A survey of blood pressure in the state of Maryland

Undertreatment of hypertension in a population-based study in The Netherlands

OBJECTIVE

To estimate the level of undertreatment of hypertension in a population-based study by taking into account the co-existence of additional cardiovascular risk factors in untreated hypertensives, uncontrolled blood pressure among pharmacologically treated hypertensives and within-person variability in blood pressure and total cholesterol.

DESIGN

Cross-sectional.

SETTING

Two population-based surveys on cardiovascular disease risk factors conducted during 1987-1995 in The Netherlands.

PARTICIPANTS

56 026 men and women aged 20-59 years.

MAIN OUTCOME MEASURES

Prevalence of hypertension, of treatment and of undertreatment of hypertension. Undertreated hypertensives were those who were treated pharmacologically, but whose blood pressure was still elevated and those who inappropriately received no medication for the treatment of hypertension.

RESULTS

During the past decade in The Netherlands, 30% of the hypertensive women and 47% of the hypertensive men aged 20-59 years were undertreated for hypertension. In both men and women treated pharmacologically, 42 and 29%, respectively, still had elevated blood pressure levels. Of those hypertensive men and women not treated pharmacologically, 53 and 34%, respectively, should have been treated when additional cardiovascular risk factors were taken into account Among those diagnosed but untreated for hypertension, 58 and 31% of the men and women, respectively, should have been treated pharmacologically.

CONCLUSION

A considerable proportion of hypertensives were undertreated for hypertension. To decrease the undertreatment of hypertension, it is necessary to obtain better control of blood pressure in patients already being treated, increase the detection of hypertension and improve adherence to the current guidelines.

Sex differences in the pharmacological treatment of hypertension: a review of population-based studies

OBJECTIVE

To summarize all available literature on sex differences in the pharmacological treatment of hypertension with respect to the percentage of hypertensive patients treated pharmacologically and the selection of antihypertensive drugs. The influences of the calendar period, age, definition of hypertension, prevalence of hypertension and country on these sex differences were examined.

DATA IDENTIFICATION

A secondary analysis of data from 46 population-based studies in 22 countries on the prevalence of pharmacologically treated hypertension was conducted to estimate sex ratios for the prevalence of drug treatment for hypertension.

RESULT

Overall, women with hypertension were 1.33-fold [95% confidence interval (CI) 1.32-1.34] more likely to be treated pharmacologically for hypertension than were hypertensive men. With increasing age, the female: male ratio for pharmacological treatment of hypertension decreased from 2.26 (95% CI 1.56-3.27) at ages 20-29 years to 1.22 (95% CI 1.11-1.34) at ages 60-69 years. In all countries more women than men were treated for hypertension, with the biggest difference observed in the USSR (1983-1986), where about twice as many women as men were treated for hypertension. Women more frequently used diuretics, whereas men more often used beta-blockers, angiotensin converting enzyme inhibitors and calcium antagonists.

CONCLUSIONS

Hypertensive women are more often treated for hypertension than hypertensive men and their pattern of use of antihypertensive drugs differs from that of men. Further research is required in order to explain sex differences in the treatment of hypertension with respect to the prevalence of pharmacological treatment of hypertension and choice of antihypertensive drugs, and to investigate the consequences of this difference for long-term outcomes.

Validity of cardiovascular disease risk factors assessed by telephone survey: the Behavioral Risk Factor Survey

The Behavioral Risk Factor Surveillance System (BRFSS) collects telephone interview data on behaviors for the leading causes of premature death and disability. Its validity has never been adequately studied. The authors replicated BRFSS methodology to validate self-reported cardiovascular disease (CVD) risk factors. Nine-hundred and eleven subjects from three upstate New York counties were interviewed between 1/89 and 5/90. Interviewees were offered physical examinations and laboratory testing for CVD risk factors; 282 men and 344 women participated. The authors studied validity by comparing objectively measured to self-reported CVD risk factors. Sensitivities for self-reported hypertension, hypercholesterolemia, obesity, smoking, and diabetes were: 43, 44, 74, 82 and 75%, respectively. Only smoking sensitivity differed by gender: men, 77%; women, 86%. Specificity was > 85% for all risk factors, except hypercholesterolemia in men (75%). Prevalence was underreported for hypertension, hypercholesterolemia, obesity, and smoking by 43, 50, 25 and 17%, respectively. Results suggest telephone survey research includes physiologic measurements for blood pressure, cholesterol, height, weight, and smoking to validate self-reported CVD risk factors. When this is impossible, results such as these can be used, in similar samples, to correct risk factor prevalence rates from telephone surveys for misclassifications.

