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Peer-reviewedCC BY 4.0PLOS One

Measurement error adjusted prevalence of undiagnosed hypertension in England: A cross-sectional study

  • Alejandra Castanon1
  • Andrew Hughes2
  • Katja Grasic1
  • Martin White2
  • James P. Sheppard3
  • Richard J. McManus3,4
  • Jonathan Pearson-Stuttard1
  • Richard Stevens3
4 affiliations
  1. 1Health Analytics, Lane Clark & Peacock LLP, London, United Kingdom
  2. 2Department of Health and Social Care, Office for Health Improvement and Disparities (OHID), London, United Kingdom
  3. 3Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
  4. 4Brighton and Sussex Medical School, University of Brighton and University of Sussex, Brighton, United Kingdom
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Abstract

Background: Hypertension case-finding and management is key to reducing premature morbidity and mortality. In England, 14.8% of people receive treatment for hypertension but the total number of hypertensive individuals remains unclear, as it can only be estimated statistically. This study aimed to estimate how many individuals aged 40 + may unknowingly have hypertension by accounting for differences between clinic and out-of-office blood pressure readings. Methods: We analysed individual-level data from the 2017–2019 Health Survey for England (HSE), including individuals aged ≥40 without a hypertension diagnosis. A validated algorithm (Predicting Out-of-Office Blood Pressure- PROOF-BP) was applied to estimate likely out-of-office measurements. Observed BP was defined as the mean of the second and third measurement taken at an HSE visit. Predicted hypertension was calculated using PROOF-BP and observed hypertension using actual clinic measurements. We explored a diagnostic threshold for predicted (out-of-office) hypertension of ≥135/85 mmHg (primary outcome) and of ≥140/90 mmHg (secondary outcome). Weighted hypertension prevalence estimates are presented by age, sex and geographical region. National population statistics were used to extrapolate results to the English population. Results: The observed prevalence of undiagnosed hypertension in the study population was 27.7% (95% Confidence Interval [CI]:26.4%−29.1%). The predicted prevalence after adjustment was 21.8% (95%CI:20.6%−23.0%). Predicted prevalence was nearly double in males (29.8%, 95%CI:27.8%−32.0%) compared to females (14.6%, 95%CI:13.3%−15.9%) and varied by region: West Midlands (26.3%, 95%CI:22.2%−31.0%), London (16.9%, 95%CI:13.5%−20.9%). Extrapolating estimates to the total population aged ≥40 in England we estimate approximately 4.2 million people in England are unaware of their hypertension. Of these we estimate that over 2.9 million could be newly diagnosed by the current diagnostic pathway. Conclusions: Over 4 million people in England are estimated to have undiagnosed hypertension. This study’s refined analytical approach provides a more precise estimate of this population, supporting targeted public health initiatives to identify and address undiagnosed cases.

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Cite

BibTeXRIS
BibTeX
@article{castanon2026measurement,
  title = {{Measurement error adjusted prevalence of undiagnosed hypertension in England: A cross-sectional study}},
  author = {Alejandra Castanon and Andrew Hughes and Katja Grasic and Martin White and James P. Sheppard and Richard J. McManus and Jonathan Pearson-Stuttard and Richard Stevens},
  journal = {PLOS One},
  year = {2026},
  month = oct,
  doi = {10.1371/journal.pone.0359861},
  url = {https://doi.org/10.1371/journal.pone.0359861},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Measurement error adjusted prevalence of undiagnosed hypertension in England: A cross-sectional study
AU  - Alejandra Castanon
AU  - Andrew Hughes
AU  - Katja Grasic
AU  - Martin White
AU  - James P. Sheppard
AU  - Richard J. McManus
AU  - Jonathan Pearson-Stuttard
AU  - Richard Stevens
PY  - 2026
DA  - 2026/10/27
JO  - PLOS One
DO  - 10.1371/journal.pone.0359861
UR  - https://doi.org/10.1371/journal.pone.0359861
AB  - Background: Hypertension case-finding and management is key to reducing premature morbidity and mortality. In England, 14.8% of people receive treatment for hypertension but the total number of hypertensive individuals remains unclear, as it can only be estimated statistically. This study aimed to estimate how many individuals aged 40 + may unknowingly have hypertension by accounting for differences between clinic and out-of-office blood pressure readings. Methods: We analysed individual-level data from the 2017–2019 Health Survey for England (HSE), including individuals aged ≥40 without a hypertension diagnosis. A validated algorithm (Predicting Out-of-Office Blood Pressure- PROOF-BP) was applied to estimate likely out-of-office measurements. Observed BP was defined as the mean of the second and third measurement taken at an HSE visit. Predicted hypertension was calculated using PROOF-BP and observed hypertension using actual clinic measurements. We explored a diagnostic threshold for predicted (out-of-office) hypertension of ≥135/85 mmHg (primary outcome) and of ≥140/90 mmHg (secondary outcome). Weighted hypertension prevalence estimates are presented by age, sex and geographical region. National population statistics were used to extrapolate results to the English population. Results: The observed prevalence of undiagnosed hypertension in the study population was 27.7% (95% Confidence Interval [CI]:26.4%−29.1%). The predicted prevalence after adjustment was 21.8% (95%CI:20.6%−23.0%). Predicted prevalence was nearly double in males (29.8%, 95%CI:27.8%−32.0%) compared to females (14.6%, 95%CI:13.3%−15.9%) and varied by region: West Midlands (26.3%, 95%CI:22.2%−31.0%), London (16.9%, 95%CI:13.5%−20.9%). Extrapolating estimates to the total population aged ≥40 in England we estimate approximately 4.2 million people in England are unaware of their hypertension. Of these we estimate that over 2.9 million could be newly diagnosed by the current diagnostic pathway. Conclusions: Over 4 million people in England are estimated to have undiagnosed hypertension. This study’s refined analytical approach provides a more precise estimate of this population, supporting targeted public health initiatives to identify and address undiagnosed cases.
SN  - 1932-6203
ER  -