Blood Pressure Control and Factors Predicting Control in a Treatment-Compliant Male Veteran Population

Do Depressive Symptoms Predict Blood Pressure Control in US Veterans?

BACKGROUND

High blood pressure is the most common chronic condition among US veterans. Blood pressure control is essential to preventing and managing cardiovascular diseases. While depressive symptoms are a known risk factor for uncontrolled blood pressure and veterans experience high rates of depressive symptoms, no research has examined the relationship between depressive symptoms and blood pressure control among US veterans.

OBJECTIVE

We examined whether moderately severe-to-severe depressive symptoms, compared to none-to-minimal, are associated with higher risk of uncontrolled blood pressure among US veterans.

DESIGN

We analyzed a population-based sample of veterans from the National Health and Nutrition Examination Survey (2013-2016). Logistic regression models were adjusted for marital status, age, and body mass index. All analyses were weighted; results are generalizable to US veterans.

PARTICIPANTS

A sample of 864 veterans was analyzed, representing approximately 18.8 million US veterans.

MAIN MEASURES

Depressive symptoms were assessed by the Patient Health Questionnaire-9. Uncontrolled blood pressure was defined as average systolic blood pressure ≥ 130 and/or diastolic blood pressure ≥ 80.

KEY RESULTS

For depressive symptoms, 78.2% (SE = 1.6) of US veterans had none-to-minimal, 18.2% (SE = 1.2) had mild-to-moderate, and 3.5% (SE = 0.8) had moderately severe-to-severe. Forty-three percent (SE = 3.0) of US veterans had uncontrolled blood pressure. Moderately severe-to-severe depressive symptoms, compared to none-to-minimal, were associated with lower risk for uncontrolled blood pressure (aOR = .28, 95% CI [.09, .85]). Mild-to-moderate depressive symptoms were not associated with blood pressure control (aOR = .98, 95% CI [.59, 1.65]).

CONCLUSIONS

US veterans with moderately severe-to-severe depressive symptoms were less likely to have uncontrolled blood pressure than veterans with none-to-minimal symptoms. Future research should examine factors unique to veterans that may explain findings opposite of the hypothesized relationship between depressive symptoms and blood pressure control.

Economic analysis of a tailored behavioral intervention to improve blood pressure control for primary care patients

BACKGROUND

Few telemedicine programs have undergone cost analyses, impeding their implementation into practice. We report on the economic analysis of a nurse-administered intervention designed to improve blood pressure control among hypertensive veterans.

METHODS

We randomized hypertensive patients at the Durham Veterans Affairs Medical Center primary care clinic to behavioral (n = 294) or nonbehavioral (n = 294) interventions. Behavioral intervention patients received tailored information bimonthly for 2 years via telephone. To calculate intervention cost, we microcosted the nurse's labor cost and computer hardware and software costs, applied a direct-to-indirect cost ratio, and distributed the costs over an estimated cohort of patients. We analyzed data from the Veterans Affairs Decision Support System to assess whether the intervention impacted overall health care utilization and costs. We used life expectancy estimates from the literature to develop decision models to calculate cost per life-year saved.

RESULTS

The mean annual intervention cost was $112 (range $61-$259). During 2 years of follow-up, patients in the intervention group incurred $7,800 in inpatient costs and $9,741 in outpatient costs; the nonintervention group incurred $6,866 in inpatient costs and $9,599 in outpatient costs. The total cost difference was not statistically significant (P = .56). Cost-effectiveness of the behavioral intervention ranged from $42,457 per life-year saved for normal-weight women to $87,300 per life-year saved for normal-weight men.

CONCLUSIONS

The study results suggest that a nurse-administered, tailored behavioral intervention can be implemented at nominal cost and be cost-effective; however, there was no apparent lowering of health care utilization and costs during the 2 years of follow-up.

Relationship of blood pressure control and hospitalization risk to medication adherence among patients with hypertension in Taiwan

BACKGROUND

Despite the efficacy of antihypertensive treatment in preventing cardiovascular complications, there are often problems with medication adherence in hypertensive patients. The objective of this study was to examine the medication adherence and its association with blood pressure (BP) control, cardiovascular disease (CVD) hospitalization, and all-cause hospitalization.

METHODS

We conducted a retrospective cohort observation of patients who were treated for hypertension from January 2005 to December 2006. Medical and pharmacy claims were obtained from Taiwan's National Health Insurance (NHI) database, whereas electronic records, including demographic characteristics and clinical information, were retrieved from a disease management program. To determine the degree of medication adherence, we calculated the proportion of days covered (PDC) by filled prescriptions. The associations of medication adherence with BP control, CVD hospitalization, and all-cause hospitalization were examined using multiple logistic regression models.

RESULTS

The study subjects comprised a total of 29,685 hypertensive patients. Of which, 40.1% of the patients had hypertension history of >5 years and 39.7% of patients had some comorbidity. In total, 85.5% of patients were categorized as adherent, with PDC >or=80; 60% of adherent patients had good BP control. Poor medication adherence was associated with poor BP control (odds ratio (OR) = 1.20, 1.13-1.29), CVD hospitalization (OR = 1.43, 1.14-1.81), and all-cause hospitalization (OR = 1.47, 1.21-1.78).

CONCLUSION

Our observation study clearly indicates that lower medication adherence is associated with poor BP control and higher risk of CVD and all-cause hospitalization in hypertensive patients.

The importance of prompt blood pressure control

Hypertension affects almost one-third of adults in the United States, but blood pressure is adequately controlled in only about 50% to 60% of persons with treated hypertension. Abundant clinical trial evidence has shown that antihypertensive therapy significantly reduces the risk of vascular events, and meta-analyses of observational and clinical trials have shown that greater reductions in blood pressure are associated with greater reductions in risk. Recent trials have also suggested that prompt control of blood pressure is beneficial in high-risk patients with hypertension. A post hoc analysis of a trial comparing an angiotensin II receptor blocker-based program with a calcium channel blocker-based treatment regimen found that the blood pressure response after 1 month (regardless of the drug used) predicted the risk of vascular events and survival. Therapy with > or =2 medications given separately or as a fixed combination is more likely than monotherapy to lower blood pressure to goal in part because drugs from different classes target different mechanisms that regulate blood pressure. Moreover, the likelihood of achieving blood pressure goals is greater if the time to achieve control is shortened, and prompt control of blood pressure is more likely with multiple-drug therapy than with monotherapy.

Hypertension: trends in prevalence, incidence, and control

Hypertension is the leading cause of cardiovascular disease worldwide. Prior to 1990, population data suggest that hypertension prevalence was decreasing; however, recent data suggest that it is again on the rise. In 1999-2002, 28.6% of the U.S. population had hypertension. Hypertension prevalence has also been increasing in other countries, and an estimated 972 million people in the world are suffering from this problem. Incidence rates of hypertension range between 3% and 18%, depending on the age, gender, ethnicity, and body size of the population studied. Despite advances in hypertension treatment, control rates continue to be suboptimal. Only about one third of all hypertensives are controlled in the United States. Programs that improve hypertension control rates and prevent hypertension are urgently needed.

Can we justify goal blood pressure of <140/90 mm hg in most hypertensives?

Hypertension is a common disorder with well-recognized consequences on the heart, brain, and kidney as target organs. Guidelines espouse a treatment goal of blood pressure reduction to <140 mm Hg for the systolic pressure and <90 mm Hg for the diastolic pressure in most hypertensive patients. In this review, the basis for these recommendations, the practical achievement of these goals in various practice settings, and the risk versus the benefit of achieving such goals in most hypertensive patients are examined.