Hypertension guideline adherence among nursing home patients

Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents

OBJECTIVES

Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 24,870 Department of Veterans Affairs (VA) nursing home residents aged ≥65 years with long-term stays (≥180 days) from 2006 to 2019.

METHODS

We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission.

RESULTS

More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years).

CONCLUSIONS AND IMPLICATIONS

Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.

Older age, kidney concordant diseases and the dilemma of adherence to guidelines: A narrative review

Evidence-based medicine is pivotal to contemporary clinical practice, and the excellence of a healthcare institution is measured by the adherence of its clinical staff to the clinical practice guidelines (CPGs) among other standards and policies. Following the recommendations of CPGs in older adults poses different challenges to prescribers. In this narrative review we explore research studies that assessed clinicians' adherence to CPGs when prescribing to older adults with chronic kidney disease and its concordant disorders, and to discuss the potential barriers and facilitators to better adherence to CPGs. Our review of the literature found that the adherence level to CPGs differed according to country, disease condition and healthcare setting. Clinicians' attitudes toward older adults and the CPGs, the unfamiliarity with the CPGs, and the lack of time, were commonly cited barriers. Interventions suggested to improve adherence to CPGs include direct mentoring, educational activities, and the integration of CPGs recommendations within hospital protocols and policies.

Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018

BACKGROUND

Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms.

METHODS

Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs.

RESULTS

The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90 mmHg). The age-adjusted prevalence of chronic low BP (average <90/60 mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90 mmHg.

CONCLUSIONS

Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care

PURPOSE OF REVIEW

We sought to summarize recent evidence regarding optimal blood pressure (BP) treatment targets and antihypertensive regimen intensity for nursing home (NH) residents and similar older, complex patients with hypertension.

RECENT FINDINGS

Recent trials have demonstrated cardiovascular benefits from more intensive BP targets among ambulatory, less complex older adults, but generalizability to NH residents is questionable. Other trials have demonstrated that de-intensifying antihypertensives in frail, older patients is feasible, with no or modest increases in BP, but most have not assessed effects on patient-centered outcomes. Observational studies with patients more representative of NH residents suggest harms associated with more intensive BP treatment and reduction in fall risk associated with deintensification, but findings and potential for bias vary across studies. Randomized trials and rigorous observational studies examining effects of deintensified BP management on patient-centered outcomes in complex, older populations are needed to inform improved guidelines and treatment for NH residents.

Economic benefits of implementing patient-centered medical home among patients with hypertension

INTRODUCTION

Despite the strong evidence of an association between adoption of the patient-centered medical home (PCMH) and improved clinical outcomes among patients with hypertension, evidence for associations between the PCMH and health care utilization and cost reduction within the general adult population with hypertension is less developed.

OBJECTIVE

This study was designed to examine the effect of PCMH on health service expenditures and utilization in a national sample of the US adult population who were diagnosed with hypertension.

METHODS

The 2010-2015 Medical Expenditure Panel Survey data were used. The study sample was limited to adults (≥18 years) diagnosed with essential hypertension. We investigated the impact of PCMH on the direct hypertension-related total and on the costs of inpatient stays, prescription medications, outpatient visits, emergency room visits, office-based services, and other medical expenditures by using log-transformed multiple linear regression models and the propensity score method.

RESULTS

Of the 18,630 adults identified with hypertension, 19.2% (n=3,583) of them had received PCMH care from 2010 to 2015. After matching, the no PCMH group showed greater mean in all hypertension-related health service costs and utilization. After adjusting for the remaining con-founders, the PCMH group showed a significant association with lower total costs, office-based services, number of office-based visits, and outpatient visits compared with the control group.

CONCLUSION

A significant relationship between experiencing PCMH care and a lower total health care expenditure was found in patients with hypertension.

Doctors' Knowledge of Hypertension Guidelines Recommendations Reflected in Their Practice

Aim

To evaluate doctors' knowledge, attitude, and practices and predictors of adherence to Malaysian hypertension guidelines (CPG 2008).

Methods

Twenty-six doctors involved in hypertension management at Penang General Hospital were enrolled in a cross-sectional study. Doctors' knowledge and attitudes towards guidelines were evaluated through a self-administered questionnaire. Their practices were evaluated by noting their prescriptions written to 520 established hypertensive outpatients (20 prescriptions/doctor). SPSS 17 was used for data analysis.

Results

Nineteen doctors (73.07%) had adequate knowledge of guidelines. Specialists and consultants had significantly better knowledge about guidelines' recommendations. Doctors were positive towards guidelines with mean attitude score of 23.15 ± 1.34 points on a 30-point scale. The median number of guidelines compliant prescriptions was 13 (range 5–20). Statistically significant correlation (r_s = 0.635, P < 0.001) was observed between doctors' knowledge and practice scores. A total of 349 (67.1%) prescriptions written were guidelines compliant. In multivariate analysis hypertension clinic (OR = 0.398, P = 0.008), left ventricular hypertrophy (OR = 0.091, P = 0.001) and heart failure (OR = 1.923, P = 0.039) were significantly associated with guidelines adherence.

