Hypertension Management and Control in Primary Care
Study Objective: To describe the management and control of hypertension in primary care practice.
Design: Retrospective medical record review.
Setting: Twenty primary care practices in 14 states.
Patients: Thirteen thousand forty-seven patients with hypertension.
Measurements and Main Results: Diagnoses, drugs prescribed, and blood pressure readings were extracted from the electronic medical record at each practice in the study. For patients with hypertension and comorbid diagnoses, the most recent blood pressure and antihypertensive drugs prescribed were determined. Analyses assessed the blood pressure control rates and the association between control and demographic variables, frequency of visits to the practice site, and pharmacologic treatment patterns. Among the 20 practices in the study, 13,047 patients had received a diagnosis of hypertension and their blood pressures had been measured within the previous 12 months. One third of the patients had comorbid coronary heart disease, diabetes mellitus, heart failure, and/or renal insufficiency. The most recent blood pressure reading was below 140/90 in half the patients. Control was associated with age 60 years or younger, female sex, more than one visit to the practice, more than one comorbidity, and type of practice (p<0.01, logistic regression). Wide variability was noted among practices in the use of multiagent antihypertensive therapy, and in antihypertensive therapy by drug class. Among patients without comorbidity treated with one drug, systolic blood pressure did not differ significantly by drug class. Diastolic blood pressure was slightly lower in patients prescribed thiazide diuretics than in those prescribed angiotensin receptor blockers (p=0.03, analysis of covariance).
Conclusion: Blood pressure control in primary care practice can be much better than reports usually indicate. Good control in this study was not due to specific drug choice, but instead may have been due to regular monitoring of blood pressure and motivation of the practice to improve patient care.
Hypertension is a common condition, affecting more than one quarter of all adults in the United States. A report from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) noted that awareness among those with hypertension was 69%, treatment 58%, and control 31%. Hypertension awareness was defined by self-report in response to an interview question. Treatment was based on self-report of antihypertensive drug therapy received, and control was defined as an average blood pressure below 140/90 mm Hg in patients receiving antihypertensive drug therapy.
Contrasts between these data and results of clinical trials in which careful patient management and drug dosage titration can lower blood pressure to below 140/90 in most patients have led to calls for better management in practices treating ambulatory patients. Specific suggestions have been offered, such as giving greater attention to isolated systolic hypertension, using both nondrug and multidrug therapy more frequently, using computer-based decision support systems, and performing more intensive case management.
However, information is limited regarding approaches to management of hypertension in ambulatory practice. In addition, ambulatory practice data and NHANES data are not strictly comparable; the former data represent patients who seek care, and the latter data represent home-based measurements from a probability sample of the United States population. Our study presents information about the management and control of more than 13,000 patients with hypertension from 20 primary care practices in 14 states across the United States.
Study Objective: To describe the management and control of hypertension in primary care practice.
Design: Retrospective medical record review.
Setting: Twenty primary care practices in 14 states.
Patients: Thirteen thousand forty-seven patients with hypertension.
Measurements and Main Results: Diagnoses, drugs prescribed, and blood pressure readings were extracted from the electronic medical record at each practice in the study. For patients with hypertension and comorbid diagnoses, the most recent blood pressure and antihypertensive drugs prescribed were determined. Analyses assessed the blood pressure control rates and the association between control and demographic variables, frequency of visits to the practice site, and pharmacologic treatment patterns. Among the 20 practices in the study, 13,047 patients had received a diagnosis of hypertension and their blood pressures had been measured within the previous 12 months. One third of the patients had comorbid coronary heart disease, diabetes mellitus, heart failure, and/or renal insufficiency. The most recent blood pressure reading was below 140/90 in half the patients. Control was associated with age 60 years or younger, female sex, more than one visit to the practice, more than one comorbidity, and type of practice (p<0.01, logistic regression). Wide variability was noted among practices in the use of multiagent antihypertensive therapy, and in antihypertensive therapy by drug class. Among patients without comorbidity treated with one drug, systolic blood pressure did not differ significantly by drug class. Diastolic blood pressure was slightly lower in patients prescribed thiazide diuretics than in those prescribed angiotensin receptor blockers (p=0.03, analysis of covariance).
Conclusion: Blood pressure control in primary care practice can be much better than reports usually indicate. Good control in this study was not due to specific drug choice, but instead may have been due to regular monitoring of blood pressure and motivation of the practice to improve patient care.
Hypertension is a common condition, affecting more than one quarter of all adults in the United States. A report from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) noted that awareness among those with hypertension was 69%, treatment 58%, and control 31%. Hypertension awareness was defined by self-report in response to an interview question. Treatment was based on self-report of antihypertensive drug therapy received, and control was defined as an average blood pressure below 140/90 mm Hg in patients receiving antihypertensive drug therapy.
Contrasts between these data and results of clinical trials in which careful patient management and drug dosage titration can lower blood pressure to below 140/90 in most patients have led to calls for better management in practices treating ambulatory patients. Specific suggestions have been offered, such as giving greater attention to isolated systolic hypertension, using both nondrug and multidrug therapy more frequently, using computer-based decision support systems, and performing more intensive case management.
However, information is limited regarding approaches to management of hypertension in ambulatory practice. In addition, ambulatory practice data and NHANES data are not strictly comparable; the former data represent patients who seek care, and the latter data represent home-based measurements from a probability sample of the United States population. Our study presents information about the management and control of more than 13,000 patients with hypertension from 20 primary care practices in 14 states across the United States.