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Helms MV, Edwards AL, Suszynsky TH, Hwang AY. Prescribing Patterns of Antihypertensive Agents and Blood Pressure Control Among Patients With Incident Stage 2 Hypertension. J Pharm Technol 2022; 38:142-147. [PMID: 35600278 PMCID: PMC9116125 DOI: 10.1177/87551225211069802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Initiation of appropriate antihypertensive therapy is crucial, particularly among patients with stage 2 hypertension, whom initiation of dual antihypertensive agents is suggested. Little is known regarding real-world prescribing of antihypertensive agents for patients with incident stage 2 hypertension. Objective: The primary objective was to describe prescribing patterns of antihypertensive therapy among patients with incident stage 2 hypertension. The secondary objectives included determining association of blood pressure (BP) control with initial multiple antihypertensive agents. Methods: Retrospective cohort analysis was conducted using electronic medical records from 6 primary care clinics between January 2014 and June 2019. Included patients were ≥18 years with an initial diagnosis of stage 2 hypertension, defined as BP ≥160/100 mm Hg Primary analysis was characterizing prescribing patterns of antihypertensive agents among patients with incident stage 2 hypertension. Investigation of BP control (<140/90 mm Hg) at 3 months of diagnosis was also performed. Results: We identified 261 patients with incident stage 2 hypertension (mean age, 52 years; 53.2% males; mean baseline BP, 162.1/100.1 mm Hg). Approximately 72% of patients were initiated on single antihypertensive agent, with the most common being angiotensin receptor blockers (ARBs; 25.7%) and angiotensin-converting-enzyme (ACE) inhibitors (24.6%). Commonly initiated multiple antihypertensive agents were ACE-inhibitor + thiazide-like diuretic (52.7%), followed by an ARB + thiazide-like diuretic (21.6%). Multiple antihypertensive therapy was associated with improved BP control at 3 months (adjusted odds ratio [OR], 3.54; 95% confidence interval [CI], 1.55-8.06). Conclusion: Majority of patients with incident stage 2 hypertension were prescribed initial single antihypertensive therapy, though better BP control at 3 months was seen among those initiated on multi-antihypertensive therapy.
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Affiliation(s)
- Micah V. Helms
- Fred Wilson School of Pharmacy, High
Point University, High Point, NC, USA
| | - Ashley L. Edwards
- Fred Wilson School of Pharmacy, High
Point University, High Point, NC, USA
| | | | - Andrew Y. Hwang
- Fred Wilson School of Pharmacy, High
Point University, High Point, NC, USA
- Andrew Y. Hwang, Department of Clinical
Sciences, Fred Wilson School of Pharmacy, High Point University, One University
Parkway, High Point, NC 27268, USA.
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Wang Y, Hua Z, Chen W, Zhu Y, Li Y. Efficacy and safety of Tengfu Jiangya tablet combined with valsartan/amlodipine in the treatment of stage 2 hypertension: study protocol for a randomized controlled trial. Trials 2022; 23:171. [PMID: 35193665 PMCID: PMC8864829 DOI: 10.1186/s13063-022-06089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background The prevalence rate of hypertension in the Chinese population is on the rise, and the control rate of hypertension is low. International guidelines, including the 2018 Chinese Guidelines for the Management of Hypertension, recommend optimized drug selection and combination therapy for patients with stage 2 hypertension and blood pressure ≥ 160/100 mmHg, including valsartan/amlodipine (Val/Aml). The traditional Chinese medicine (TCM) compound Tengfu Jiangya tablet (TJT; No. Z20110021, Shandong Provincial Food and Drug Administration) is prepared in the medical institution of Affiliated Hospital of Shandong University of Traditional Chinese Medicine. It is an effective compound preparation of TCM for the treatment of hypertension in the national clinical research base of TCM. The aim of this study was to evaluate the efficacy and safety of TJT combined with Val/Aml in the treatment of stage 2 hypertension with hyperactivity of liver yang. Methods This randomized double-blind, placebo-controlled, multicenter trial will be conducted with a total of 288 participants with stage 2 hypertension at seven clinical trial centers. The stratified random method will be used, and the subcenter will be taken as the stratification factor. Eligible patients will be randomly assigned (1:1) into groups receiving either TJT or placebo three times daily for 28 days, both combined with Val/Aml 80/5 mg. The primary efficacy endpoint is the reduction in the mean sitting systolic blood pressure (msSBP) and the mean sitting diastolic blood pressure (msDBP) from baseline to week 4. Adverse events and laboratory test results will be monitored throughout the trial. Discussion This is the first placebo-controlled randomized trial conducted to evaluate the efficacy and safety of a Chinese herbal extract combined with Val/Aml in patients with stage 2 hypertension. Our study may help to provide evidence-based recommendations of a complementary preventive measure for stage 2 hypertension. Trial registration Chinese Clinical Trial Registry ChiCTR2000030611. Registered on 8 March 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06089-z.
