Who is using antihypertensive drugs? A prescription analysis from Finland

Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: COMPARISON BETWEEN MEN AND WOMEN

PURPOSE

To compare functional and cardiovascular variables of men and women with peripheral artery disease (PAD).

METHODS

This observational, cross-sectional study included 67 women and 144 men (age 66 ± 9 and 67 ± 10 yr, respectively) with PAD. Patients were submitted to a clinical evaluation, 6-min walk test (6MWT) and cardiovascular evaluation, including blood pressure, arterial stiffness variables, and heart rate variability.

RESULTS

Women had lower claudication onset distance (P = .033) and 6MWT distance (P < .001), and similar percentage of the predicted 6MWT distance (P > .05). Women had higher pulse pressure (P = .002), augmentation index (P < .001), augmentation index corrected by 75 bpm (P < .001), and brachial and central systolic blood pressure (P = .041 and P = .029). Diastolic blood pressure, pulse wave velocity, and heart rate variability were similar between sexes (P > .05).

CONCLUSION

Although predicted 6MWT performance was similar between sexes, women had higher blood pressure and wave reflection variables compared with men. Interventions to reduce blood pressure and wave reflection should be emphasized in women with PAD.

Cancer pattern among hypertensive patients in North Karelia, Finland

The objective of this study was to determine the site-specific cancer incidence of hypertensive patients and examine the effect of blood pressure-related variables on the risk of cancers with elevated incidence among the hypertensive patients. A record linkage study of Hypertension Register of the North Karelia Project and the Finnish Cancer Registry was conducted. The mean follow-up time was 16 years. A total of 20 529 hypertensive patients were studied. Main outcome measures were standardised incidence ratios and hazard ratios. The overall cancer incidence was close to that of the general population for both men and women. The incidence rate for the kidney cancer was significantly increased in hypertensive patients (standardised incidence ratio 1.34, 95% confidence interval (CI) 1.11-1.60), as well as incidence rates for cancers of pancreas (1.26, 1.02-1.54), and endometrium (1.22, 1.01-1.44) in hypertensive women. The incidence of lung cancer was significantly decreased (0.86, 0.77-0.95). The incidence of liver cancer was elevated with borderline significance (1.36, 0.99-1.82). In Cox regression models, the use of antihypertensive drugs at baseline was a significant predictor of kidney (hazard ratio for use of antihypertensive drugs 1.89, 95% CI 0.96-3.75) and pancreatic cancer (1.78, 0.99-3.22) in women but not in men. The incidence of endometrial cancer or liver cancer was not related to blood pressure levels or the use of antihypertensive drugs. In women, obesity was a significant predictor of cancers of the endometrium, kidney and liver. In conclusion, increased occurrence of some cancer types among hypertensive patients seem to be partly explained by obesity and the use of antihypertensive drugs.

How well have practices followed guidelines in prescribing antihypertensive drugs: the role of health insurance

BACKGROUND

The US Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure issues guidelines on the optimal first-line drug therapy in treating hypertension. Despite broad dissemination of these guidelines, prescribing practices have long remained discrepant with recommendations. The purpose of this study was to examine the role of insurance type in the selection of drugs for hypertension treatment in light of the JNC guidelines.

METHODS

Subjects were derived from the 1996 Medical Expenditures Panel Survey who had a diagnosis of essential hypertension and who were prescribed a diuretic, beta-blocker, calcium channel blocker (CCB), or ACE inhibitor (ACEI) as monotherapy. Using the nationally representative sample, this study presents the first estimates of the impact of insurance policies on the choice of antihypertensive drugs while controlling for predisposing, enabling, and need variables in the context of a logistic health-care utilization model.

RESULTS

Nationally in 1996, more than twice as many subjects (7.3 million) were taking ACEIs or CCBs compared to diuretics or beta-blockers (3.1 million) as the first-line drug therapy, a sharp contrast to the JNC guidelines. Patients with health maintenance organization (HMO) insurance were much less likely than fee for service (FFS) patients to follow the JNC guidelines in this respect (odds ratio 0.50, P <.01), controlling for all other factors. Individuals with all other public insurance and no insurance were not statistically different from the FFS group in the use of the study drugs. Other significant factors in the regression model were being of African American descent, being unmarried, having higher out-of-pocket payment, being in excellent physical health, having diabetes, and being diagnosed with essential hypertension after 1988. Each was associated with a decreased likelihood of following the JNC recommendations for the use of diuretics or beta-blockers.

