Hypertension control and medication increase in primary care

Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic

Background While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP). Methodology With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record. Results Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively). Conclusions Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

Perspectives of patients and physicians regarding hypertensive management from an online survey for excellence: a subanalysis of the PARADOX study by physician categories

An existing clinical problem in Japan is the high prevalence of uncontrolled hypertension despite the availability of various effective therapies. Here, we analyzed survey data to gain insight into this paradox from physicians’ perspectives, with results categorized according to specialty (i.e., with or without certification by the Japanese Society of Hypertension [JSH]), institution type, gender, and age. A web-based survey of typical educational activities for patients regarding hypertension management was conducted in Japan between October 19 and 31, 2017. Differences between physician groups were investigated per category. Survey results from 541 physicians were analyzed: 59 JSH certified (i.e., ‘specialist’) vs 482 non-JSH certified (i.e., ‘nonspecialist’) physicians; 192 general practitioners vs 349 hospital physicians; 500 males vs 41 females; and 178 younger (mean age: 40.7 years), 174 middle-aged (52.0 years) or 189 older (61.3 years) physicians. The most statistically significant differences between groups were observed in the category of physician specialty. Compared with nonspecialists, specialist physicians were more conscious of providing education on patient lifestyle modifications, more aware of patient- and physician-derived issues, and understood and followed the treatment guidelines. General practitioners cared more about the patient’s burden than did hospital physicians. Younger physicians identified the need to incorporate the patient’s perspective into their treatment. This analysis shows that the provision and perceptions of education differ between physician categories. Compared with specialist physicians, nonspecialists were less likely to provide adequate guidance on lifestyle modifications, possibly due to their uncertainty in understanding treatment guideline recommendations. Further education of nonspecialists on hypertension management may be warranted.

Racial disparities in hypertension control, but not treatment intensification

BACKGROUND

Racial disparities in hypertension control are well documented, yet the contribution of providers to these disparities remains unclear. The objective of this study was to examine whether provider management of uncontrolled hypertension differed by patient race.

METHODS

In a retrospective cohort of 16,881 hypertensive adults in six academic primary care practices from 1/2004 to 12/2006, we evaluated hypertension control in black vs. white patients according to expert guidelines and, among those with uncontrolled hypertension, whether antihypertensive drugs were intensified by providers. Generalized estimating equations accounted for clustering and adjusted sequentially and additively for patient, provider, and practice characteristics, as well as health-care utilization and antihypertensive medication potency.

RESULTS

Black patients' visits (55.5% of 132,730 visits) had a higher unadjusted odds (1.63, 95% confidence interval (CI) 1.57-1.69) of uncontrolled hypertension than white patients' visits; the fully adjusted odds ratio remained significant (1.40, CI 1.33-1.48, P < 0.001). Among 66,327 visits with uncontrolled hypertension, no intensification of antihypertensive drugs was less likely for blacks' visits before adjustment (0.80, CI 0.76-0.83, P < 0.001) but moderated in the fully adjusted model (adjusted odds ratio 0.93, CI 0.87-0.99, P < 0.05) compared with whites' visits. Accounting for provider race, intensification was more likely at black patients' visits compared with white patients' visits.

CONCLUSIONS

In our study, black patients had poorer hypertension control, and providers were more likely to intensify antihypertensive drugs at visits of black compared with white patients as appropriate. These data suggest that more research is needed to understand racial disparities in hypertension control.

Awareness of hypertension guidelines in primary healthcare in Poland

The study was aimed at evaluating knowledge of the recent ESH-ESC Guidelines for the management of hypertension among Polish primary care physicians. A validated questionnaire including 30 multiple-choice questions was developed. A representative sample of primary care physicians in Poland was asked to complete the questionnaire. The influence of physicians' characteristics and features of their practices on the quality of the answers was analyzed. The sample included 192 physicians; 125 of them responded to the questionnaire. The mean number of correct answers was 13.4+/-3.1. The best results were observed with regard to treatment (61.2% correct answers), with weaker scores for diagnosis of hypertension (35.2%) and diagnostic tests (31.8%). The results were significantly better among female physicians and physicians working in large towns. The final score was significantly correlated with length of professional experience in practice (r = -0.246, p<0.01). A similar but non-significant correlation with the age of the physician was observed. The study showed that knowledge of hypertension guidelines among primary care physicians in Poland is modest. Educational programs must be especially directed at practitioners with longer primary care experience and those from smaller towns and villages.

