti-VEGF injections in the United States.
Researchers have been searching for a better alternative to monthly injections almost from the moment anti-VEGFs were introduced. Gene therapy is emerging as one of the more promising alternatives to long-term anti-VEGF treatment.
The goal of Dr. Kiss’ research is to develop a gene therapy that allows the eye to make its own anti-VEGF medicine. The ideal gene therapy would be administered not through a surgical procedure in an operating room, but through an injection into the eye that can be done in the doctor’s office, just like routine anti-VEGF treatment is done today.
To do this, Dr. Kiss and colleagues have developed a next-generation vector that can insert into the cells of the eye, genetic material that makes a molecule similar to a widely used anti-VEGF medicine called aflibercept. Once inside the cells, the DNA sequence begins making the aflibercept protein.
“Instead of taking a vile of aflibercept and injecting it into the eye, your eye makes the aflibercept,” Dr. Kiss explained. “The goal is a potentially one-and-done treatment. You may need a booster once in a while, but this gene therapy could theoretically last a lifetime.”
In animal studies, Dr. Kiss and colleagues have shown that this gene therapy works just as well as an injection of aflibercept, with a favorable and manageable side-effect profile.
Dr. Kiss will be presenting today early data on the first human subjects treated. The phase 1 clinical trial has thus far enrolled 12 patients who received a single injection of gene therapy for wet AMD. Prior to the study, the patients had received an average of 35 anti-VEGF injections; one patient had 109. Since entering the gene therapy trial, the patients required no rescue treatments through the first six months.

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Researchers advance search for safer, easier way to deliver vision-saving gene therapy

https://medicalxpress.com/news/2019-10-in-office-gene-therapy-age-related-macular.html

The surprising benefits of weight training

The most common misconception about weight training is that it adds bulky muscle mass, a fear of some women. While elite male lifters can—and want to—get very developed, for most people the result is simply well-toned muscles.
Other benefits are increased mobility, more support for your joints and the ability to stay self-sufficient into your late years.
As an added bonus, having more muscle can also help you with your weight goal. That’s because the more muscle you have, the higher your metabolic rate and the more calories you burn. Add a calorie cut into the mix and you’ll lose weight.
Muscle is denser than fat and it also takes up less room. That’s why you can look leaner yet actually weigh more than someone without muscle definition.
To make the most of strength training, lift heavier weights than you think you’re able to. Yes, challenge yourself, staying within safe limits. You don’t want to try to lift a weight you can barely pick up off the weight rack, but most people underestimate the amount they can handle or fail to progress to heavier weights, according to the American Council on Exercise, and that limits the effectiveness of strength training.
Keep in mind, too, that you don’t have to spend hours in the gym. All you need are 20 to 30 minutes every other day to accomplish training goals. Do one to three short sets—eight reps per set—with high weights and a mix of exercises that target all the major muscle groups.
If you’re new to strength training, get your doctor’s OK first and work with a trainer on proper form.

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Finding the right number of ‘reps’ when strength training

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More information: The American Council on Exercise has more advice on training to lose weight.

https://medicalxpress.com/news/2019-10-benefits-weight.html

AbbVie Stays Busy While Working to Complete Allergan Acquisition

As the $63 billion acquisition of Allergan by Chicago-based AbbVie slowly churns through the Federal Trade Commission (FTC) process, the company continues to make the news. Here’s a look.
Earlier this week, AbbVie presented new data evaluating the safety and efficacy of Skyrizi (risankizumab) at two-and-a-half years in adults with moderate to severe plaque psoriasis. AbbVie also provided additional data on Humira (adalimumab) and its JAK inhibitor upadacitinib at the 28th European Academy of Dermatology and Venereology (EADV) Congress held in Madrid, Spain.
“Leveraging more than two decades of clinical experience with Humira, AbbVie recently expanded its dermatology portfolio with the approval of Skyrizi for patients living with moderate to severe plaque psoriasis,” said Marek Honczarenko, vice president, global immunology development, AbbVie. “The new data presented at EADV will advance the knowledge around new and existing treatments for serious skin diseases, like psoriasis, as well as diseases with high levels of unmet need, such as atopic dermatitis and hidradenitis suppurativa.”
In somewhat related news, AbbVie’s newest TV ads for Skyrizi hit the air yesterday. There are three ads, one 60-second and two 30-second spots. According to TV ad tracker iSpot.tv, the spending hits around $15.6 million.
Skyrizi launched in May and the first TV ad ran in late August. The campaign is called “Nothing is Everything,” focused on the joy of clearer skin.
At least part of the idea is for Skyrizi to replace Humira, which is facing the patent cliff in the next couple years. That’s a steep hill to climb, though. Although Skyrizi brought in $48 million in its first two months of sales, Humira, even though it is beginning to slow from biosimilar competition, brought in $19.9 billion in 2018.
Skyrizi faces competition from Johnson & Johnson’s Tremfya, which was approved in 2017, and Novartis’ Cosentyx and Eli Lilly’s Taltz.
AbbVie told FiercePharma that the public needed more education about psoriasis solutions because many patients “still struggle to achieve their treatment goals due to the complex nature of the disease and variability of treatment response. Skyrizi is an important advance in the treatment of adults with moderate to severe plaque psoriasis who are seeking high levels of skin clearance that can be maintained over time.”
https://www.biospace.com/article/abbvie-stays-busy-while-working-to-complete-allergan-acquisition/

