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Petersen LA, Urech T, Simpson K, Pietz K, Hysong SJ, Profit J, Conrad D, Dudley RA, Lutschg MZ, Petzel R, Woodard LD. Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol. Implement Sci 2011; 6:114. [PMID: 21967830 PMCID: PMC3197549 DOI: 10.1186/1748-5908-6-114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 10/03/2011] [Indexed: 11/29/2022] Open
Abstract
Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens. Methods/design This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period. Discussion We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements. Trial Registration http://www.clinicaltrials.govNCT00302718
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Affiliation(s)
- Laura A Petersen
- Health Policy and Quality Program, Michael E, DeBakey VA Medical Center Health Services Research and Development Center of Excellence, and Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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152
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Banegas JR, Lundelin K, de la Figuera M, de la Cruz JJ, Graciani A, Rodríguez-Artalejo F, Puig JG. Physician perception of blood pressure control and treatment behavior in high-risk hypertensive patients: a cross-sectional study. PLoS One 2011; 6:e24569. [PMID: 21935425 PMCID: PMC3173407 DOI: 10.1371/journal.pone.0024569] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 08/11/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We examined physician perception of blood pressure control and treatment behavior in patients with previous cardiovascular disease and uncontrolled hypertension as defined by European Guidelines. METHODS A cross-sectional study was conducted in which 321 primary care physicians throughout Spain consecutively studied 1,614 patients aged ≥18 years who had been diagnosed and treated for hypertension (blood pressure ≥140/90 mmHg), and had suffered a documented cardiovascular event. The mean value of three blood pressure measurements taken using standardized procedures was used for statistical analysis. RESULTS Mean blood pressure was 143.4/84.9 mmHg, and only 11.6% of these cardiovascular patients were controlled according to 2007 European Guidelines for Hypertension Management target of <130/80 mmHg. In 702 (49.2%) of the 1426 uncontrolled patients, antihypertensive medication was not changed, and in 480 (68.4%) of these cases this was due to the physicians judgment that blood pressure was adequately controlled. In 320 (66.7%) of the latter patients, blood pressure was 130-139/80-89 mmHg. Blood pressure level was the main factor associated (inversely) with no change in treatment due to physician perception of adequate control, irrespective of sociodemographic and clinical factors. CONCLUSIONS Physicians do not change antihypertensive treatment in many uncontrolled cardiovascular patients because they considered it unnecessary, especially when the BP values are only slightly above the guideline target. It is possible that the guidelines may be correct, but there is also the possibility that the care by the physicians is appropriate since BP <130/80 mmHg is hard to achieve, and recent reviews suggest there is insufficient evidence to support such a low BP target.
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Affiliation(s)
- José R Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain.
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153
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Warren-Findlow J, Seymour RB. Prevalence rates of hypertension self-care activities among African Americans. J Natl Med Assoc 2011; 103:503-12. [PMID: 21830634 DOI: 10.1016/s0027-9684(15)30365-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND A comprehensive understanding of the self-care activities that contribute to blood pressure control may explain health disparities experienced by African Americans with hypertension. This study assessed the prevalence of self-care activities among African Americans with high blood pressure and examined differences between adherers and nonadherers to self-care activities. METHODS Interviews were conducted with 186 African Americans. Self-care activities were measured using the H-SCALE (Hypertension Self-Care Activity Level Effects), which was developed to assess the behavioral activities recommended for optimal management of high blood pressure. RESULTS More than half of participants reported adhering to medication recommendations and prescribed physical activity levels (58.6% and 52.2%, respectively). Following practices related to weight management was less frequent, (30.1%) and adherence to low-salt diet recommendations was also low (22.0%). Three-fourths were nonsmokers and 65% abstained from alcohol. Across the self-care activities, adherers were more likely to be older and female. Nonadherers were more likely to be uninsured. CONCLUSIONS Many African Americans still face challenges related to hypertension self-care, particularly with weight management and salt reduction. The H-SCALE was a valid and reliable measure of hypertension self-care activities. In addition to monitoring blood pressure, health care providers should assess patients' hypertension self-care activities using the H-SCALE.
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Affiliation(s)
- Jan Warren-Findlow
- Department of Public Health Sciences, The University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA.
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154
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An Algorithm for the Management of Hypertension in the Setting of Vascular Endothelial Growth Factor Signaling Inhibition. Clin Colorectal Cancer 2011; 10:151-6. [DOI: 10.1016/j.clcc.2011.03.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 01/03/2011] [Accepted: 01/24/2011] [Indexed: 11/18/2022]
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155
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Egan BM, Zhao Y, Axon RN, Brzezinski WA, Ferdinand KC. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation 2011; 124:1046-58. [PMID: 21824920 DOI: 10.1161/circulationaha.111.030189] [Citation(s) in RCA: 453] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure control. METHODS AND RESULTS Subjects included 13,375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANESs) subdivided into 1988 to 1994, 1999 to 2004, and 2005 to 2008. Uncontrolled hypertension was defined as blood pressure ≥140/≥90 mm Hg and apparent treatment-resistant hypertension (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1 to 2 blood pressure medications, and aTRH across all 3 survey periods. More than half of uncontrolled hypertensives were untreated across surveys, including 52.2% in 2005 to 2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0 to 1 per year), body mass index <25 kg/m2, absence of chronic kidney disease, and Framingham 10-year coronary risk <10% (P<0.01). Most treated uncontrolled patients reported taking 1 to 2 blood pressure medications, a proxy for therapeutic inertia. This group was older, had higher Framingham 10-year coronary risk than patients controlled on 1 to 2 medications (P<0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005 to 2008. We found that aTRH increased from 15.9% (1998-2004) to 28.0% (2005-2008) of treated patients (P<0.001). Clinical characteristics associated with aTRH included ≥4 visits per year, obesity, chronic kidney disease, and Framingham 10-year coronary risk >20% (P<0.01). CONCLUSION Untreated, undertreated, and aTRH patients have consistent characteristics that could inform strategies to improve blood pressure control by decreasing untreated hypertension, reducing therapeutic inertia in undertreated patients, and enhancing therapeutic efficiency in aTRH.
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Affiliation(s)
- Brent M Egan
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Ave, 1230 RT, Charleston, SC 29425, USA.
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156
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Seo MH, Lee WJ, Park CY, Kim SR, Park JY, Yoon KH, Lee MK, Park SW. Management of blood pressure in patients with type 2 diabetes mellitus: a nationwide survey in korean. Diabetes Metab J 2011; 35:348-53. [PMID: 21977454 PMCID: PMC3178695 DOI: 10.4093/dmj.2011.35.4.348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 08/11/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Hypertension is common in patients with type 2 diabetes, affecting up to 60% of patients. The Korean Diabetes Association performed a nationwide survey about prevalence, awareness and control of hypertension among diabetic Koreans. METHODS The current survey included 3,859 diabetic patients recruited from 43 hospitals in Korea. Age, gender, height, weight and blood pressure (BP) were measured by standard methods. Data on fasting plasma glucose, glycosylated hemoglobin (HbA1c), awareness of hypertension, and compliance of antihypertensive medication were collected via interview and reviewed using patient medical records. RESULTS A total of 57.5% of all patients were >60 years old. Their mean HbA1c was 7.6±1.5%. Among antihypertensive medication users, 39.9% had <130 mm Hg and <80 mm Hg, whereas 60.1% had ≥130 mm Hg or ≥80 mm Hg. The answer "BP is under good control" was given by 75.1% of the antihypertensive medication users. Out of these patients, 26.4% had <130 mm Hg and <80 mm Hg, whereas 73.6% had ≥130 mm Hg or ≥80 mm Hg. A total of 75.5% of antihypertensive medication users answered that they had taken their antihypertensive medication every day for the past 2 weeks. "Forgetfulness" was most frequently the reason of non-compliance for patients that did not take their antihypertensive medication regularly. CONCLUSION Approximately one third of the patients with diabetes were found to reach target blood pressure control in the 43 hospitals across Korea. Stricter control is needed to reduce severe complications of diabetes in Korea.