CONCLUSIONS

After controlling for other predisposing, enabling, and need variables, patients who had HMO coverage were significantly more likely than FFS patients to receive ACEIs or CCBs. Given a popular public perception of HMOs being most cost conscious in providing health care, further research is needed to understand why prescribing patterns associated with HMOs have poorly followed the JNC recommendations.

Antihypertensive drug treatment in a Swedish community: Skaraborg Hypertension and Diabetes Project

PURPOSE

To describe and compare the pattern of antihypertensive drug prescriptions during different time periods.

METHODS

Antihypertensive prescriptions were registered in all patients who underwent an annual follow-up during 1998 (n = 984), 1992-1993 (n = 924), and 1981 (n = 689), at the hypertension outpatient clinic in primary health care, Skara, Sweden.

RESULTS

From 1981 to 1998 the total prescriptions of thiazides declined from 61 to 10% (p < 0.001), whilst prescriptions of calcium antagonists increased from 4 to 30% (p < 0.001), and ACE inhibitors from zero to 23% (p < 0.001). Prescriptions of calcium antagonists and ACE inhibitors increased during 1990-1995, but during 1996-1998 a significant decrease in primary prescriptions of calcium antagonists was demonstrated (OR: 0.15; 95% CI: 0.06-0.36). During all periods, females were more frequently treated with older types of antihypertensive drugs than males. In the analysis of total prescriptions in 1998 women were prescribed calcium antagonists (OR: 0.59; 95% CI: 0.45-0.78) and ACE inhibitors (OR: 0.43; 95% CI: 0.31-0.58) less frequently than men.

CONCLUSION

There were significant changes in type of antihypertensive drugs used, both by time and between genders. Changes during the latest years indicate that the prescription pattern can be greatly influenced by new scientific reports and economic debate.

Antihypertensive drug prescription trends at the primary health care centres in Bahrain

PURPOSE

To determine the antihypertensive drug prescribing pattern by primary care physicians in patients with uncomplicated essential hypertension; to identify whether such pattern of prescription is appropriate and in accordance with international guidelines for pharmacotherapy of hypertension; and to estimate the impact of such prescriptions on cost of treatment.

METHODS

A prescription-based survey among patients with uncomplicated essential hypertension was conducted in seven out of a total of 18 health centres in Bahrain. The relevant data for our study was collected using cards, designed for chronically-ill patients.

RESULTS

A total of 1019 male and 1395 female (62.9%) out of 3838 of the study population were on monotherapy, whereas 596 male and 828 female (37.1%) were on antihypertensive combination therapy. Among the monotherapy category, the various antihypertensive drugs used were as follows: beta-blockers (58.8%), angiotensin converting enzyme (ACE) inhibitors (14.2%), calcium channel blockers (11.1%), diuretics (8.1%) and alpha-methyldopa (7.0%). With respect to overall utilization pattern, beta-blockers were the most frequently prescribed (65.5%), diuretics ranked second (27.4%), followed by ACE inhibitors (20.6%), calcium channel blockers (19.9%) and alpha-methyldopa (8.5%). Within each class of antihypertensives used, the most frequently used individual agents were as follows: (a) among beta-blockers 97.7% used atenolol; (b) among the diuretics, indapamide (35.4%), hydrochlorothiazide (HCTZ) (32.7%), HCTZ in combination with triamterene (25.7%), and chlorthalidone (4.6%); (c) among the ACE inhibitors, captopril (44.9%), enalapril (29.7%), and lisinopril (19.0%); (d) among the calcium channel blockers, nifedipine (98.2%). Significant age- and gender-related differences in prescribing patterns were seen. Short-acting nifedipine monotherapy was inappropriately prescribed in a significant number of patients above the age of 50 years. ACE inhibitors accounted for approximately two-thirds of the total antihypertensive drug expenditure, although these drugs represent only one-fifth of overall antihypertensives used. There is a trend towards excessive use of expensive thiazide-like diuretics such as indapamide which seems to be unjustifiable practice, particularly in a study population free from diabetic hypertensive patients.

CONCLUSIONS

The general pattern of antihypertensive utilization appears to be in accordance with the guidelines of WHO and the Joint National Committee issued in the 1990s. The trends of prescribing of antihypertensives were in favour of conventional ones such as the beta blockers and diuretics, and the introduction of newer classes of antihypertensives had a generally minimal impact on the prescribing profile. Almost two-thirds of the patients were treated with monotherapy. A disproportionately large percentage of antihypertensive drug cost was due to overt use of ACE inhibitors, and indapamide, instead of thiazide diuretics. The use of short-acting calcium channel blockers especially in the elderly is unjustifiable.