ObamaCare, not Trump, is adding to the number of uninsured Americans

On Sept. 10, the Census Bureau announced that the share of Americans without health insurance increased for the first time since 2010, the year the Affordable Care Act became law.

Defenders of ObamaCare immediately blamed President Trump for the increase in the uninsured rate. House Speaker Nancy Pelosi, never one to mince words, said Trump’s “cruel health care sabotage has left 2 million more people without health insurance.”

But a look at the actual data indicates that ObamaCare itself is driving people into the ranks of the uninsured. Sky-high premiums on the exchanges have priced millions of middle-class families out of the insurance market.

Up until recently, ObamaCare’s expansion of Medicaid had masked the thinning of the exchange pool. Medicaid enrollment swelled by more than 7.5 million between 2013, the year before expansion of the program went into effect, and 2017. So the exit of millions of middle-class families from the exchanges didn’t show up in the total uninsured numbers.
But it was happening nonetheless.
ObamaCare promised to make insurance more affordable by subsidizing premiums, and in some cases out-of-pocket costs, for families with incomes below 400 percent of the poverty line.
At the same time, it piled on benefit mandates and rate regulations that caused premiums to spiral upward. From 2013 to 2017, average individual-market premiums more than doubled. They shot up another 27 percent in 2018.

For those eligible for subsidies, these increases didn’t matter that much. Taxpayers took care of them. Those with incomes above 400 percent of poverty bore the full brunt of these premiums hikes.
So the subsidized part of the ObamaCare market remained stable. But the unsubsidized part started to collapse.

After 2015, the number of people buying insurance on the individual market who weren’t eligible for subsidies plateaued. In 2016, 10 states saw significant enrollment drops: 18 percent in Alaska, 14 percent in Minnesota. In 2017, 44 states saw sharp declines in this market; 43 had declines again last year.
Overall, 1.3 million people dropped out of the unsubsidized individual market in 2017. Last year, another 1.2 dropped out. That’s a 40 percent decline in just two years.
Another half million people who only get partial subsidies because their incomes are close to 400 percent of the poverty level left the individual market in 2018.
In other words, 1.7 million of the 1.9 million who lost insurance in 2018 came from people priced out of insurance by ObamaCare itself.
It is true that this year, average exchange premiums nationwide declined for the first time. But that average obscures the fact that several states continued to see huge jumps. In Washington, they climbed almost 14 percent. They were up 13 percent in Washington, D.C., 12.5 percent in Kentucky, and almost 9 percent in New York.
Premiums for next year are likely to follow a similar pattern. Average premiums will likely be nearly flat. But D.C. residents can expect another 9 percent increase. Premiums in Louisiana will be up almost 12 percent, and in Vermont, 11 percent. New Yorkers will face another 7 percent hike. In Louisiana, that 12 percent increase means unsubsidized families will have to cough up nearly an additional $900 in premiums.
Contrary to the talking points trotted out by ObamaCare’s defenders, average premiums declined in part because of waivers the Trump administration granted to several states, which let them use ObamaCare subsidy money more effectively. A study by the Heritage Foundation found that the median premium in six of these waiver states fell almost 11 percent this year. The median premium increased in the non-waiver states by more than 3 percent.