How can we improve the effectiveness of treatment in elderly hypertensives?

Despite evidence for the benefits of treating hypertension in old age, only a small number of elderly patients have adequate blood pressure control. The reasons are complex and include a combination of factors related to physician, patient adherence to therapy and properties of the antihypertensive drugs. Substantial gaps have been documented between the development and dissemination of recommendations and their implementation in practice. Older patients are more likely to have difficulty with medication adherence. Better compliance achievement among the elderly patients should include a complex strategy. Moreover, physician information strategies must be improved.

Treatment intensification and risk factor control: toward more clinically relevant quality measures

BACKGROUND

Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality.

OBJECTIVE

To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California.

DESIGN

Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003.

PATIENTS

Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively.

MEASUREMENTS

Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control.

RESULTS

Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively.

CONCLUSIONS

Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

Expert recommendations on the challenges of hypertension in Asia

A consensus meeting of leading Asian hypertension experts was held in January 2007 in Seoul, Korea, to discuss how to address the growing challenge of hypertension management in the region. This report summarises key recommendations from the group, including: raising public awareness about the impact of hypertension; improving physician education and training; increasing early detection, for example through routine blood pressure measurement; and development and adoption of pan-Asian treatment guidelines, which would greatly facilitate research into hypertension and its management. The group conclude that these challenges can only be met through a collaborative effort of government, healthcare professionals, food and healthcare industries, and patients and the public. Food and healthcare industries need to develop healthy foods and support healthy living programmes, while increasing research into antihypertensive medications in Asia. Government officials and policy makers need to be made aware of the value of investing in hypertension awareness, prevention and management programmes.

Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification

BACKGROUND

Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved.

OBJECTIVE

To examine the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target cardiovascular disease (CVD) risk factor levels.

DESIGN

Cross-sectional assessment.

PARTICIPANTS

In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study.

MEASUREMENT

"Above target" was defined as most recent A1c >/=7.0% for hyperglycemia, LDL-c >/=100 mg/dL for hyperlipidemia, and SBP >/=130 mmHg for hypertension. Poor adherence was defined as medication gaps for >/=20% of days covered for all medications for each condition separately. Treatment intensification was defined as an increase in the number of drug classes, increased dosage of a class, or a switch to a different class within the 3 months before or after notation of above target levels.

RESULTS

Poor adherence was found in 20-23% of patients across the 3 conditions. No evidence of poor adherence with no treatment intensification was found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients, and 36% of hypertension patients. Poor adherence or lack of therapy intensification was evident in 53-68% of patients above target levels across conditions.

CONCLUSIONS

Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control.

Compliance with hypertension guidelines in general practice in Slovenia

INTRODUCTION

Compliance with hypertension guidelines in clinical practice is generally poor, but there was no data about compliance with any guidelines in general practice in Slovenia.

OBJECTIVE

Our aim was to find out whether general practitioners in Slovenia managed their hypertensive patients according to the national guidelines, based on 1999 WHO/ISH guideline recommendations.

METHOD

42 family physicians registered all patients with the diagnosis of arterial hypertension among 300 consecutive regular office visits. We used data about blood pressure management from paper medical records.

RESULTS

We collected data from 2752 patients with hypertension; the mean age was 64.1 years (SD = 12.4 years, from 21 to 97 years). All elements of the minimal diagnostic program in the last five years were performed in 23.8% of the patients. In 1809 (65.7%) patients, whose cardiovascular risk was estimated, the minimal diagnostic program was performed more frequently (p < 0.001). Non-pharmacological measures were performed in 1210 (47.0%) patients. 2649 (97.6%) patients had drug therapy in accordance with the guidelines. Follow-up in accordance with the guidelines was performed in 1492 (55.3%) patients. Only 256 (9.3%) patients were managed completely according to the guidelines and only 347 (15.5%) of study population reached the target values of blood pressure.

