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Zwarenstein M, Grimshaw JM, Presseau J, Francis JJ, Godin G, Johnston M, Eccles MP, Tetroe J, Shiller SK, Croxford R, Kelsall D, Paterson JM, Austin PC, Tu K, Yun L, Hux JE. Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651]. Implement Sci 2016; 11:124. [PMID: 27640126 PMCID: PMC5027087 DOI: 10.1186/s13012-016-0486-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 08/26/2016] [Indexed: 12/22/2022] Open
Abstract
Background Evidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes. This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system. Methods The study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group). Setting The setting involves all Ontario general/family practice physicians. Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an “insert” (two-page evidence-based article) and/or one of two different versions of an “outsert” (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides). The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices. Results Four thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54. Conclusions The study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension. Trial registration ISRCTN72772651 Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0486-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, London, Ontario, N6A 3K7, Canada. .,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario, K1H 8L6, Canada.,Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario, K1H 8L6, Canada.,School of Epidemiology, Public Health and Preventive Medicine, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Jill J Francis
- School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB, UK
| | - Gaston Godin
- Faculty of Nursing, Laval University, Pavillon Ferdinand-Vandry, 1050 Avenue de la Medicine, Room 1445, Quebec City, Quebec, G1V 0A6, Canada
| | - Marie Johnston
- Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, 2nd floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle Upon Tyne, NE2 4AX, UK
| | | | - Susan K Shiller
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Ruth Croxford
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Diane Kelsall
- Canadian Medical Association Journal, 1867 Alta Vista Drive, Ottawa, Ontario, K1G 5W8, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Faculty of Medicine, University of Toronto, 1 King's College Circle, Medical Sciences Building, Toronto, Ontario, M5S 1A8, Canada
| | - Lingsong Yun
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Janet E Hux
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.,Canadian Diabetes Association, 522 University Ave, Toronto, Ontario, M5G 2A2, Canada
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Pont L, Alhawassi T. Challenges in the Management of Hypertension in Older Populations. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:167-180. [PMID: 27815929 DOI: 10.1007/5584_2016_149] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.
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Affiliation(s)
- Lisa Pont
- Centre for Health System and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.
| | - Tariq Alhawassi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Alhawassi TM, Krass I, Pont LG. Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review. J Pharm Policy Pract 2015; 8:24. [PMID: 26473036 PMCID: PMC4607150 DOI: 10.1186/s40545-015-0042-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 09/01/2015] [Indexed: 12/24/2022] Open
Abstract
Objectives Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients. Methods A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged. Results The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified. Conclusions Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.
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Affiliation(s)
- Tariq M Alhawassi
- Faculty of Pharmacy, University of Sydney, Sydney, Australia ; College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ines Krass
- Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - Lisa G Pont
- Centre for Health Systems and Safety Research, Australian Insititue of Health Innovation, Macquarie University, North Ryde, Australia
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Axon RN, Nietert PJ, Egan BM. Antihypertensive medication prescribing patterns in a university teaching hospital. J Clin Hypertens (Greenwich) 2010; 12:246-52. [PMID: 20433545 DOI: 10.1111/j.1751-7176.2009.00254.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of hypertension among hospitalized patients represents an opportunity to improve blood pressure recognition and treatment. To address this issue, the authors examined patterns of antihypertensive medication prescribing among 5668 hypertensive inpatients. Outcomes were treatment with any antihypertensive medication and treatment with first-line therapy, defined as angiotensin-converting enzyme inhibitors, beta-blockers, thiazide diuretics, or calcium channel blockers. Logistic regression models adjusting for age, sex, race, length of stay, service line, and comorbidity were used for all comparisons. The multivariate-adjusted odds ratios for treatment were higher for men (1.4, P<.001), older patients (2.5 for age older than 80 vs 1.0 for age younger than 40; P<.001), non-white race (1.2 vs 1.0 for white race; P<.004), and generalist service line (1.4 vs 1.0 for all other services; P<.001). Multivariate-adjusted odds ratios for receiving first-line agents were higher for older patients and generalist service line. Among surgical patients, receipt of medical consultation was only marginally associated with higher odds of antihypertensive or first-line treatment after adjustment for relevant clinical variables. Demographic factors and service line appear to play a major role in determining the likelihood of inpatient hypertension treatment. Understanding and addressing these disparities has the potential to incrementally improve hypertension control rates in the population.
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Affiliation(s)
- R Neal Axon
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA.
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Gregori JAA, Nuñez JFM, Domínguez-Gil A. Costs of eprosartan versus diuretics for treatment of hypertension in a geriatric population: an observational, open-label, multicentre study. Drugs Aging 2009; 26:617-26. [PMID: 19655828 DOI: 10.2165/11316370-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Diuretics are considered to be agents of first choice when treating hypertension in the elderly because of their clinical efficacy and, in particular, their low cost. Indeed, the latter consideration has been used by health resource managers to promote the use of diuretics. However, when considering the costs of treating hypertension in a population it is also necessary to assess the adverse effects that diuretics produce, particularly in elderly people. OBJECTIVE To compare the overall expenditure associated with the treatment of hypertension (specifically the angiotensin II type 1 receptor antagonist eprosartan vs diuretics) in an elderly population, taking into consideration not only the drug acquisition costs but also the adverse effects of treatment and the costs associated with such adverse effects. METHODS This was a prospective, observational, nonrandomized, open-label, multicentre study based in eight community health centres and the Hypertension Unit of the University Hospital of Salamanca, Spain. The study included 220 hypertensive geriatric outpatients (males and females aged >or=65 years) referred from general practitioners and the Hypertension Unit, with a mean age of 71.8 years and distributed into two groups: one (n = 90) treated with diuretics and the other (n = 130) treated with eprosartan. Following an initial clinical assessment of patients at the beginning of the study, monitoring of treatment continued for 1 year with follow-up consultations scheduled for 3, 6 and 12 months. Both the costs relating to acquisition of the drugs and the costs derived from secondary adverse effects of drug treatment were included in the analysis. RESULTS The response to the antihypertensive therapy was similar in both groups. In patients taking diuretics, adverse events resulted in increased use of healthcare resources because of urinary incontinence, purchase of adsorbents, hyponatraemia and the need to admit two patients to hospital. The patient/day cost was euro 1.05 for the group treated with diuretics and euro 0.98 for the group treated with eprosartan (year of costing 2006). CONCLUSION In the geriatric population, the acquisition cost of the prescribed diuretics is not representative of the actual antihypertensive treatment expenditure. According to the results obtained in our study, the overall costs of eprosartan therapy were no different to those of diuretics, despite the fact that eprosartan had a higher acquisition cost. This is consistent with a more favourable safety profile for eprosartan, which may possibly contribute to improved prescription compliance. This conclusion should be taken into consideration when evaluating economic restrictions on the use of drugs.
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