Inadequate Management of Blood Pressure in a Hypertensive Population
Dan R. Berlowitz, M.D., M.P.H., Arlene S. Ash, Ph.D., Elaine C. Hickey, R.N., M.S., Robert H. Friedman, M.D., Mark Glickman, Ph.D., Boris Kader, Ph.D., and Mark A. Moskowitz, M.D.
Background Many patients with hypertension have inadequate controlof their blood pressure. Improving the treatment of hypertensionrequires an understanding of the ways in which physicians managethis condition and a means of assessing the efficacy of thiscare.
Methods We examined the care of 800 hypertensive men at fiveDepartment of Veterans Affairs sites in New England over a two-yearperiod. Their mean (±SD) age was 65.5±9.1 years,and the average duration of hypertension was 12.6±5.3years. We used recursive partitioning to assess the probabilitythat antihypertensive therapy would be increased at a givenclinic visit using several variables. We then used these predictionsto define the intensity of treatment for each patient duringthe study period, and we examined the associations between theintensity of treatment and the degree of control of blood pressure.
Results Approximately 40 percent of the patients had a bloodpressure of 160/90 mm Hg despite an average of more than sixhypertension-related visits per year. Increases in therapy occurredduring 6.7 percent of visits. Characteristics associated withan increase in antihypertensive therapy included increased levelsof both systolic and diastolic blood pressure at that visit(but not previous visits), a previous change in therapy, thepresence of coronary artery disease, and a scheduled visit.Patients who had more intensive therapy had significantly (P<0.01)better control of blood pressure. During the two-year period,systolic blood pressure declined by 6.3 mm Hg among patientswith the most intensive treatment, but increased by 4.8 mm Hgamong the patients with the least intensive treatment.
Conclusions In a selected population of older men, blood pressurewas poorly controlled in many. Those who received more intensivemedical therapy had better control. Many physicians are notaggressive enough in their approach to hypertension.
Source Information
From the Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Affairs Hospital, Bedford, Mass. (D.R.B., E.C.H., B.K.); the Health Care Research Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston (D.R.B., A.S.A., R.H.F., M.A.M.); and the Department of Mathematics, Boston University, Boston (M.G.).
Address reprint requests to Dr. Berlowitz at the HSR&D Field Program, Bedford Veterans Affairs Hospital, 200 Springs Rd., Bedford, MA 01730.
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