CONCLUSION

The impact of hypertension guidelines on patients' management in everyday primary care appears marginal. More emphasis should be placed on the efficient implementation of the guidelines.

Medication adherence before an increase in antihypertensive therapy: A cohort study using pharmacy claims data

BACKGROUND

Less than one third of patients with hypertension achieve optimal blood pressure control. Poor medication adherence has been identified as one contributor to uncontrolled blood pressure.

OBJECTIVE

This study was conducted to test the hypothesis that patients who require an increase in their antihypertensive regimen have poorer adherence with medication compared with patients who remain on a stable regimen.

METHODS

Health plan enrollment and pharmacy claims data were used to perform a prospective cohort study and a nested case-control study in patients newly starting antihypertensive therapy. In the prospective cohort study, cumulative medication adherence (CMA, the percentage of days the patient had pills available, calculated as the total number of days of medication dispensed, excluding the final prescription, divided by the total number of days between the first and last antihypertensive prescriptions in the observation period) was compared between patients who required an increase in therapy and patients who remained on a stable antihypertensive regimen. In the nested case-control analysis, interval medication adherence (IMA, the ratio of the number of days of medication dispensed in a single prescription divided by the number of days until the next prescription is filled) during the prescription interval immediately before an increase in the antihypertensive regimen was compared with a similar interval in control patients without an increase matched by age, medication, number of days of medication dispensed, and months since initiation of therapy.

RESULTS

The study included data from 5089 patients (mean [SD] age, 47.8 [13.0] years; 50.0% women). Over a median (interquartile range) of 23 (9-49) months of initial antihypertensive treatment, 935 patients (18.4%) had an increase in regimen. After adjusting for age, duration of treatment, number of prescribing physicians, and specific medication, patients with a regimen increase had a 12.0% higher CMA compared with patients remaining on a stable regimen (P < 0.001). IMA for the period immediately before the increase was not significantly different in patients with an increase compared with matched controls (98.3% vs 101.0%, respectively).

CONCLUSIONS

Among these insured patients newly starting antihypertensive therapy, patients who required an increase in therapy had similar or slightly better medication adherence compared with patients remaining on a stable regimen. Poor adherence was not predictive of intensification of the antihypertensive regimen.

Comparison of Muscle Torque, Balance, and Confidence in Older Tai Chi and Healthy Adults

PURPOSE

The objectives of this cross-sectional study were to examine whether older Tai Chi practitioners had better knee muscle strength, less body sway in perturbed single-leg stance, and greater balance confidence than healthy older adults.

METHODS

Tai Chi and control subjects (N = 24 each, aged 69.3 +/- 5.0 and 71.6 +/- 6.1 yr, respectively) were matched with respect to age, gender, height, weight, and physical activity level. Concentric and eccentric isokinetic tests of the subjects" dominant knee extensors and flexors were conducted at an angular velocity of 30 degrees.s(-1). Control of body sway was assessed in static double-leg stance and in single-leg stance perturbed by forward or backward platform perturbations. The Activities-specific Balance Confidence (ABC) scale was used to investigate subjects" balance confidence in daily activities.

RESULTS

Tai Chi practitioners had higher peak torque-to-body weight ratios in concentric and eccentric isokinetic contractions of their knee extensors and flexors (P = 0.044). They manifested less anteroposterior body sway angles in perturbed single-leg but not static double-leg stance than did control subjects (P < 0.001). Tai Chi practitioners also reported significantly higher balance confidence score ratios (P = 0.001). Older adults" knee muscle strengths showed negative correlations with body sway angles in perturbed single-leg stance and positive correlations with ABC score ratios. Moreover, their body sway angles in perturbed single-leg stance were negatively correlated with their ABC score ratios (all P < 0.05).

CONCLUSION

Our results demonstrate that long-term Tai Chi practitioners had better knee muscle strength, less body sway in perturbed single-leg stance, and greater balance confidence. Significant correlations among these three measures uncover the importance of knee muscle strength and balance control during perturbed single-leg stance in older adults" balance confidence in their daily activities.