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Affiliation(s)
- Mi Hae Seo
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Je Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol Young Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Rae Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Joong Yeol Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kun-Ho Yoon
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Moon Kyu Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Woo Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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157
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Nuckols TK, Aledort JE, Adams J, Lai J, Go MH, Keesey J, McGlynn E. Cost implications of improving blood pressure management among U.S. adults. Health Serv Res 2011; 46:1124-57. [PMID: 21306365 PMCID: PMC3165181 DOI: 10.1111/j.1475-6773.2010.01239.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the cost-effectiveness of improving blood pressure management from the payer perspective. DATA SOURCE/STUDY SETTING Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature. STUDY DESIGN A probability tree depicted blood pressure management over 2 years. DATA COLLECTION/EXTRACTION METHODS We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. PRINCIPAL FINDINGS Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185. CONCLUSIONS Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
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158
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Fearn CL, Brick GY, Lizer S, Doughty A, MacDowell M. Assessment of blood pressure knowledge among workers in a midwestern manufacturing plant. A pilot study. ACTA ACUST UNITED AC 2011; 59:253-63. [PMID: 21627061 DOI: 10.3928/08910162-20110525-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 04/04/2011] [Indexed: 11/20/2022]
Abstract
This pilot study assessed knowledge of blood pressure among employees in a midwestern manufacturing plant. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines were used to define blood pressure categories. The Roy Adaptation Model served as the framework. Results indicated two statistically significant relationships-one between knowledge of blood pressure and employees taking blood pressure medication, and one between employees' knowledge of blood pressure readings and increased interest in learning about lifestyle modifications impacting blood pressure. Of those correctly identifying the blood pressure ranges for prehypertension, 94.4% indicated interest in learning about lifestyle modifications to improve blood pressure. Occupational health nurses in industrial settings have a unique opportunity to influence employees' blood pressure knowledge, which can propel employees to consider lifestyle modifications or wellness programs that may favorably impact indirect and direct costs.
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Affiliation(s)
- Cindy L Fearn
- Workers Compensation and Occupational Health Services, Rockford Orthopedic Associates, Rockford, IL, USA.
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159
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Daugherty SL, Masoudi FA, Ellis JL, Ho PM, Schmittdiel JA, Tavel HM, Selby JV, O'Connor PJ, Margolis KL, Magid DJ. Age-dependent gender differences in hypertension management. J Hypertens 2011; 29:1005-11. [PMID: 21330934 PMCID: PMC3319751 DOI: 10.1097/hjh.0b013e3283449512] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Despite gender-neutral guidelines, prior studies suggest that women have lower rates of hypertension control and these differences may vary with age. Accordingly, we compared rates of hypertension control between women and men as a function of age. METHODS Within three integrated healthcare systems in the Cardiovascular Research Network, we studied all patients seen from 2001 to 2007 with incident hypertension. Within 1 year of cohort entry, patient's hypertension was categorized as controlled based upon achieving guideline-recommended blood pressure levels, recognized if hypertension was diagnosed or a hypertension medication dispensed, and treated based on hypertension medications dispensed. Multivariable logistic regression models assessed the association between gender and 1-year hypertension outcomes, adjusted for patient characteristics. RESULTS Among the 152,561 patients with incident hypertension, 55.6% were women. Compared to men, women were older, had more kidney disease and more blood pressure measures during follow-up. Overall, men tended to have lower rates of hypertension control compared to women (41.2 vs. 45.7%, adjusted odds ratio 0.93, 95% confidence interval 0.91-0.95). A significant gender by age interaction was found with men aged 18-49 having 17% lower odds of hypertension control and men aged at least 65 having 12% higher odds of hypertension control compared to women of similar ages (P<0.001). CONCLUSION In this incident hypertension cohort, younger men and older women had lower rates of hypertension control compared to similarly aged peers. Future studies should investigate why gender differences vary by age in order to plan appropriate means of improving hypertension management regardless of gender or age.
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Affiliation(s)
- Stacie L Daugherty
- Division of Cardiology, 12605 E, 16th Avenue, Mailstop B130, PO Box 6511, Aurora, CO 80045, USA.
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160
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High blood pressure prevalence and control in a middle-aged French population and their associated factors: the MONA LISA study. J Hypertens 2011; 29:43-50. [PMID: 20852444 DOI: 10.1097/hjh.0b013e32833f9c4d] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS This work aims to assess high blood pressure (BP) prevalence and control and their associated factors in a population-based study conducted in three French areas: the Urban Community of Lille and the districts of Bas-Rhin and Haute-Garonne, between 2005 and 2007. METHODS Participants were randomly recruited from electoral rolls after stratification on sex, 10-year age group (35-74 years) and town size. BP was measured by trained medical staff following standardized procedures. High BP was defined as BP at least 140/90 mmHg and/or taking antihypertensive drugs or following a specific diet. BP below 140/90 mmHg among treated individuals was considered adequately controlled (<130/80 mmHg among diabetics). RESULTS Four thousand eight hundred and twenty-five participants were recruited (mean age 55.5 ± 11.3 years). The prevalence of high BP was greater in men (47%) than in women (35%). Antihypertensive treatment concerned 80% of the hypertensive individuals with most often a combination therapy. Control rates concerned only 38% of women and 22% of men and decreased with age. Metabolic risk factors and aging were independently associated with high BP prevalence as were low educational level and alcohol consumption. Diabetes and high cardiovascular risk were strong independent predictors of uncontrolled BP. The use of multiple drug treatment did not predict a better control. CONCLUSIONS Hypertension is frequent in France, particularly in the age group 55-74 years. Control rates remain low, particularly in high-risk, older and diabetic individuals. Intensified efforts are required to improve lifestyle, awareness of the condition, and use of appropriate and well tolerated combination therapy.
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161
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Berni A, Ciani E, Cecioni I, Poggesi L, Abbate R, Boddi M. Adherence to antihypertensive therapy affects Ambulatory Arterial Stiffness Index. Eur J Intern Med 2011; 22:93-8. [PMID: 21238902 DOI: 10.1016/j.ejim.2010.07.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 07/20/2010] [Accepted: 07/21/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND A major contributor to poor blood pressure (BP) control is nonadherence to therapy, which remains poorly recognized by physicians. The prevention of hypertension-induced changes in arterial wall, namely increased arterial stiffness and peripheral vascular resistance, is a reasoned adequate end-point of hypertension treatment. Indirect measurement of these arterial factors can be derived from the analysis of 24-hour Ambulatory BP Monitoring (24 h-ABPM). This pilot study evaluated the association between antihypertensive therapy adherence and 24 h-ABPM-derived parameters in hypertensive patients. METHODS We studied 42 hypertensive patients (70±10 years) in chronic antihypertensive therapy. Patients were divided according to the Morisky Medication Adherence Scale (MMAS) in Low-Adher (MMAS <6) and High-Adher (MMAS 6-8) groups. The Ambulatory Arterial Stiffness Index (AASI) and its symmetric calculation (Sym_AASI) were derived from 24 h-ABPM. A bivariate logistic regression analysis was performed to evaluate the predictive value of MMAS for increased AASIs (i.e. above the median). RESULTS Low-Adher group (n=17) showed higher AASIs compared to High-Adher group (n=25). The two groups were similar in terms of BP burden at the 24 h-ABPM. AASIs were inversely related to MMAS. MMAS resulted a predictor for both increased AASI (O.R. 0.49, 95% CI 0.31-0.76, P<0.01) and increased Sym_AASI (O.R. 0.67, 95% CI 0.47-0.95, P=0.026). After adjustment for PP, age and nocturnal diastolic BP reduction, MMAS persisted as an inverse predictor only of increased AASI. MMAS was also related to the diastolic vs systolic BP correlation coefficient r. CONCLUSIONS Low adherence to antihypertensive therapy seems to be associated with increased standard AASI. In this setting, AASI could represent an additional information derived from the 24 h-ABPM in hypertensive patient evaluation.
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Affiliation(s)
- Andrea Berni
- Department of Medical and Surgical Critical Care, University of Florence, Italy.