The use of antihypertensive therapy in Spain (1986-1994)

We aimed to analyze the trends in antihypertensive therapy in Spain during the period 1986 to 1994, as well as the change in the pattern of different drugs, in relation to different national/international recommendations for hypertension treatment. Antihypertensive consumption was studied using the defined daily dose (DDD) and the DHD (DDD/1000 inhabitants/day) of each drug, as defined by the Drug Utilization Research Group of the European Office of the World Health Organization. The anatomical classification of hypotensive drugs has been made according to EPhMRA (European Pharmaceutical Market Association) guidelines. A significant increase of 117.4% (41.39/90 DHD) in antihypertensive drug consumption was observed in the period 1986 to 1994. In 1986 diuretics were the most consumed (30.27 DHD), followed by calcium antagonists (5.37), beta-blockers (3.93), and the angiotensin-converting enzyme (ACE) inhibitor (1.37). In 1994 ACE inhibitors, calcium antagonists, and beta-blockers increased significantly (P < .0001), whereas diuretics were still the most commonly prescribed. Nifedipine and captopril were the most used among calcium antagonists and ACE inhibitors. National and international recommendations had no effect on prescription patterns. Antihypertensive therapy of all types is increasing in Spain. Diuretics remain the most popular, beta-blockers stay stable, whereas the newer types are rising rapidly. National and international recommendations had no effect on prescription patterns.

An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France

OBJECTIVE

To assess drug prescribing by primary care physicians in France for various types of conditions, and to identify patterns and risk factors for poor prescribing quality.

METHODS

The orders (n = 23,080) written for patients with five target diseases (acute nasopharyngitis, acute tonsillitis, essential hypertension, osteoarthrosis, and back and periarticular disorders), by primary care physicians (n = 1,049) were extracted from a nationwide prescription database and analyzed according to 17 quantitative indicators of drug prescribing quality constructed on explicit a priori criteria.

RESULTS

Ineffective drugs were prescribed in 32% to 88% of orders according to the target disease. Six percent to 40% of orders resulted in drug interactions, age problems, and overdosage. A consistent pattern of associations between indicators was found, which suggests that drug prescribing quality is multidimensional and is composed of at least five dimensions: placebo, novelty, exoticism, misdosage, and interaction. Several factors associated with indicators were also identified, some of them defining groups of patients at risk (women, elderly, and less educated), physicians at risk (women, aged, and isolated), and contexts at risk (patient's home and disease frequently treated by the physician) of poor drug prescribing quality.

CONCLUSIONS

Drug prescribing by French primary care physicians appears nonoptimal, in terms of both risk of iatrogeny and waste of money. This study further documents the complexity and the multidimensionality of drug prescribing quality. It suggests that more attention must be paid to patients' and physicians' risk factors for poor drug prescribing quality if educational programs and regulatory processes are to succeed in promoting safer and more cost-effective practices.

Population trends in antihypertensive drug use: results from the MONICA Augsburg Project 1984 to 1995

Trends in antihypertensive drug use were assessed among 25- to 64-year-old participants of three independent surveys of the MONICA Augsburg region in 1984/85, 1989/90, and in 1994/95. Despite constant prevalences of hypertension, the percentage of hypertensives taking medication increased over the study period. The latter was mainly due to significant rises in antihypertensive monotherapy. By contrast, the use of combination treatments with two or more agents remained constant; however, although combinations composed of only two drugs were taken more often in 1995, those with three or more agents and fixed-dose preparations decreased substantially. Beta-blockers were most frequently, and with a rising tendency, taken as antihypertensive monotherapy. Newer drug classes like calcium channel blockers and ACE-inhibitors were introduced as monotherapy more hesitantly. Diuretics persisted as the basis of antihypertensive combination therapy. The use of combination therapies containing obsolete drugs, like reserpine, declined significantly with corresponding increases in drug combinations of, in particular, calcium channel blockers or ACE-inhibitors. We conclude that monotherapies account for most of the rising antihypertensive treatment rates and probably reflect intensified therapy of borderline hypertensives. The trends in antihypertensive drug classes and treatment regimens reflect a less rapid adoption of novel therapeutic concepts but a fairly close adherence to national and international guidelines.