Five more states have put in for these waivers for next year, with the expectation that it will drive premiums down between 6 percent and 20 percent.
The waivers offer evidence that relaxing ObamaCare’s rigid rules and regulations can make insurance more affordable. And making insurance more affordable is the only sustainable way to make coverage accessible to everyone, especially those that ObamaCare drove into the ranks of the uninsured.
https://www.foxnews.com/opinion/sally-pipes-obamacare-not-trump-is-adding-to-the-number-of-uninsured-americans

Hypertension in youth: ID’ing kids that will develop it is important next step

Target Audience and Goal Statement: Pediatricians, pediatric nephrologists, pediatric cardiologists, pediatric gastroenterologists, family physicians
The goal of this systematic review and meta-analysis was to assess the prevalence of hypertension in the general pediatric population.
Question Addressed:

• What is the prevalence of hypertension in the general pediatric population?

Study Synopsis and Perspective:
How common is high blood pressure (BP) among children and adolescents ages 19 and younger? In a systematic review and meta-analysis of 47 articles (1994-2018), researchers reported that hypertension affected 4% of children worldwide.
Compared with the 1.9% prevalence seen in children and adolescents with normal weight, Yajie Zhu, PhD, of the George Institute for Global Health at the University of Oxford in England, and colleagues found a higher prevalence of hypertension in overweight (4.99%) and obese (15.27%) children.

Action Points

• In a systematic review and meta-analysis of 47 articles, researchers reported that hypertension affected 4% of children ages 19 and younger worldwide.
• Note that the findings suggest that childhood hypertension is becoming more common in the general pediatric population, representing a considerable public health challenge.

While common hypertension varied when measured by different devices, a trend of increasing prevalence of childhood hypertension was seen during the study period, which spanned roughly 2 decades. Taken together, these study findings, published in JAMA Pediatrics, suggest that hypertension is relatively common in children and adolescents. Thus, pediatricians are likely to see children with hypertension in routine clinical practice.
Hypertension in adults, which can take years to develop, is known to be a major risk factor for more than heart disease. Left uncontrolled, the condition can damage the arteries, brain, kidneys, and eyes, among many other effects on the body. About half of people with untreated hypertension die of heart disease. Different lines of evidence have emerged that show that hypertension has immediate adverse effects on the heart and brain and, if present during childhood and adolescence, is linked to markers of subclinical atherosclerosis in adulthood.
From a public health perspective, reliable estimates of the prevalence of childhood hypertension could inform management of the condition and the prevention of its consequences, as well as aid in evidence-based health resource allocation and policy making, according to the group.

Because BP is so variable, hypertension definitions require systolic BP (SBP) or diastolic BP (DBP) to be persistently in the ≥95th percentile on three separate occasions, an approach recommended for children up to age 13 in the most recent American Academy of Pediatrics clinical practice guidelines. Adult guidelines for elevated BP (120-129/<80 mm Hg) and hypertension (BP >130/80 mm Hg) are used for children ≥13 years, but these measurements also need to be elevated persistently on three separate occasions.
“In children, the measurement of blood pressure is relatively complicated and unstable, so it needs to be repeated across at least three different visits to avoid false positive cases,” Zhu told MedPage Today. “Until recently, reliable estimates of childhood hypertension prevalence were lacking.” A previous meta-analysis reported the pooled prevalence of childhood hypertension at 11.2%, for example, but that analysis included studies with only one BP measurement.
Because studies included in the current review and meta-analysis were performed before new guidelines became available, the researchers used standardized definitions of hypertension based on the fourth report from the National High Blood Pressure Education Program (NHBPEP) working group for children and adolescents. Standardized definitions for some of the key BP metrics in this review were:

• Prehypertension: an SBP and/or DBP ≥90th percentile but <95th percentile (for age, sex, and height) or ≥120/80 mm Hg
• Hypertension: an SBP and/or DBP ≥95th percentile (for age, sex, and height) on ≥3 separate occasions
• Stage 1 hypertension: an SBP and/or DBP ≥95th percentile (for age, sex, and height) but ≤99th percentile plus 5 mm Hg (for age, sex, and height) on ≥3 separate occasions
• Stage 2 hypertension: an SBP and/or DBP >99th percentile plus 5 mm Hg (for age, sex, and height) on ≥3 separate occasions