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162
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DeVore AD, Sorrentino M, Arnsdorf MF, Ward RP, Bakris GL, Blankstein R. Predictors of hypertension control in a diverse general cardiology practice. J Clin Hypertens (Greenwich) 2010; 12:570-7. [PMID: 20695933 DOI: 10.1111/j.1751-7176.2010.00298.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Factors influencing hypertension (HTN) control in the United States are not well understood. The authors utilized a newly designed survey instrument to interview patients presenting to a diverse, general cardiology practice at a tertiary care center in order to identify factors associated with HTN control. The study was completed in 154 participants, and 121 (78.6%) had HTN. Of those, 111 (91.7%) had awareness of HTN, and 72 (59.5%) had HTN control, defined as <140/90 mm Hg. In a multivariate analysis, race/ethnicity was not associated with HTN control, but private insurance (odds ratio [OR] 3.40, 95% confidence interval [CI] 1.25-9.28), nonsmoker status (OR 4.36, CI 1.22-15.51), and number of medications used (OR 1.32, CI 1.12-1.56) were associated with HTN control. Correct recognition of systolic blood pressure goal and knowledge of one's current state of HTN control were also associated with control. In conclusion, in a general cardiology practice where patients had a high degree of healthcare access, race/ethnicity was not associated with HTN control, while type of insurance, nonsmoker status, and increased number of medications used were associated. In addition, 2 novel predictors of HTN control, recognition of systolic blood pressure goal and knowledge of HTN control, were identified that can be utilized in creating new HTN treatment interventions.
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Affiliation(s)
- Adam D DeVore
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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163
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Van der Niepen P, Verbeelen D. Gender and hypertension management: A sub-analysis of the I-inSYST survey. Blood Press 2010; 20:69-76. [DOI: 10.3109/08037051.2010.532304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Patricia Van der Niepen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dierik Verbeelen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussels, Belgium
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164
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Hocker S, Morales-Vidal S, Schneck MJ. Management of Arterial Blood Pressure in Acute Ischemic and Hemorrhagic Stroke. Neurol Clin 2010; 28:863-86. [DOI: 10.1016/j.ncl.2010.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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165
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Gore JM, Peterson E, Amin A, Anderson FA, Dasta JF, Levy PD, O'Neil BJ, Sung GY, Varon J, Wyman A, Granger CB. Predictors of 90-day readmission among patients with acute severe hypertension. The cross-sectional observational Studying the Treatment of Acute hyperTension (STAT) study. Am Heart J 2010; 160:521-527.e1. [PMID: 20826262 DOI: 10.1016/j.ahj.2010.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/23/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute severe hypertension can be a life-threatening emergency. The objective of this study was to describe the frequency of rehospitalization for patients with acute severe hypertension and to identify clinical predictors of 90-day rehospitalization. METHODS In this observational cross-sectional study, consecutive patients were identified retrospectively (January 2007 to April 2008) through uniform data query of hospital pharmacy databases in 25 hospitals in the United States. Eligible patients were > or =18 years old, had systolic blood pressure >180 mm Hg and/or diastolic blood pressure >110 mm Hg, and had received intravenous antihypertensive therapy within 24 hours of presentation. Data were collected on patient demographics, medical history, laboratory findings, antihypertensive therapies, resource utilization, hospital-associated events, readmission within 90 days of hospital discharge, and death up to 6 months following the index hospitalization. RESULTS The 90-day readmission rate was 35% (354/1,009) of patients discharged home alive and with known readmission status; 41% (144/354) were readmitted more than once. Of these 354 patients, readmission was for acute severe hypertension in 29% (n = 101). Eighteen (1.9%) patients died between hospital discharge and 90 days. Factors associated with readmission for hypertension included previous hospitalization for acute severe hypertension, history of drug abuse, and presenting with seizures or shortness of breath. Patients with an admitting diagnosis of hypertension were 94% more likely to be readmitted. CONCLUSIONS More than one third of patients discharged home after hospitalization for severe hypertension were rehospitalized at least once within 90 days, more than one quarter for acute severe hypertension. Further studies are warranted to determine the impact of other variables on readmission rates and clinical outcomes in this population.
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166
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Naik AD, Rodriguez E, Rao R, Teinert D, Abraham NS, Kalavar J. Quality improvement initiative for rapid induction of hypertension control in primary care. Circ Cardiovasc Qual Outcomes 2010; 3:558-64. [PMID: 20841550 PMCID: PMC3057033 DOI: 10.1161/circoutcomes.109.913137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 07/07/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Aanand D Naik
- Houston Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA.
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167
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Hypertension in the ED: a multifaceted intervention to change provider practice. Am J Emerg Med 2010; 29:796-801. [PMID: 20685061 DOI: 10.1016/j.ajem.2010.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 05/04/2010] [Accepted: 05/08/2010] [Indexed: 01/11/2023] Open
Abstract
This project measured the effect of a multifaceted intervention on health care provider identification and treatment of undiagnosed hypertensive patients. The intervention comprised provider education, audit, and feedback. The primary outcomes were pre-/postintervention differences in the proportion of patients presenting with elevated blood pressure who were (1) identified, (2) given blood pressure measurements, (3) counseled regarding behavior change, (4) prescribed medications, and (5) advised of the need for follow-up. These 5 behaviors were selected based on the recommendations in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Rates of all 5 outcomes improved significantly after the intervention, with prevalence differences ranging from 5% to 25%. However, despite increases, rates for each behavior remained low. At no point during the study were all 5 practitioner behaviors documented for an individual patient. In conclusion, while an intervention composed of education and practitioner audit and feedback improved practitioner behaviors in treating patients with elevated blood pressure, additional interventions are needed to bring practitioner behaviors up to the level of JACHO standards.
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168
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Schmieder RE, Böhm M. Efficacy and safety of olmesartan medoxomil plus amlodipine in age, gender and hypertension severity defined subgroups of hypertensive patients. J Hum Hypertens 2010; 25:354-63. [PMID: 20686499 DOI: 10.1038/jhh.2010.74] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Effective antihypertensive therapy is crucial for preventing cardiovascular events; however, blood pressure (BP) control rates remain poor. The objective of this analysis was to determine the efficacy of olmesartan/amlodipine in age, severity and gender-based subgroups of patients with moderate-to-severe hypertension uncontrolled by amlodipine monotherapy. Patients with uncontrolled BP after 8 weeks' amlodipine 5 mg monotherapy (n=755) were randomized to continue amlodipine 5 mg or receive olmesartan (10-40 mg) plus amlodipine 5 mg for 8 weeks. Patients whose BP remained suboptimal were up-titrated to olmesartan/amlodipine 20/5, 40/5 or 40/10 mg. Changes in BP and numbers of controlled patients were calculated separately to assess efficacy in patients aged <65 or ≥65 years, in those with moderate or severe hypertension, and in males and females. The antihypertensive effects of olmesartan/amlodipine were similar in patients aged <65 and ≥65 years of age. Compared with patients with moderate hypertension at baseline, those with severe hypertension tended to show higher decreases in BP, but achieved lower goal rates despite this. Females showed larger mean reductions in diastolic (1.61 mm Hg; P=0.003) and systolic BP (1.72 mm Hg; P=0.053) than males, independent of age and dose. This gender difference appeared to be higher and more consistent across dose groups for patients <50 years of age, but the difference in the pattern between both age groups was not statistically significant (P=0.1526). These results suggest that olmesartan/amlodipine is effective and safe in a wide range of patients, regardless of age or hypertension severity. Small differences in responsiveness between females and males may exist, which require further investigation.
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Affiliation(s)
- R E Schmieder
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, Erlangen, Germany.
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169
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Hsu YH, Mao CL, Wey M. Antihypertensive Medication Adherence Among Elderly Chinese Americans. J Transcult Nurs 2010; 21:297-305. [DOI: 10.1177/1043659609360707] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored the level of antihypertensive medication adherence and examined certain demographic attributes and influential factors in relation to antihypertensive medication nonadherence among Chinese American elders using a descriptive cross-sectional survey design. Findings revealed that 52% of the elderly Chinese Americans adhered to their antihypertensive medications. Gender, education, years of residency in the United States, years of diagnosed hypertension, and perceived safety of taking antihypertensive medications did not contribute to the differences in medication adherence. Forgetfulness, medication adverse effects, language difficulties, and cultural barriers were the influential factors that hinder antihypertensive medication adherence. Developing effective and culturally appropriate strategies for Chinese American elders is recommended.