Test characteristics of self-reported hypertension among the Hispanic population: findings from the Hispanic Health and Nutrition Examination Survey

Data from the Hispanic Health and Nutrition Examination Survey conducted from 1982 to 1984 were analyzed for the sensitivity, specificity, and positive and negative predictive value of self-reported hypertension in 5195 Hispanics of both sexes between the ages of 18 and 74 years. On the basis of a hypertension definition of 140/90 mmHg or of the use of antihypertensive medications, overall sensitivity of self-reported hypertension was 56% for Mexican-Americans, 71% for Cuban-Americans and 72% for Puerto Ricans. Sensitivity was higher among women, among the obese, and among those with access to a regular place for medical care; increased with increasing age; and decreased with education and the time interval since last medical visit. Independent associations for sensitivity were noted for sex, body mass index (BMI), and time interval since last medical visit among Mexican-Americans; and for time interval since last medical visit and for being divorced or separated for Cuban-Americans. Overall positive predictive value reached 49% among Mexican-Americans, 53% among Cuban-Americans, and 39% among Puerto Ricans. Raising the hypertension-threshold to 160/95 mmHg tended to increase the sensitivity but reduced the positive predictive value.

Antihypertensive drug therapy and survival by treatment status in a national survey

The National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, an investigation of a cohort originally examined during the period 1971-1975, provided an opportunity to assess the frequency of antihypertensive drug therapy in the United States during the period 1982-1984. For most age-sex-race subgroups, the frequency of medication use during 1982-1984 was higher than that observed during 1976-1980 based on the NHANES II. In the interval 1982-1984, diuretic agents were the most frequent medications prescribed (47% of drugs prescribed), and beta-blockers were second (17%). At the time of the initial survey in 1971-1975, participants had their blood pressures measured and a history of diagnosis and treatment of hypertension ascertained. Follow-up for vital status was 93% complete by 1984 (average length of follow-up, 9 years). In white men and women aged 50 years and older, the relative risk of death increased steadily, from those with elevated blood pressure (systolic blood pressure greater than or equal to 160 mm Hg or diastolic blood pressure greater than or equal to 95 mm Hg) but no history of hypertension to those treated for hypertension but whose blood pressure was still elevated. Regardless of history or treatment, those with an elevated blood pressure had about a 25-30% excess risk of death. Evidence from these national studies shows a high frequency of antihypertensive drug therapy in 1982-1984 and suggests the importance of adequate blood pressure control for optimal survival.

Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers

This study introduced trained paraprofessionals, community health workers (CHWs), into the emergency department (ED) to supplement providers' routine efforts in high blood pressure (HBP) detection, treatment, and follow-up among high-risk black men. In a demonstration project over a 2-year period, CHWs provided (1) BP and pulse measurements, and educational counseling regarding HBP and cardiovascular risk factors; (2) telephone preappointment reminders to improve ED follow-up visit rates; and (3) recontact of patients failing to show for their ED follow-up visits to improve return rates even after missed BP appointments. Results of preappointment reminders by CHWs showed a 19% improvement in appointment keeping (P less than .001). With a sample of patients who had failed to return for a follow-up visit, CHW contact was also effective, showing an overall improvement rate of 7% (P less than .001). The results reported support the idea that individuals from the community, trained as paraprofessionals, can improve appointment keeping as well as be useful in assisting in screening and counseling for chronic conditions within the ED. These CHWs are seen as having the additional advantage of enhancing the integration of the ED, the community, and continuing care sites. The approaches used in this study should be applicable and may serve as a model for the approach to other chronic conditions experienced in urban high-risk communities.