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Affiliation(s)
- Yu Wang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, Shandong, China
| | - Zhen Hua
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, Shandong, China
| | - Wenjing Chen
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, Shandong, China
| | - Yushuo Zhu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, Shandong, China
| | - Yunlun Li
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, Shandong, China. .,Shandong University of Traditional Chinese Medicine, Jinan, 250355, Shandong, China.
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Blood Pressure Visit Intensification in Treatment (BP-Visit) Findings: a Pragmatic Stepped Wedge Cluster Randomized Trial. J Gen Intern Med 2022; 37:32-39. [PMID: 34379277 PMCID: PMC8738829 DOI: 10.1007/s11606-021-07016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Shortening time between office visits for patients with uncontrolled hypertension represents a potential strategy for improving blood pressure (BP). OBJECTIVE We evaluated the impact of multimodal strategies on time between visits and on improvement in systolic BP (SBP) among patients with uncontrolled hypertension. DESIGN We used a stepped-wedge cluster randomized controlled trial with three wedges involving 12 federally qualified health centers with three study periods: pre-intervention, intervention, and post-intervention. PARTICIPANTS Adult patients with diagnosed hypertension and two BPs ≥ 140/90 pre-randomization and at least one visit during post-randomization control period (N = 4277). INTERVENTION The core intervention included three, clinician hypertension group-based trainings, monthly clinician feedback reports, and monthly meetings with practice champions to facilitate implementation. MAIN MEASURES The main measures were change in time between visits when BP was not controlled and change in SBP. A secondary planned outcome was changed in BP control among all hypertension patients in the practices. KEY RESULTS Median follow-up times were 34, 32, and 32 days and the mean SBPs were 142.0, 139.5, and 139.8 mmHg, respectively. In adjusted analyses, the intervention did not improve time to the next visit compared with control periods, HR = 1.01 (95% CI: 0.98, 1.04). SBP was reduced by 1.13 mmHg (95% CI: -2.10, -0.16), but was not maintained during follow-up. Hypertension control (< 140/90) in the practices improved by 5% during intervention (95% CI: 2.6%, 7.3%) and was sustained post-intervention 5.4% (95% CI: 2.6%, 8.2%). CONCLUSIONS The intervention failed to shorten follow-up time for patients with uncontrolled BP and showed very small, statistically significant improvements in SBP that were not sustained. However, the intervention showed statistically and clinically relevant improvement in hypertension control suggesting that the intervention affected clinician decision-making regarding BP control apart from visit frequency. Future practice initiatives should consider hypertension control as a primary outcome. CLINICAL TRIAL www.ClinicalTrials.gov Identifier: NCT02164331.
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Burkitt KH, Rodriguez KL, Mor MK, Fine MJ, Clark WJ, Macpherson DS, Mannozzi CM, Muldoon MF, Long JA, Hausmann LRM. Evaluation of a collaborative VA network initiative to reduce racial disparities in blood pressure control among veterans with severe hypertension. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100485. [PMID: 34175098 DOI: 10.1016/j.hjdsi.2020.100485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 09/24/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. OBJECTIVE To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). METHODS Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. RESULTS Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). CONCLUSIONS A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.
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Affiliation(s)
- Kelly H Burkitt
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Keri L Rodriguez
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Fine
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walter J Clark
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - David S Macpherson
- Retired, Veterans Integrated Service Network (VISN) 4, Pittsburgh, PA, USA
| | | | - Matthew F Muldoon
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judith A Long
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; University of Pennsylvania, Perelman School of Medicine, Division of General Internal Medicine, Philadelphia, PA, USA
| | - Leslie R M Hausmann
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Coyle R, Feher M, Jones S, Hamilton M, de Lusignan S. Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice. PLoS One 2019; 14:e0210657. [PMID: 30629703 PMCID: PMC6328229 DOI: 10.1371/journal.pone.0210657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/28/2018] [Indexed: 01/13/2023] Open
Abstract
Background Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database. Methods and finding We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4–18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1–25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5–38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8–47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion. Conclusions Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.