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Affiliation(s)
- Ya-Hui Hsu
- Santa Clara Valley Health and Hospital System, San Jose, CA, USA
| | | | - Mercy Wey
- San Jose State University, San Jose, CA, USA,
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170
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Go AS, Magid DJ, Wells B, Sung SH, Cassidy-Bushrow AE, Greenlee RT, Langer RD, Lieu TA, Margolis KL, Masoudi FA, McNeal CJ, Murata GH, Newton KM, Novotny R, Reynolds K, Roblin DW, Smith DH, Vupputuri S, White RE, Olson J, Rumsfeld JS, Gurwitz JH. The Cardiovascular Research Network: a new paradigm for cardiovascular quality and outcomes research. Circ Cardiovasc Qual Outcomes 2010; 1:138-47. [PMID: 20031802 DOI: 10.1161/circoutcomes.108.801654] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A clear need exists for a more systematic understanding of the epidemiology, diagnosis, and management of cardiovascular diseases. More robust data are also needed on how well clinical trials are translated into contemporary community practice and the associated resource use, costs, and outcomes. METHODS AND RESULTS The National Heart, Lung, and Blood Institute recently established the Cardiovascular Research Network, which represents a new paradigm to evaluate the epidemiology, quality of care, and outcomes of cardiovascular disease and to conduct future clinical trials using a community-based model. The network includes 15 geographically distributed health plans with dedicated research centers, National Heart, Lung, and Blood Institute representatives, and an external collaboration and advisory committee. Cardiovascular research network sites bring complementary content and methodological expertise and a diverse population of approximately 11 million individuals treated through various health care delivery models. Each site's rich electronic databases (eg, sociodemographic characteristics, inpatient and outpatient diagnoses and procedures, pharmacy, laboratory, and cost data) are being mapped to create a standardized virtual data warehouse to facilitate rapid and efficient large-scale research studies. Initial projects focus on (1) hypertension recognition and management, (2) quality and outcomes of warfarin therapy, and (3) use, outcomes, and costs of implantable cardioverter defibrillators. CONCLUSIONS The Cardiovascular Research Network represents a new paradigm in the approach to cardiovascular quality of care and outcomes research among community-based populations. Its unique ability to characterize longitudinally large, diverse populations will yield novel insights into contemporary disease and risk factor surveillance, management, outcomes, and costs. The Cardiovascular Research Network aims to become the national research partner of choice for efforts to improve the prevention, diagnosis, treatment, and outcomes of cardiovascular diseases.
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Affiliation(s)
- Alan S Go
- Kaiser Permanente Northern California, University of California, San Francisco, Calif, USA.
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171
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Mechtouff L, Touzé E, Steg PG, Ohman EM, Goto S, Hirsch AT, Röther J, Aichner FT, Weimar C, Bhatt DL, Alberts MJ, Mas JL. Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease. J Intern Med 2010; 267:621-33. [PMID: 20210837 DOI: 10.1111/j.1365-2796.2009.02198.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Poor blood pressure (BP) control is common amongst patients with symptomatic atherothrombotic disease. It is unclear whether BP control and management differ across atherothrombotic disease subtypes. METHODS We analysed the baseline data of 44,984 patients with documented coronary artery disease (CAD) only (n = 30,414), cerebrovascular disease (CVD) only (n = 11,359) and peripheral arterial disease (PAD) only (n = 3211) from the international REduction of Atherothrombosis for Continued Health Registry and investigated the impact of atherothrombotic disease subtype on BP control and use of antihypertensive drugs. RESULTS The proportion of patients with BP controlled (<140/90 mmHg) was higher in CAD (58.1%) than in CVD (44.8%) or PAD (38.9%) patients (P < 0.001). Amongst patients with treated hypertension, CAD patients were more likely to have BP controlled than were CVD patients [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.59-1.75] or PAD (OR = 2.30; 95% CI = 2.10-2.52). These differences were smaller in women than in men and decreased with age. Amongst treated patients, CAD patients were more likely to receive > or =3-drug combination therapies than were CVD (OR = 1.73; 95% CI = 1.64-1.83) or PAD (OR = 1.64; 95% CI = 1.49-1.80) patients. Adjustment for age, gender, waist obesity, diabetes, education level and world region did not alter the results. CONCLUSIONS Coronary artery disease patients are more likely than CVD or PAD patients to have BP controlled and to receive antihypertensive drugs, particularly combination therapies. Promotion of more effective BP control through combination antihypertensive therapies could improve secondary prevention and therefore prevent complications in CVD and PAD patients.
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Affiliation(s)
- L Mechtouff
- Department of Neurology, Hôpital Sainte-Anne, Paris-Descartes University, INSERM U894, Paris, France
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172
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Abstract
Eprosartan is an angiotensin II receptor antagonist (angiotensin II receptor blocker [ARB]) used in the treatment of hypertension. In large, randomized trials, eprosartan (with or without hydrochlorothiazide [HCTZ]) demonstrated superior antihypertensive efficacy to that of placebo and, when administered at comparable dosage regimens, had similar blood pressure-lowering effects to enalapril. Eprosartan was generally well tolerated in clinical trials and had a lower incidence of persistent dry cough than enalapril. Eprosartan has a neutral effect on metabolic parameters, such as serum lipid levels and glucose homeostasis, and a low propensity for pharmacokinetic drug interactions. The use of eprosartan or other ARBs in combination with HCTZ tends to reverse the potassium loss associated with thiazide diuretics. Independent of its antihypertensive effects, eprosartan was associated with improved clinical outcomes (primary composite endpoint of all causes of mortality and all cardiovascular and cerebrovascular events, including all recurrent events) compared with nitrendipine in a randomized, secondary prevention trial in hypertensive patients with previous cerebrovascular events (MOSES trial). Eprosartan also reduced blood pressure and was associated with a modest improvement in cognitive function in a large observational study in patients > or =50 years of age with newly diagnosed hypertension (OSCAR study). In both of these trials, additional antihypertensive therapy, such as HCTZ, was permitted. Therefore, eprosartan is a useful treatment option in the management of a broad range of patients with hypertension, and its use with HCTZ provides a rational combination regimen.
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173
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Signorovitch J, Zhang J, Wu EQ, Latremouille-Viau D, Yu AP, Dastani HB, Kahler KH. Economic impact of switching from valsartan to other angiotensin receptor blockers in patients with hypertension. Curr Med Res Opin 2010; 26:849-60. [PMID: 20141381 DOI: 10.1185/03007991003613910] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The approaching availability of lower-cost generic angiotensin receptor blockers (ARBs) may affect formulary policies for patients maintained on the ARB valsartan. OBJECTIVE Estimate the economic impact of switching from valsartan (including valsartan-based single-pill combinations) to other ARBs without apparent medical reasons. RESEARCH DESIGN AND METHODS Patients with essential hypertension and at least 6 months of continuous valsartan treatment free of hospitalization, cardiovascular events, renal events or ARB-associated adverse events were identified from the MarketScan administrative claims database from January 1, 2004 to March 31, 2008. Those who subsequently switched to a different ARB with at least a 5% copayment decrease (switchers) were matched to those who did not switch (maintainers) according to propensity score quintiles and selected baseline characteristics. Refills were not required after the index fill for the switched-to ARB or maintained valsartan. Matched switchers and maintainers were compared in terms of medication discontinuation, healthcare resource use and costs during the 6 months following the index fill. RESULTS A total of 99,926 valsartan maintainers and 2150 switchers (with a mean copayment decrease of $16.5 per month) were identified and matched. After matching, switching from versus maintaining valsartan was associated with an 8% higher risk of medication discontinuation (p < 0.008), 19.1 additional outpatient visits/100 patients (p = 0.002) and 9.3 additional hypertension-related inpatient days/100 patients (p = 0.030). Concurrently, switching from versus maintaining valsartan was associated with higher total medical costs by $748/patient (p < 0.001), driven largely by higher costs for hypertension-related medical services by $492/patient (p = 0.004). LIMITATIONS Exact reasons for switching were not available and the study assessed only the short-term impacts of switching. CONCLUSIONS Hypertension patients maintained on valsartan who switched to a different ARB with a lower copayment experienced substantial increases in medication discontinuation, healthcare resource use and costs compared to those who maintained valsartan treatment.