Conclusion

Doctors' knowledge of guidelines is reflected in their practice. The gap between guidelines recommendations and practice was seen in the pharmacotherapy of uncomplicated hypertension and hypertension with left ventricular hypertrophy, renal disease, and diabetes mellitus.

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.

Guidelines adherence and hypertension control at a tertiary hospital in Malaysia

RATIONALE, AIMS AND OBJECTIVES

Existing literature suggests that doctors' poor adherence with guidelines is one of the major contributing factors to suboptimal control of hypertension. This study aims to evaluate doctors' adherence with Malaysian clinical practice guideline (CPG 2008) in a tertiary care hospital, and factors associated with guideline adherence and hypertension control.

METHODS

This was a cross-sectional study conducted at Hospital Pulau Pinang, Penang, Malaysia. Prescriptions written by 26 enrolled doctors to 650 established hypertensive outpatients (25 prescriptions per enrolled doctor) were noted on visit 1 along with patients' demographic and clinical data. The noted prescriptions were classified either as compliant or non-compliant to CPG (2008). Five hundred twenty (80%) of the enrolled patients (20 patients per enrolled doctor) were followed for one more visit. Blood pressure (BP) noted on visit 2 was related to the prescription written on visit 1. SPSS 16 (SPSS Inc., Chicago, IL, USA) was used for data analysis.

RESULTS

Three hundred forty-nine (67.1%) patients received guidelines compliant pharmacotherapy. In multivariate analysis, hypertension clinic had significant negative association with guidelines adherence. Two hundred sixty-five patients (51%) were at goal BP on visit 2. In multivariate analysis, angiotensin-converting enzyme inhibitors and guidelines adherence had significant positive, while renal disease, diabetes mellitus and diabetic clinic had significant negative association with hypertension control.

CONCLUSIONS

An overall fair level of adherence with guidelines and better control of hypertension was observed. Guidelines compliant practices resulted in better control of hypertension. The gaps between what guidelines recommend and clinical practice were especially seen in the pharmacotherapy of uncomplicated hypertension and hypertension with diabetes mellitus and renal disease.

The treatment of hypertension in care home residents: a systematic review of observational studies

AIM

To describe the prevalence of hypertension in care home residents, its treatment, change in treatment over time, and the achievement of blood pressure (BP) control.

METHOD

The PubMed, Cochrane, Embase, and PsychINFO databases were searched for observational studies involving care home residents with a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onward. Abstracts and titles were reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analyzed and appraised.

RESULTS

Sixteen articles were identified for analysis, of which half were studies carried out in the United States. The prevalence of hypertension in care home residents was 35% (range 16%-71%); 72% of these were on at least 1 antihypertensive (mean 1.5 antihypertensives per individual), with diuretics being the most common. The prevalence of hypertension in study populations was greater in more recent studies (P = .004). ACEi/ARBs (P = .001) and β-blockers (P = .04) were prescribed more frequently in recent studies, whereas use of calcium-channel blockers and diuretics remained unchanged over time. The number of antihypertensives prescribed per patient was higher (correlation 0.332, P = .009), whereas fewer patients achieved target BP (correlation -0.671, P = .099) in more recent studies.

CONCLUSION

Hypertension is common in care home residents and is commonly treated with antihypertensive drugs, which were prescribed more frequently in more recent studies but with no better BP control. These studies indicate a tendency toward increasing polypharmacy over time, with associated risk of adverse events, without demonstrable benefit in terms of BP control.

Perspective: a practical approach to defining professional practice gaps for continuing medical education

The Accreditation Council for Continuing Medical Education mandates that continuing medical education (CME) be developed around professional practice gaps. Accordingly, CME course directors must identify the intended learners, assess learners' needs, identify gaps in knowledge, and evaluate their CME activities. Writing gap statements is challenging for CME course directors because there is not a universally accepted format for writing these statements. The authors describe a practical approach to defining gaps for CME accreditation, which involves four steps indicated by the mnemonic LASO (learner, assessment, standard, outcomes): (1) define the learner population's characteristics, (2) create a learning needs assessment, (3) determine if the standard is met, and (4) state educational outcome for the CME activity. Based on this model, the difference between the practice standard and the current practice represents the gap in practice. The LASO approach has assisted in making CME content learner centered, relevant, and measurable at the authors' institution. The authors anticipate that LASO will be able to provide all CME course directors with a practical approach to defining educational gaps for CME accreditation.

Hypertension management in a student-run free clinic: meeting national standards?

PURPOSE

Affecting one in three adults, hypertension is one of the most prevalent disorders in the United States. The purpose of this analysis was to evaluate, using national care guidelines and quality standards, the quality of care provided at the Student Family Health Care Center (SFHCC) of the University of Medicine and Dentistry of New Jersey (Newark).

METHOD

The authors performed a chart review of all patients seen from June 2008 to June 2009, collecting the following data: age, gender, ethnicity, body mass index, most recent blood pressure measurement, comorbid conditions, number of visits, free medications dispensed, and smoking status. The authors used the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines and Healthy People 2010 quality standards to analyze results.

