Evaluation of the agreement between guidelines and initial antihypertensive drug treatment using a national health care reimbursement database

Combination Antihypertensive Therapy Prescribing and Blood Pressure Control in a Real-World Setting

BACKGROUND

Specific combinations of two drug classes are recommended in a variety of clinical situations in the management of hypertension. These preferred combinations are based on complimentary blood pressure (BP) lowering mechanisms or benefit for a concomitant disease.

METHODS

Using electronic health records (EHRs) data from 27,579 ambulatory hypertensive patients, we investigated antihypertensive therapy prescribing patterns and associations of preferred two drug classes with BP control.

RESULTS

Overall, BP control, defined as BP <140/90 mm Hg, was 65% among treated patients. Preferred dual antihypertensive therapy was prescribed in 55% of patients with uncomplicated hypertension, 49% of patients with diabetes, and 47% of patients with a history of myocardial infarction (MI); these prescribing frequencies of preferred combinations were not explained by worse BP control on those combinations. In fact, we found suggestive evidence of association between prescribing of preferred two drug classes and improved BP control among post-MI (OR: 1.21, 95% CI: 0.99-1.48, P = 0.061) and uncomplicated hypertensive (OR: 1.11, 95% CI: 0.98-1.26, P = 0.089) patients.

CONCLUSIONS

Prescribing of guideline-recommended antihypertensive drug classes for concomitant diseases is suboptimal and prescribing of preferred/optimized drug class combinations was moderate. We did not find a clear association between the use of optimized drug class combinations and greater BP control. Overall, using EHR data, we identified potential opportunities for re-examining prescribing practices with implications for clinical decision support and healthcare improvement at the community and health system-wide levels.

Current practice of usual clinic blood pressure measurement in people with and without diabetes: a survey and prospective 'mystery shopper' study in UK primary care

OBJECTIVES

Hypertension trials and epidemiological studies use multiple clinic blood pressure (BP) measurements at each visit. Repeat measurement is also recommended in international guidance; however, little is known about how BP is measured routinely. This is important for individual patient management and because routinely recorded readings form part of research databases. We aimed to determine the current practice of BP measurement during routine general practice appointments.

DESIGN

(1) An online cross-sectional survey and (2) a prospective 'mystery shopper' study where patients agreed to report how BP was measured during their next appointment.

SETTING

Primary care.

PARTICIPANTS

Patient charity/involvement group members completing an online survey between July 2015 and January 2016. 334 participants completed the prospective study (51.5% male, mean age=59.3 years) of which 279 (83.5%) had diabetes.

PRIMARY OUTCOME

Proportion of patients having BP measured according to guidelines.

RESULTS

217 participants with (183) and without diabetes (34) had their BP measured at their last appointment. BP was measured in line with UK guidance in 63.7% and 60.0% of participants with and without diabetes, respectively. Initial pressures were significantly higher in those who had their BP measured more than once compared with only once (p=0.016/0.089 systolic and p<0.001/p=0.022 diastolic, in patients with/without diabetes, respectively).

CONCLUSIONS

Current practice of routine BP measurement in UK primary care is often concordant with guidelines for repeat measurement. Further studies are required to confirm findings in broader populations, to confirm when a third repeat reading is obtained routinely and to assess adherence to other aspects of BP measurement guidance.

Antihypertensive treatment and blood pressure control relative to hypertension treatment guidelines

PURPOSE

To describe initial antihypertensive management relative to important aspects of JNC7 hypertension guidelines, to identify predictors of receiving JNC7 discordant therapy, and to determine the association between receiving JNC7-concordant antihypertensive treatment and achieving blood pressure (BP) control. This study focused on aspects of the JNC7 guidelines which are consistent with other guidelines that have been published since JNC7.

METHODS

EMR data from eleven multi-specialty medical groups in the US were retrospectively collected between 2008-2011. The study cohort included incident hypertensive patients who received an antihypertensive prescription during the 6-month follow-up period. Patients with existing hypertension were excluded. JNC7-concordance of the prescribed antihypertensive regimen was evaluated. Using multivariable logistic regression, we determined the association between JNC7-concordance and achieving BP control. Additionally, we determined predictors of receiving JNC7-discordant treatment.

RESULTS

14,910 incident hypertensive patients who were treated with an antihypertensive during the 6-month follow-up period were included. Overall, 79.4% patients were prescribed antihypertensive therapy concordant with JNC7; however among patients with stage 2 hypertension, the concordance was found to be 50%. BP control was achieved by 64.1% and 48.5% of patients who received JNC7-concordant and JNC7-discordant therapy, respectively. The overall adjusted odds ratio (95% CI) for BP control and JNC7-concordance was 1.53 (1.40, 1.68). The association was attenuated for cohort members with diabetes, chronic kidney disease (CKD), and stage 2 hypertension. Predictors of receiving JNC7-discordant therapy were congestive heart failure, CKD, and diabetes.

CONCLUSION

JNC7-concordance is high overall, but drops substantially when JNC7 recommendations are more demanding (e.g., among patients with stage 2 hypertension and/or CKD, CHF, diabetes). Overall, patients who are prescribed an antihypertensive regimen that is JNC7-concordant are more likely to achieve BP control.

Distinctive unhealthy eating pattern in free-living middle-aged hypertensives when compared with dyslipidemic or overweight patients

OBJECTIVE

To evaluate habitual dietary intakes in patients with established hypertension, dyslipidemia and/or overweight.

METHODS

A national sample of 6167 French free-living patients, aged 45-65 years, in whom daily food and nutrient intakes (24-h records) and clinical status were regularly monitored between 1994 and 2002.

RESULTS

For each disorder, affected patients have reduced fat and energy intakes compared with nonaffected participants after adjustment for confounding factors. In addition, after further adjustment for energy intake, dyslipidemic patients eat less cheeses, sweets, eggs and appetizers, whereas overweight patients eat less bread and sweets, more yoghurts, vegetables, meats and poultries in comparison to their nonaffected counterparts. By contrast, hypertensive patients drink more wines and less milk, eat less yoghurts, fruits and vegetables, more processed meats than participants without hypertension. Nutrient intakes also reflect these distinctive eating patterns as shown by reduced carbohydrate intake and increased protein and mineral intakes in overweight patients and increased alcohol intake and decreased mineral intakes in hypertensives when compared with nonaffected participants. Among affected patients, antihypertensive and hypolipidemic drug treatments are not associated with additional differences in daily food and nutrient intakes except eggs that are consumed in smaller amounts by treated dyslipidemic patients.

CONCLUSION

Hypertensive patients maintain an unhealthy eating pattern that tends to perpetuate their disorder in contrast to dyslipidemic or overweight patients who adopt more protective diets. The origin of this behavioural difference and poor adherence to practice guidelines between hypertensives and other cardiovascular risk patients needs to be investigated.