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174
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Chen J, Normand SLT, Wang Y, Drye EE, Schreiner GC, Krumholz HM. Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges. Circulation 2010; 121:1322-8. [PMID: 20212281 DOI: 10.1161/circulationaha.109.862094] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Amid recent efforts to reduce cardiovascular risk, whether rates of acute myocardial infarction (AMI) in the United States have declined for elderly patients is unknown. METHODS AND RESULTS Medicare fee-for-service patients hospitalized in the United States with a principal discharge diagnosis of AMI were identified through the use of data from the Centers for Medicare and Medicaid Services from 2002 to 2007, a time period selected to reduce changes arising from the new definition of AMI. The Medicare beneficiary denominator file was used to determine the population at risk. AMI hospitalization rates were calculated annually per 100,000 beneficiary-years with Poisson regression analysis and stratified according to age, sex, and race. The annual AMI hospitalization rate in the fee-for-service Medicare population fell from 1131 per 100,000 beneficiary-years in 2002 to 866 in 2007, a relative 23.4% decline. After adjustment for age, sex, and race, the AMI hospitalization rate declined by 5.8%/y. From 2002 to 2007, white men experienced a 24.4% decrease in AMI hospitalizations, whereas black men experienced a smaller decline (18.0%; P<0.001 for interaction). Black women had a smaller decline in AMI hospitalization rate compared with white women (18.4% versus 23.3%, respectively; P<0.001 for interaction). CONCLUSIONS AMI hospitalization rates fell markedly in the Medicare fee-for-service population between 2002 and 2007. However, black men and women appeared to have had a slower rate of decline compared with their white counterparts.
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Affiliation(s)
- Jersey Chen
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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175
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Yang SJ, Jung D, Choi AS. Prediction model of blood pressure control in community-dwelling hypertensive adults in Korea. Nurs Health Sci 2010; 12:105-12. [DOI: 10.1111/j.1442-2018.2009.00501.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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176
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Mukherjee JJ, Khoo CM, Thai AC, Chionh SB, Pin L, Lee KO. Type 2 diabetic patients with resistant hypertension should be screened for primary aldosteronism. Diab Vasc Dis Res 2010; 7:6-13. [PMID: 20368227 DOI: 10.1177/1479164109350556] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BP control in diabetic patients is often poor. The contribution of secondary hypertension due to undiagnosed PA in hypertensive type 2 diabetic patients is not well studied. We prospectively screened 100 consecutive Asian type 2 diabetic patients with difficult-to-control or resistant hypertension for PA. PAC (pmol/L) to PRA (ng/mL/h) ratio was measured; those with PAC-to-PRA ratio >550 (corresponding PAC >415) underwent intravenous 0.9% SLT. Patients with PAC >/=140 following SLT had CT adrenals and bilateral AVS. Thirteen patients (13%) were confirmed to have PA, and all had resistant hypertension. Eight had a surgically correctable form of PA. Patients with PA had higher mean (SD) systolic [159.0 (10.6) vs. 146.0 (10.7) mmHg, p=0.001] and diastolic BP [94.6 (6.0) vs. 87.6 (5.9) mmHg, p=0.001], lower serum potassium [3.5 (0.6) vs. 4.3 (0.5) mmol/L, p=0.001], and higher PAC [679.3 (291.0) vs. 239.5 (169.4) pmol/L, p=0.001]. Identification and institution of definitive treatment for PA resulted in better BP control and in a reduction in the use of antihypertensive medications. Our findings demonstrate a high prevalence of PA in type 2 diabetic patients with resistant hypertension. Systematic screening for PA in this select group is recommended, as targeted treatment improves BP control.
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Affiliation(s)
- J J Mukherjee
- Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore.
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177
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Iyer A, Ahmed MI, Filippatos G, Ekundayo OJ, Aban I, Love TE, Nanda N, Bakris GL, Fonarow G, Aronow WS, Ahmed A. Uncontrolled hypertension and increased risk for incident heart failure in older adults with hypertension: findings from a propensity-matched prospective population study. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2010; 4:22-31. [PMID: 20374948 PMCID: PMC2914566 DOI: 10.1016/j.jash.2010.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Revised: 01/20/2010] [Accepted: 02/02/2010] [Indexed: 11/29/2022]
Abstract
Hypertension is a risk factor for incident heart failure (HF). However, the effect of uncontrolled blood pressure (BP) on incident HF in older adults with hypertension has not been prospectively examined in propensity-matched studies. Of the 5795 Cardiovascular Health Study participants, > or =65 years, 2562 with self-reported physician-diagnosed hypertension had no baseline HF. Of these, 1391 had uncontrolled hypertension, defined as systolic BP (SBP) > or =140 (n = 1373) or diastolic BP > or =90 mm Hg (n = 18). Propensity scores for uncontrolled hypertension, calculated for each participant, were used to assemble a cohort of 1021 pairs of participants with controlled and uncontrolled hypertension who were balanced on 31 baseline characteristics. Centrally adjudicated incident HF developed in 23% and 26% of participants with controlled and uncontrolled hypertension respectively during 13 years of follow-up (matched hazard ratio [HR] when uncontrolled hypertension was compared with controlled hypertension, 1.39; 95% confidence interval [CI], 1.12 to 1.73; P = .003). HRs (95% CI) for incident HF for those with (n = 503) and without (n = 1539) chronic kidney disease (CKD) were 1.73 (95% CI, 1.26 to 2.38; P = .001) and 1.08 (95% CI, 0.87 to 1.34; P = .486) respectively (P for interaction, .012). Compared with participants with controlled hypertension, HRs for incident HF associated with SBP 140 to 159 and > or =160 mm Hg were 1.06 (95% CI, 0.86 to 1.31; P = .572) and 1.58 (95% CI, 1.27 to 1.96; P < .0001), respectively. In community-dwelling older adults with hypertension, those with uncontrolled (versus controlled) BP have increased risk of new-onset HF, which is more pronounced in those with SBP > or =160 mm Hg and with CKD.
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Affiliation(s)
- Anand Iyer
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - O James Ekundayo
- University of California at Los Angeles, Los Angeles, California, USA
| | - Inmaculada Aban
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Navin Nanda
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Gregg Fonarow
- University of California at Los Angeles, Los Angeles, California, USA
| | | | - Ali Ahmed
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- VA Medical Center, Birmingham, Alabama, USA
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178
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Ferrario CM, Flack JM, Strobeck JE, Smits G, Peters C. Individualizing hypertension treatment with impedance cardiography: a meta-analysis of published trials. Ther Adv Cardiovasc Dis 2009; 4:5-16. [DOI: 10.1177/1753944709348236] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Hypertension affects 73 million Americans and costs the US healthcare system over $73 billion annually. Despite increasing awareness of the consequences of uncontrolled hypertension, numerous antihypertensive pharmacologic clinical studies and consistent updates to hypertension guidelines, control rates are suboptimal and have not met national goals. Among treated hypertensives, only 45% of women and 51% of men have reached blood pressure (BP) levels below 140/90 mmHg. Individualization of antihypertensive regimens with hemodynamic information from impedance cardiography (ICG) has been advocated to further improve hypertension control rates. We therefore undertook a quantitative analysis of the trials evaluating the role of ICG as an adjunct to therapeutic decision-making in the treatment of hypertension and the attainment of BP control. Methods: Five studies comprising a total population of 759 patients met the inclusion criteria. Two randomized controlled trials (RCTs) involving a total of 268 patients and three single-arm prospective trials with 491 patients were evaluated using ICG data to guide therapeutic decision-making in the treatment of hypertensive patients. Results: Significant benefit was found in both RCTs for ICG-guided BP treatment. The combined odds ratio for the two trials was 2.41 (95% CI = 1.44-4.05, p = 0.0008), in favor of ICG treatment, meaning that it was more than twice as likely to achieve BP success when using ICG than if ICG was not used. Success attainment of goal BP of <140/90 mmHg was 67% in the ICG-guided arms of the combined randomized trials. Overall success in the single-arm prospective trials of ICG-guided BP treatment was a similar 68%. Conclusion: The results of this meta-analysis confirm the value of using ICG-derived hemodynamic data as an adjunct to therapeutic decision-making in the treatment of hypertension. The data reviewed here demonstrate that ICG-based approaches are in keeping with previously advocated strategies incorporating patient-individualized drug regimens, evidence-based medicine, and practical, easy to apply, cost-effective principles to further improve hypertension control rates.