RESULTS

Of the 119 SFHCC patients seen during the study period, 60 had a diagnosis of hypertension. Overall, 30 (50%) of these patients were at target blood pressure. Of the 19 patients (32% of 60) with diabetes and hypertension, 5 (26%) were controlled compared with 25 (61% of 41) with hypertension only. Thirty-eight patients (63%) were taking a thiazide, 42 (70%) were on multidrug regimens, and all 19 of the patients with diabetes (100%) were on an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, as per the JNC 7 guidelines.

CONCLUSIONS

SFHCC patients with hypertension received pharmacotherapy as recommended by JNC 7 guidelines and were at the blood pressure goal set by Healthy People 2010.

Hypertension treatment and outcomes in US nursing homes: results from the US National Nursing Home Survey

OBJECTIVES

The objective of this study was to describe antihypertensive medication use, determine what effects comorbid illness has on prescribing of commonly used antihypertensive medications, and explore how treatment affected selected clinical and functional outcomes in US nursing home residents.

DESIGN

Cross-sectional observational study using data from the 2004 National Nursing Home Survey, a nationally representative sample of US nursing home residents.

RESULTS

More than one half, 53.8%, of all residents had hypertension as a primary admission or current diagnosis. A large majority (84%) of residents with the diagnosis of hypertension were receiving at least one legend medication indicated for hypertension. The most common selection of pharmacologic agent was monotherapy with diuretics in 11% of all residents receiving antihypertensive medications. Hypertensive residents with a diagnosis of arrhythmia (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.02-1.38), stroke (OR = 1.18, 95% CI = 1.05-1.34), or heart failure (OR = 1.17, 95% CI = 1.04-1.32) were more likely to be receiving a beta blocker. Those with diabetes (OR = 0.86, 95% CI = 0.77-0.96), depression (OR = 0.78, 95% CI = 0.70-0.87), constipation (OR = 0.72, 95% CI = 0.61-0.84), or asthma (OR = 0.51, 95% CI = 0.34-0.74) were less likely to be receiving a beta blocker. Hospital admission was less likely (OR = 0.50, 95% CI = 0.36-0.69) when residents were taking any commonly used antihypertensive medication (diuretics, beta blockers, angiotensin-converting enzyme/angiotensin receptor blockers [ACE/ARBs], calcium channel blockers, or alpha-blockers) but significantly more likely when therapy included a beta blocker (OR = 1.45, 95% CI = 1.18 - 1.78). Beta blockers were associated with an increased likelihood of falls (OR = 1.14, 95% CI = 1.04-1.27) and a decreased likelihood of constipation (OR 0.72, 95% CI = 0.61-0.84). Beta blockers were associated with a decreased likelihood of depression (OR 0.83, 95% CI = 0.74-0.92) as was the use of any commonly used antihypertensive (OR = 0.76, 95% CI = 0.63-0.90).

CONCLUSION

Hypertension is prevalent in US nursing home residents and most residents with that diagnosis (84%) are being treated with antihypertensive medication. Through examination of the National Nursing Home Survey database, associations between the use of selected antihypertensive medication, comorbid illness, and specified outcomes were observed.

Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents

BACKGROUND

Previous studies have examined differences in care for acute myocardial infarction (AMI) according to patient characteristics such as age, gender, or insurance, but little attention has been given to whether admission source is related to guideline adherence.

OBJECTIVE

To investigate: (1) the use of aspirin and reperfusion in the care of post-acute/long-term care (PAC/LTC) patients who are hospitalized for AMI, and (2) 30-day mortality associated with these treatments.

DESIGN

Secondary examination of data from the Cooperative Cardiovascular Project (CCP) national baseline data.

SETTING

A total of 4013 U.S. hospitals.

SUBJECTS

Patients hospitalized with a confirmed AMI admitted from PAC/LTC (n = 8151) or community-dwelling (n = 120,032) settings.

MEASUREMENTS

Early administration of aspirin and reperfusion via either thrombolysis or percutaneous intervention.

RESULTS

PAC/LTC patients were less likely to receive treatment for AMI, even after adjustment for multiple variables associated with treatment choice. Differences persisted with additional econometric adjustment using seemingly-unrelated regression. Multivariable logistic regression results indicated that aspirin was related to improved 30-day survival for both PAC/LTC and community admissions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.58 for PAC/LTC, and OR, 0.57; 95% CI, 0.54-0.60 for community). Reperfusion was associated with higher ORs for mortality for eligible patients admitted from community setting (OR, 1.24; 95% CI, 1.13-1.35), but ideally-eligible candidates had lower ORs for mortality (OR, 0.58; 95% CI, 0.35-0.95 for PAC/LTC, and OR, 0.74; 95% CI, 0.68-0.81 for community).

CONCLUSIONS

Patients transferred from PAC/LTC settings were less likely to receive early treatment for AMI than other patients. Future trials should inform which guidelines are applicable to PAC/LTC patients.