To be eligible for the systematic review, studies needed to be based on a generally representative sample of children and adolescents (≤19 years of age) and provide numerical prevalence estimates of hypertension, prehypertension, stage 1 hypertension, stage 2 hypertension, or different phenotypes of hypertension (systolic hypertension, diastolic hypertension, isolated systolic hypertension, isolated diastolic hypertension, or systolic-diastolic hypertension). Only studies that repeated BP measurements on at least three separate occasions were included in the analysis.
More than two-thirds of the articles (68%) were published from 2010 onwards and the most commonly used device for BP measurement was a mercury sphygmomanometer (40.4%), followed by an oscillometric sphygmomanometer (34%). More than half the studies were conducted in low- and middle-income countries and no single study had an excessive influence on the pooled prevalence.
Pooled prevalence estimates for prehypertension and stage 2 hypertension in children ages 19 and younger were 9.67% and 0.95%, respectively. During a 15-year period (2000-2015), the prevalence of childhood hypertension across a specified age range (6 to 19 years) rose at a relative rate of 75% to 79%. A trend of hypertension with respect to age was also observed. In 2015, the prevalence of hypertension ranged from 4.32% among children age 6 years to 3.28% among those age 19, and peaked at 7.89% among children age 14.

While Zhu’s group unified the definitions of childhood hypertension and its subtypes before pooling the prevalence estimates, they acknowledged the presence of substantial heterogeneity. Uncertainties for pooled prevalence estimates were increased because of the small number of included studies for prehypertension, stage 1 hypertension, and stage 2 hypertension in children. Researchers also noted that the prevalence at the regional level was not optimal for the six World Health Organization regions covered.
Source References: JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.3310
Editorial: JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.3333
Study Highlights and Explanation of Findings:
Using 47 studies that covered urban, rural, and mixed childhood populations in many different countries, combined with a strict definition of hypertension, researchers were able to quantitate its overall prevalence as 4% in children 19 years or younger. Overweight and obese children were more likely to have hypertension than their normal-weight counterparts. Among children ages 6 to 19, the prevalence of hypertension increased from 75% to 79% from 2000 through 2015.
Researchers noted that, to the best of their knowledge, this was the first systematic review and meta-analysis to explore the global prevalence of childhood hypertension based on BP measurements on at least three separate occasions. Study strengths included comprehensive search strategies, a double review process, and stringent selection criteria, increasing the chances of generalizability by selecting studies that were conducted in the general pediatric population.

Hypertension continued to increase before the onset of puberty and during puberty, but this may not be sustained after puberty. “This finding is consistent with the clinical observation of adolescents with persistently high blood pressure, especially during periods of rapid growth in height, who can then have normal blood pressure later in adolescence and young adulthood,” wrote Stephen Daniels, MD, PhD, of the University of Colorado in Aurora, in an accompanying editorial. “It is important for adolescents with hypertension to be followed up over time to determine which adolescents will become healthier and which will develop persistent hypertension.”
Although the authors were not able to use the most recent definition of hypertension, Atul Sharma, MD, and colleagues pointed out that the use of the new clinical practice guidelines would result in elevated BP using National Health and Nutrition Examination Survey data in a separate JAMA Pediatrics study. By extension, Daniels reasoned that the prevalence of hypertension might have been increased in the current analysis.
Consistent with a prior study, the group found systolic hypertension to be common in children and adolescents. Daniels noted that elevated SBP is more closely associated with left ventricular hypertrophy than DBP. Therefore, increases in SBP might not be linked to stress and anxiety “and should be considered to be important for further workup and potential treatment.”
BP measurements should be measured at routine health maintenance visits, and when elevated BP is found, it is important for additional measurements to be made to determine whether hypertension is present, Daniels concluded.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

Primary Source

JAMA Pediatrics

Source Reference: Song P, et al “Global prevalence of hypertension in children: a systematic review and meta-analysis” JAMA Pediatr 2019; DOI: 10.1001/jamapediatrics.2019.3310.

Secondary Source

JAMA Pediatrics

Source Reference: Daniels SR “Understanding the global prevalence of hypertension in children and adolescents” JAMA Pediatr 2019; DOI: 10.1001/jamapediatrics.2019.3333.

Additional Source

MedPage Today

Source Reference: George J “More Children Have High Blood Pressure” 2019.

https://www.medpagetoday.org/neurology/generalneurology/82694?_ga=2.88878491.1081251847.1570409347-265074527.1569866268