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Affiliation(s)
- Carlos M. Ferrario
- Hypertension and Vascular Research Center, Wake Forest University Medical Center, Winston-Salem, North Carolina, USA,
| | - John M. Flack
- Wayne State University, University Health Center, Detroit, MI 48201, USA
| | - John E. Strobeck
- Heart-Lung Associates of America, PA, Hawthorne, New Jersey 07506
| | - Gerard Smits
- Biostatistical Consulting Services, Santa Barbara, CA 93105, USA
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179
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Banegas JR, Messerli FH, Waeber B, Rodríguez-Artalejo F, de la Sierra A, Segura J, Roca-Cusachs A, Aranda P, Ruilope LM. Discrepancies between office and ambulatory blood pressure: clinical implications. Am J Med 2009; 122:1136-41. [PMID: 19958892 DOI: 10.1016/j.amjmed.2009.05.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/27/2009] [Accepted: 05/01/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent trials have documented no benefit from small reductions in blood pressure measured in the clinical office. However, ambulatory blood pressure is a better predictor of cardiovascular events than office-based blood pressure. We assessed control of ambulatory blood pressure in treated hypertensive patients at high cardiovascular risk. METHODS We selected 4729 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Patients were aged >/=55 years and presented with at least one of the following co-morbidities: coronary heart disease, stroke, and diabetes with end-organ damage. An average of 2 measures of blood pressure in the office was used for analyses. Also, 24-hour ambulatory blood pressure was recorded at 20-minute intervals with a SpaceLabs 90207 device. RESULTS Patients had a mean age of 69.6 (+/-8.2) years, and 60.8% of them were male. Average time from the diagnosis of hypertension to recruitment into the Registry was 10.9 (+/-8.4) years. Mean blood pressure in the office was 152.3/82.3 mm Hg, and mean 24-hour ambulatory blood pressure was 133.3/72.4 mm Hg. About 60% of patients with an office-pressure of 130-139/85-89 mm Hg, 42.4% with office-pressure of 140-159/90-99 mm Hg, and 23.3% with office-pressure > or =160/100 mm Hg were actually normotensive, according to 24-hour ambulatory blood pressure criteria (<130/80 mm Hg). CONCLUSION We suggest that the lack of benefit of antihypertensive therapy in some trials may partly be due to some patients having normal pressure at trial baseline. Ambulatory monitoring of blood pressure may allow for a better assessment of trial eligibility.
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Affiliation(s)
- José R Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Spain
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180
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[Use of C-arm CT for improving the hit rate for selective blood sampling from adrenal veins]. Radiologe 2009; 49:848-51. [PMID: 19697002 DOI: 10.1007/s00117-009-1865-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary hyperaldosteronism is the most common curable cause of hypertension with a prevalence of up to 12% among patients with hypertension. Selective blood sampling from adrenal veins is considered the diagnostic gold standard. However, it is underutilized due to the high technical failure rate. The use of C-arm CT during the sampling procedure can reduce or even eliminate this failure rate. If adrenal vein sampling is augmented by native C-arm CT to check for the correct catheter position, the technical success rate increases substantially. General use of this technique will result in correct diagnosis and treatment for patients with primary hyperaldosteronism.
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181
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Trends in blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004. J Hypertens 2009; 27:1908-16. [PMID: 19491704 DOI: 10.1097/hjh.0b013e32832d4aee] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to examine the trends in the prevalence of type 2 diabetic patients with comorbid hypertension and blood pressure (BP) control rates in the United States and determine factors associated with these outcomes. METHODS We used data from National Health and Nutrition Examination Surveys (NHANES) III (1988-1994) and NHANES 1999-2004, a cross-sectional sample of the noninstitutionalized US populations. Type 2 diabetic patients were identified as patients at least 30 years of age with physician-diagnosed diabetes who were taking insulin or oral antidiabetic drugs to manage the condition. A diagnosis of hypertension was based on physician diagnosis, treatment with antihypertensive medications, or BP at least 140/90 mmHg. BP control was defined as diabetic patients who maintained BP <130/80 mmHg. Logistic regression was used to estimate risks of high BP, and odds of high BP treatment and control rates, after adjusting for demographic and clinical risk factors. RESULTS The age-adjusted prevalence of diabetic patients and those with hypertension increased significantly from 5.8 to 7.1% and 3.9 to 4.7%, respectively, from NHANES III to NHANES 1999-2004. Among diabetic patients with hypertension, patients who were treated with medication or lifestyle or behavioral modification therapy have increased significantly from 76.5 to 87.8% during the observation period. The proportion of patients who controlled BP increased from 15.9 to 29.6%, but 70% of patients still did not meet the target BP goal. CONCLUSION Aggressive public health efforts are needed to improve BP control in type 2 diabetic patients with hypertension.
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182
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Despite evidence-based guidelines, systolic blood pressure remains inadequately controlled in older hypertensive adults. J Hum Hypertens 2009; 24:439-46. [DOI: 10.1038/jhh.2009.85] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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183
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Ham OK, Yang SJ. Lifestyle factors associated with blood pressure control among those taking antihypertensive medication. Asia Pac J Public Health 2009; 23:485-95. [PMID: 19825840 DOI: 10.1177/1010539509347941] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to explore the relations between lifestyle factors and blood pressure (BP) control among patients with hypertension who were regularly taking antihypertensive medication as prescribed. From the 2005 Korean National Health and Nutrition Examination Survey data, the 690 individuals diagnosed with hypertension who were regularly taking antihypertensive medication were identified. Slightly more than half of the patients (54.3%) had their BP under control. Younger patients, those having one or more comorbidities and those performing physical activity at least 4 days a week were more likely to have their BP under control, while overweight patients, heavy alcohol drinkers, and those with mild to very severe stress had lower rates of BP control. The study results suggested that to reduce uncontrolled BP, public health efforts should target old and overweight patients and those with unhealthy lifestyles including heavy alcohol drinking, stress, and lack of physical activity.
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184
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Gupta S, Agrawal BK, Goel RK, Sehajpal PK. Angiotensin-converting enzyme gene polymorphism in hypertensive rural population of Haryana, India. J Emerg Trauma Shock 2009; 2:150-4. [PMID: 20009302 PMCID: PMC2776360 DOI: 10.4103/0974-2700.55323] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 04/03/2009] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Essential hypertension is a complex genetic disorder influenced by diverse environmental factors. Of the various physiological pathways affecting the homeostasis of blood pressure, the renin-angiotensin system (RAS) is known to play a critical role. Angiotensin-I converting enzyme (ACE) is a significant component of RAS and an insertion/deletion (I/D) polymorphism in its gene has been implicated in predisposition to hypertension. OBJECTIVE The present study is aimed to determine the association, if any, of ACE I/D polymorphism with essential hypertension in a rural population of Haryana, India. MATERIALS AND METHODS The blood samples were collected from the patients visiting M. M. Institute of Medical Sciences, Mullana, Haryana. DNA from the patients (106) and control (110) specimens were isolated, amplified by PCR and analyzed employing agarose gel electrophoresis. RESULTS There was no significant difference in the distribution of DD, II and I/D genotypes of ACE polymorphism in essential hypertensive patients (28.8, 25.5, and 46.2%) and their ethnically matched normal control (24.5, 30, and 45.5), respectively. The two groups also presented with very similar allelic frequencies and were also found to be in Hardy-Weinberg equilibrium. CONCLUSIONS The present study demonstrates that ACE I/D polymorphism is not a risk factor for essential hypertension in the hitherto unstudied rural population of Haryana.
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Affiliation(s)
- Sumeet Gupta
- Department of Pharmacology, M. M. College of Pharmacy, M. M. University, Mullana, Haryana, India
| | - Bimal K Agrawal
- Department of Medicine, M. M. Institute of Medical Sciences, M. M. University, Mullana, Haryana, India
| | - Rajesh K Goel
- Department of Pharmacology, Punjabi university, Patiala, Punjab, India
| | - Prabodh K Sehajpal
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritstar, Punjab, India
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185
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Evaluation of the awareness, control and cost-effectiveness of hypertension treatment in a Brazilian city: populational study. J Hypertens 2009; 27:1900-7. [DOI: 10.1097/hjh.0b013e32832dd10f] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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186
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Antihypertensive properties of plant-based prebiotics. Int J Mol Sci 2009; 10:3517-3530. [PMID: 20111692 PMCID: PMC2812835 DOI: 10.3390/ijms10083517] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 07/14/2009] [Accepted: 07/28/2009] [Indexed: 11/17/2022] Open
Abstract
Hypertension is one of the major risk factors for cardiovascular disease. Although various drugs for its treatment have been synthesized, the occurring side effects have generated the need for natural interventions for the treatment and prevention of hypertension. Dietary intervention such as the administration of prebiotics has been seen as a highly acceptable approach. Prebiotics are indigestible food ingredients that bypass digestion and reach the lower gut as substrates for indigenous microflora. Most of the prebiotics used as food adjuncts, such as inulin, fructooligosaccharides, dietary fiber and gums, are derived from plants. Experimental evidence from recent studies has suggested that prebiotics are capable of reducing and preventing hypertension. This paper will discuss some of the mechanisms involved, the evidence generated from both in-vitro experiments and in-vivo trials and some controversial findings that are raised.