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Affiliation(s)
- Rachel Coyle
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
- * E-mail:
| | - Michael Feher
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
| | - Simon Jones
- Department of Population Health, Division of Healthcare Delivery Science, NYU School of Medicine, New York, United States of America
| | - Mark Hamilton
- Director, Surrey Heartlands Clinical Academy, Guildford, United Kingdom
| | - Simon de Lusignan
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
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Vonesh E, Gooch KL, Khangulov V, Schermer CR, Johnston KM, Szabo SM, Rumsfeld JS. Cardiovascular risk profile in individuals initiating treatment for overactive bladder - Challenges and learnings for comparative analysis using linked claims and electronic medical record databases. PLoS One 2018; 13:e0205640. [PMID: 30325968 PMCID: PMC6191128 DOI: 10.1371/journal.pone.0205640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/28/2018] [Indexed: 11/19/2022] Open
Abstract
For managing overactive bladder (OAB), mirabegron, a β3 adrenergic receptor agonist, is typically used as second-line pharmacotherapy after antimuscarinics. Therefore, patients initiating treatment with mirabegron and antimuscarinics may differ, potentially impacting associated clinical outcomes. When using observational data to evaluate real-world safety and effectiveness of OAB treatments, residual bias due to unmeasured confounding and/or confounding by indication are important considerations. Falsification analysis, in which clinically irrelevant endpoints are tested as a reference, can be used to assess residual bias. The objective in this study was to compare baseline cardiovascular risk among OAB patients by treatment, and assess the presence of residual bias via falsification analysis of OAB patients treated with mirabegron or antimuscarinics, to determine whether clinically relevant comparisons across groups would be feasible. Linked electronic health record and claims data (Optum/Humedica) for OAB patients in the United States from 2011-2015 were available, with index defined as first date of OAB treatment during this period. Unadjusted characteristics were compared across groups at index and propensity-matching conducted. Falsification endpoints (hepatitis C, shingles, community-acquired pneumonia) were compared between groups using odds ratios (ORs) and 95% confidence intervals (CI). The study identified 10,311 antimuscarinic- and 408 mirabegron-treated patients. Mirabegron patients were predominantly older males, with more comorbidities. The analytic sample included 1,188 antimuscarinic patients propensity-matched to 396 mirabegron patients; after matching, no significant baseline differences remained. Estimates of falsification ORs were 0.7 (CI:0.3-1.7) for shingles, 1.5 (CI:0.3-8.2) for hepatitis C, 0.8 (CI:0.4-1.8) and 0.9 (CI:0.6-1.4) for pneumonia. While propensity matching successfully balanced observed covariates, wide CIs prevented definitive conclusions regarding residual bias. Accordingly, further observational comparisons by treatment group were not pursued. In real-world analysis, bias-detection methods could not confirm that differences in cardiovascular risk in patients receiving mirabegron versus antimuscarinics were fully adjusted for, precluding clinically relevant comparisons across treatment groups.
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Affiliation(s)
- E. Vonesh
- Department of Biostatistics, Northwestern Medicine, Chicago, IL, United States of America
| | - K. L. Gooch
- Medical Affairs, Astellas Pharma USA, Northbrook, IL, United States of America
| | - V. Khangulov
- Boston Strategic Partners, Boston, MA, United States of America
| | - C. R. Schermer
- Medical Affairs, Astellas Pharma USA, Northbrook, IL, United States of America
| | | | | | - J. S. Rumsfeld
- Faculty of Medicine, University of Colorado, Denver, CO, United States of America
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What Contributes to the Regularity of Patients with Hypertension or Diabetes Seeking Health Services? A Pilot Follow-Up, Observational Study in Two Sites in Hubei Province, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13121268. [PMID: 28009850 PMCID: PMC5201409 DOI: 10.3390/ijerph13121268] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 01/13/2023]
Abstract
Regular maintenance of non-communicable chronic diseases can constrain disease progression in diabetic and hypertensive patients. To identify the individual and social factors that are associated with positive health-seeking behaviors and regular maintenance of chronic diseases, we have conducted a follow up study in 2015 on diabetic and hypertensive patients in Hubei Province. We used binary logistic regression models to determine specific factors associated with diabetic and hypertensive patients that sought healthcare services for their conditions in accordance with current Chinese Centers for Disease Prevention and Control (CDC) guidelines. Our findings show that 42.16% of 510 people living with chronic conditions (PLCDs) sought health services in line with existing guidelines. Findings also show a higher probability (8.418 times) for PLCDs seeking healthcare services at higher-tiered hospitals (secondary and tertiary hospitals) than for PLCDs seeking care at primary hospitals (odds ratio (OR) = 8.418, 95% confidence interval (CI) = 4.82, 14.27, p < 0.001). These analyses underscore the importance of having patient advocates who can provide support, where necessary, and encourage positive health-seeking behavior. The study also shows a negative impact on regular maintenance for PLCDs in households with high financial constraints. In contrast, the study shows positive impacts for increased household income, age, and residency in rural locations. In sum, this study underscores the importance of primary hospitals as key points of care and critical players in care coordination for PLCDs. The study provides more evidence for Chinese policymakers seeking to contain costs and improve population health. The findings also underscore the need for community-based interventions, specifically interventions that link local primary hospitals, friends/family members, and PLCDs.
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