Prevalence and treatment of cardiovascular disease and traditional risk factors in Australian adults with renal insufficiency

AIM

To evaluate the prevalence and treatment of cardiovascular disease and traditional cardiovascular disease risk factors in Australian adults with renal insufficiency.

METHODS

The Australian Diabetes, Obesity and Lifestyle Study was a cross-sectional survey of Australian adults undertaken in 1999-2000. Participants were categorized based on the Cockcroft-Gault estimated glomerular filtration rate in terms of normal renal function (<60 mL/min per 1.73 m(2)) and renal insufficiency (<60 mL/min per 1.73 m(2)). Outcome measures were the prevalence of cardiovascular disease, estimated risk of cardiovascular disease (20% over 10 years) and traditional cardiovascular risk factors, and frequency of pharmacological treatment of traditional cardiovascular risk factors.

RESULTS

Among adults with renal insufficiency, cardiovascular disease was present in 29.4 (95% CI: 25.1-33.6) per 100, with an additional 47.9 (95% CI: 44.9-50.9) per 100 having an estimated risk of cardiovascular disease (20% over 10 years). At least one cardiovascular risk factor was present in 90.1%. Hypertension and type 2 diabetes mellitus were three times more frequent, while hyperlipidaemia was nearly twice as frequent in those participants with renal insufficiency. Of those with renal insufficiency, 58.2% with hypertension were treated, with only 14.5% of this group being treated to current recommended target levels of blood pressure, while only 32.5% with hyperlipidaemia were treated, with 7.4% of this group being treated to target lipid levels.

CONCLUSION

The present study demonstrates significant scope to reduce the high burden of cardiovascular risk factors in Australian adults with renal insufficiency in the general community, through treatment of traditional risk factors for cardiovascular disease.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

Risk factors for uncontrolled hypertension in Italy

To identify factors related to poor control of blood pressure in primary care, we designed a retrospective case-control analysis of clinical and demographic data recorded in the General Practitioners (GP) database. Study data were provided on a voluntary basis by 21 GPs from a practice-based network in primary care. The study included 2519 hypertensive patients enrolled between January 1 and December 31, 2000. The interventions were antihypertensive medication, and the main outcome measures were control of systolic and diastolic blood pressure (BP). The independent variables considered were: age of patient and GP; patient gender, body mass index, history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction or heart failure, and number of admissions for surgery; length of patient follow-up, type of antihypertensive medication, mean daily dosage, adherence to the drug regimen, and number of other medications currently being taken by the patient. Blood pressure was uncontrolled (>140/90 mmHg) in 1525 (60%) of the 2519 hypertensive patients enrolled. The presence of diabetes mellitus, increasing patient age, and increasing GP age significantly increased the risk of uncontrolled BP. Factors significantly associated with a reduced risk of uncontrolled BP were the number of other medications currently being taken by the patient and a prior history of MI. We conclude that the failure of antihypertensive medication to adequately control BP is determined by both the patient's characteristics and factors related to the patient-doctor relationship. Successful treatment of hypertension requires patient adherence to the regimen that has been agreed on by the patient and the physician.

Effect of education through a periodic newsletter on persistence with antihypertensive therapy

Sufficient persistence with therapy is important to achieve the desired benefits of antihypertensive therapy. This study was designed to describe the rates of persistence with antihypertensive therapy for 1 year and to assess the effect of patient education by a periodic newsletter on persistence rates in general practice in Japan. Information on 5,324 patients who received the newsletter once a month for 1 year (intervention group; 53.9% of those originally registered) and 666 patients who did not receive the newsletter (control group; 94.3% of those originally registered) was obtained from a physician questionnaire (response rate: 54.3%). The rate of persistence with antihypertensive therapy in the intervention group was similar to that in the control group (91.7% vs. 90.7%, respectively). The patient questionnaire (response rate: 28.2%) indicated that most patients consistently read the newsletter and found it useful in understanding the management of hypertension. The results of this 1-year study showed that about 90% of patients persisted with therapy for 1 year. Although most of them evaluated the newsletter favorably, no clear effect of the newsletter on their persistence with therapy was revealed. However, these results do not rule out a possible effect of education on persistence with therapy over the long-term, and thus there is need of a longer-term study employing follow-up questionnaires.