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187
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Dall TM, Fulgoni VL, Zhang Y, Reimers KJ, Packard PT, Astwood JD. Predicted national productivity implications of calorie and sodium reductions in the American diet. Am J Health Promot 2009; 23:423-30. [PMID: 19601482 DOI: 10.4278/ajhp.081010-quan-227] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To model the potential long-term national productivity benefits from reduced daily intake of calories and sodium. DESIGN Simulation based on secondary data analysis; quantitative research. Measures include absenteeism, presenteeism, disability, and premature mortality under various hypothetical dietary changes. SETTING United States. SUBJECTS Two hundred twenty-five million adults. MEASURES Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports. ANALYSIS We compare current estimates of national productivity loss associated with overweight, obesity, and hypertension to estimates for hypothetical scenarios in which national prevalence of these risk factors is lower. Using the simulation model, we illustrate how modest dietary change can achieve lower national prevalence of excess weight and hypertension. RESULTS We estimate that permanent 100-kcal reductions in daily intake among the overweight/obese would eliminate approximately 71.2 million cases of overweight/obesity. In the long term, this could increase national productivity by $45.7 billion annually. Long-term sodium reductions of 400 mg in those with uncontrolled hypertension would eliminate about 1.5 million cases, potentially increasing productivity by $2.5 billion annually. More aggressive diet changes of 500 kcal and 1100 mg of sodium reductions yield potential productivity benefits of $133.3 and $5.8 billion, respectively. CONCLUSIONS The potential long-term benefit of reduced calories and sodium, combining medical cost savings with productivity increases, ranges from $108.5 billion for moderate reductions to $255.6 billion for aggressive reductions. These findings help inform public health policy and the business case for improving diet. (AmJ Health Promot 2009;23[6]:423-430.)
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Affiliation(s)
- Timothy M Dall
- The Lewin Group, 3130 Fairview Park Dr, Suite 800, Falls Church, VA 22042, USA.
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Dall TM, Fulgoni VL, Zhang Y, Reimers KJ, Packard PT, Astwood JD. Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet. Am J Health Promot 2009; 23:412-22. [PMID: 19601481 DOI: 10.4278/ajhp.080930-quan-226] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Model the potential national health benefits and medical savings from reduced daily intake of calories, sodium, and saturated fat among the U.S. adult population. DESIGN Simulation based on secondary data analysis; quantitative research. Measures include the prevalence of overweight/obesity, uncontrolled hypertension, elevated cholesterol, and related chronic conditions under various hypothetical dietary changes. SETTING United States. SUBJECTS Two hundred twenty-four million adults. MEASURES Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports. ANALYSIS The simulation model predicts disease prevalence and medical expenditures under hypothetical dietary change scenarios. RESULTS We estimate that permanent 100-kcal reductions in daily intake would eliminate approximately 71.2 million cases of overweight/obesity and save $58 billion annually. Long-term sodium intake reductions of 400 mg/d in those with uncontrolled hypertension would eliminate about 1.5 million cases, saving $2.3 billion annually. Decreasing 5 g/d of saturated fat intake in those with elevated cholesterol would eliminate 3.9 million cases, saving $2.0 billion annually. CONCLUSIONS Modest to aggressive changes in diet can improve health and reduce annual national medical expenditures by $60 billion to $120 billion. One use of the model is to estimate the impact of dietary change related to setting public health priorities for dietary guidance. The findings here argue that emphasis on reduction in caloric intake should be the highest priority.
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Affiliation(s)
- Timothy M Dall
- The Lewin Group, 3130 Fairview Park Dr, Suite 800, Falls Church, VA 22042, USA.
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189
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Abstract
PURPOSE The purpose of this article is to discuss the holistic evaluation of the hypertensive patient and review evidence-based nonpharmacological treatments to help patients achieve maximum therapeutic benefits with minimal side effects. DATA SOURCES Health sciences literature was reviewed using the following databases: Medline, PubMed, and Cumulative Index to Nursing and Allied Health Literature. CONCLUSIONS Hypertension remains a major public health problem, affecting 65 million Americans and contributing to excess morbidity, mortality, and indirect and direct healthcare costs. Improving clinical outcomes will reduce human suffering as well as the economic burden associated with this disease. Nonpharmacological strategies are recommended as successful primary and adjunctive treatment options for lowering blood pressure. Moreover, the benefits of many of these approaches extend to and promote overall health and well-being. IMPLICATIONS FOR PRACTICE Nurse practitioners who incorporate nonpharmacological options in the management of hypertension can improve clinical outcomes.
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Affiliation(s)
- M Elayne DeSimone
- Stony Brook University School of Nursing, Stony Brook, New York 11794-8240, USA.
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190
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van der Wel M, Bakx C, de Grauw W, van Gerwen W, Mulder J, van Weel C. The influence of guideline revisions on the process and outcome of hypertension management in general practice: A descriptive study. Eur J Gen Pract 2009; 14 Suppl 1:47-52. [DOI: 10.1080/13814780802436200] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract
Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.
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Affiliation(s)
- Carol R Horowitz
- Department of Health Policy, Mount Sinai School of Medicine, 1425 Madison Ave, New York, NY 10029, USA.
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193
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Banegas J, de la Sierra A, Segura J, Gorostidi M, de la Cruz J, Rodríguez-Artalejo F, Ruilope L. Control of hypertension in coronary heart disease. Int J Cardiol 2009; 134:245-7. [DOI: 10.1016/j.ijcard.2007.12.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 12/26/2007] [Indexed: 10/22/2022]
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194
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Prevalence of children with blood pressure measurements exceeding adult cutoffs for optimal blood pressure in Germany. ACTA ACUST UNITED AC 2009; 16:195-200. [DOI: 10.1097/hjr.0b013e3283271e6c] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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195
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Plosker GL, White WB. Telmisartan/Hydrochlorothiazide: a review of its use as fixed-dose combinations in essential hypertension. Drugs 2009; 68:1877-99. [PMID: 18729541 DOI: 10.2165/00003495-200868130-00010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Fixed-dose combinations of telmisartan and hydrochlorothiazide (HCTZ) [Micardis Plus, Micardis HCT, PritorPlus] are available in many countries for the treatment of patients with essential hypertension. Combining the angiotensin II receptor antagonist (angiotensin II receptor blocker [ARB]) telmisartan with the thiazide diuretic HCTZ provides antihypertensive therapy with complementary mechanisms of action. In the US and EU, telmisartan/HCTZ is approved for patients whose hypertension is not adequately controlled with telmisartan monotherapy; US labelling for the fixed-dose combination also includes inadequate control of blood pressure (BP) with HCTZ monotherapy.The antihypertensive efficacy of once-daily telmisartan/HCTZ has been demonstrated in several large, randomized trials in patients with stages 1 and 2 hypertension. The addition of HCTZ to telmisartan achieved significant reductions in BP in nonresponders to telmisartan monotherapy, and the antihypertensive efficacy of telmisartan/HCTZ was similar to or significantly greater than that of various comparator agents. Moreover, in studies that used ambulatory BP monitoring, telmisartan/HCTZ provided consistent 24-hour BP reductions throughout morning, daytime and night-time periods. The BP-lowering efficacy over the entire 24-hour dose administration interval is consistent with the pharmacokinetic profile of telmisartan, which has the longest elimination half-life among currently available ARBs and a unique chemical structure. Adverse events with telmisartan/HCTZ in clinical trials were typically mild and transient, and no unexpected events occurred that had not been previously reported with either telmisartan or HCTZ. Extensive tolerability data are available for telmisartan, in particular from the ONTARGET study, the largest clinical outcomes trial with an ARB. As such, fixed-dose combinations of telmisartan/HCTZ provide an effective, rational and generally well tolerated treatment option for the management of patients with hypertension.
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196
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Banegas JR, Segura J, de la Sierra A, Gorostidi M, Rodríguez-Artalejo F, Sobrino J, de la Cruz JJ, Vinyoles E, del Rey RH, Graciani A, Ruilope LM. Gender differences in office and ambulatory control of hypertension. Am J Med 2008; 121:1078-84. [PMID: 19028204 DOI: 10.1016/j.amjmed.2008.06.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 05/13/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gender differences in hypertension control have not been explored fully. METHODS We studied 15,212 white men and 13,936 white women with treated hypertension who were drawn from the Spanish Ambulatory Blood Pressure Registry. For each participant, we obtained office blood pressure (BP) (average of 2 readings) and 24-hour ambulatory BP (average of measurements performed every 20 minutes during day and night). RESULTS Only 16.4% of women and 14.7% of men had both office (<140/90 mm Hg) and ambulatory (<130/80 mm Hg) BP controlled (P<.001). Women had a lower frequency of masked hypertension (office BP<140/90 mm Hg and ambulatory BP> or =130/80 mm Hg) than men (5.9% vs 7.9%, P<.001). Women had a higher frequency of isolated office hypertension (office BP> or =140/90 mm Hg and ambulatory BP<130/80 mm Hg) (32.5% vs 24.2%, P<.001). Although office BP control (office BP<140/90 mm Hg, regardless of ambulatory values) was similar in women and men (22.3% vs 22.6%, P=.542), ambulatory BP control (ambulatory BP<130/80 mm Hg, regardless of office values) was higher in women than in men (48.9% vs 38.9%, P<.001). After adjustment for age, number of antihypertensive drugs, hypertension duration, and risk factors, gender differences in BP control remained practically unchanged. CONCLUSION Ambulatory BP control was higher in women than in men. This may be due to the higher frequency of isolated office hypertension in women, and it is not explained by gender differences in other important clinical characteristics.
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Affiliation(s)
- José R Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, CIBER en Epidemiología y Salud Pública, Madrid, Spain.
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197
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Méndez-Chacón E, Santamaría-Ulloa C, Rosero-Bixby L. Factors associated with hypertension prevalence, unawareness and treatment among Costa Rican elderly. BMC Public Health 2008; 8:275. [PMID: 18681969 PMCID: PMC2519084 DOI: 10.1186/1471-2458-8-275] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 08/05/2008] [Indexed: 11/29/2022] Open
Abstract
Background Reliable information on the prevalence of hypertension is crucial in the development of health policies for prevention, control, and early diagnosis of this condition. This study describes the prevalence of hypertension among Costa Rican elderly, and identifies co-factors associated with its prevalence, unawareness and treatment. Methods The prevalence of hypertension is estimated for the Costa Rican elderly. Measurement error is assessed, and factors associated with high blood pressure are explored. Data for this study came from a nationally representative sample of about 2,800 individuals from CRELES (Costa Rica: Longevity and Healthy Aging Study). Two blood pressure measures were collected using digital monitors. Self reports of previous diagnosis, and medications taken were also recorded as part of the study. Results No evidence of information bias was found among interviewers, or over time. Hypertension prevalence in elderly Costa Ricans was found to be 65% (Males = 60%, Females = 69%). Twenty-five percent of the studied population did not report previous diagnoses of hypertension, but according to our measurement they had high blood pressure. The proportion of unaware men is higher than the proportion of unaware women (32% vs. 20%). The main factors associated with hypertension are: age, being overweight or obese, and family history of hypertension. For men, current smokers are 3 times more likely to be unaware of their condition than non smokers. Both men and women are less likely to be unaware of their condition if they have a family history of hypertension. Those women who are obese, diabetic, have suffered heart disease or stroke, or have been home visited by community health workers are less likely to be unaware of their hypertension. The odds of being treated are higher in educated individuals, those with a family history of hypertension, elderly with diabetes or those who have had heart disease. Conclusion Sex differences in terms of hypertension prevalence, unawareness, and treatment in elderly people have been found. Despite national programs for hypertension detection and education, unawareness of hypertension remains high, particularly among elderly men. Modifiable factors identified to be associated with prevalence such as obesity and alcohol intake could be used in educational programs aimed at the detection and treatment of those individuals who have the condition.
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Affiliation(s)
- Ericka Méndez-Chacón
- Centro Centroamericano de Población, Universidad de Costa Rica, Sede Rodrigo Facio, 2060, Costa Rica.
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198
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Risk for Obstructive Sleep Apnea by Berlin Questionnaire, but not daytime sleepiness, is associated with resistant hypertension: a case-control study. Am J Hypertens 2008; 21:832-5. [PMID: 18451807 DOI: 10.1038/ajh.2008.184] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Obstructive Sleep Apnea Syndrome (OSAS) is a risk factor for resistant hypertension. Overnight polysomnography and portable sleep monitors are not generally available and questionnaires may be useful for screening OSAS. In a case-control study, we investigate the association between resistant hypertension and sleep disorders evaluated by the Berlin Questionnaire and Epworth Sleepiness Scale (ESS). METHODS Cases were 63 patients with resistant hypertension (either systolic blood pressure (BP) > or =140 mm Hg or diastolic BP > or =90 mm Hg using at least three BP-lowering drugs, including a diuretic). Controls were 63 patients with controlled BP under drug treatment. All the patients were submitted to ambulatory BP monitoring and level III polysomnography by means of a portable monitor. The prevalence of high risk in the Berlin Questionnaire and high score in the ESS (>10) was compared between the groups. Diagnostic performance for OSAS of both questionnaires was calculated. RESULTS The prevalence of high score in ESS was 44% in both groups. There was a higher prevalence of high risk for OSAS in Berlin Questionnaire in the cases group (78% vs. 48%; P < 0.001). In a logistic regression model, high risk for OSAS in Berlin Questionnaire was independently associated with resistant hypertension (odds ratio 4.1; confidence interval 95% 1.80-9.31; P < 0.01). Sensitivity and specificity for the diagnosis of OSAS was 85.5% (75.3-92.0%) and 65.0% (52.0-76.0%), respectively. CONCLUSIONS High risk for OSAS assessed by the Berlin Questionnaire is highly prevalent and associated with resistant hypertension. This questionnaire may be used as screening for OSAS in patients with this clinical condition.
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Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, Carrell D, Tyll L, Larson EB, Thompson RS. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA 2008; 299:2857-67. [PMID: 18577730 PMCID: PMC2715866 DOI: 10.1001/jama.299.24.2857] [Citation(s) in RCA: 470] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Treating hypertension decreases mortality and disability from cardiovascular disease, but most hypertension remains inadequately controlled. OBJECTIVE To determine if a new model of care that uses patient Web services, home blood pressure (BP) monitoring, and pharmacist-assisted care improves BP control. DESIGN, SETTING, AND PARTICIPANTS A 3-group randomized controlled trial, the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model. The trial was conducted at an integrated group practice in Washington state, enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access. Care was delivered over a secure patient Web site from June 2005 to December 2007. INTERVENTIONS Participants were randomly assigned to usual care, home BP monitoring and secure patient Web site training only, or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications. MAIN OUTCOME MEASURES Percentage of patients with controlled BP (<140/90 mm Hg) and changes in systolic and diastolic BP at 12 months. RESULTS Of 778 patients, 730 (94%) completed the 1-year follow-up visit. Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP (<140/90 mm Hg) compared with usual care (36% [95% confidence interval {CI}, 30%-42%] vs 31% [95% CI, 25%-37%]; P = .21). Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP (56%; 95% CI, 49%-62%) compared with usual care (P < .001) and home BP monitoring and Web training only (P < .001). Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care. Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups. Compared with usual care, the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP (-13.2 mm Hg [95% CI, -19.2 to -7.1]; P < .001) and diastolic BP (-4.6 mm Hg [95% CI, -8.0 to -1.2]; P < .001), and improved BP control (relative risk, 3.32 [95% CI, 1.86 to 5.94]; P<.001). CONCLUSION Pharmacist care management delivered through secure patient Web communications improved BP control in patients with hypertension. Trial Registration clinicaltrials.gov Identifier: NCT00158639.
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Affiliation(s)
- Beverly B Green
- Group Health Center for Health Studies, 1730 Minor Ave, Ste 1600, Seattle, WA 98110, USA.
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200
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Gray CL, Ndefo UA. Nebivolol: A new antihypertensive agent. Am J Health Syst Pharm 2008; 65:1125-33. [DOI: 10.2146/ajhp070459] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Uche A. Ndefo
- College of Pharmacy & Health Science, Texas Southern University, Houston
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