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Treating Hypertension: Opportunities Aplenty

Author Information (click to view)

Raman Ravi Khanna, MD, MAS

Assistant Clinical Professor of Medicine
Division of Hospital Medicine
University of California, San Francisco

Raman Ravi Khanna, MD, MAS, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Raman Ravi Khanna, MD, MAS (click to view)

Raman Ravi Khanna, MD, MAS

Assistant Clinical Professor of Medicine
Division of Hospital Medicine
University of California, San Francisco

Raman Ravi Khanna, MD, MAS, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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New data clearly show that physicians are missing many opportunities to prescribe new blood pressure (BP) medications. Taking advantage of these teachable moments could result in improved BP control among patients.
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Guidelines recommend that people with high blood pressure (BP) be prescribed medication and those on BP medications get a new one if their condition worsens or if BP control remains inadequate. It’s unclear how often these guidelines are followed on a national level. It’s likely that physicians are missing out on key opportunities to better control their patients’ high BP.

Are Hypertension Guidelines Being Followed?

In the September 24, 2012 Archives of Internal Medicine, my colleagues and I had a study published that analyzed new BP medication prescriptions for patients with uncontrolled hypertension. Using the National Ambulatory Medical Care Survey (NAMCS), we aimed to determine if physicians were following national recommendations and find out which factors influenced prescribing decisions. Data were reviewed on 16,473 visits between 2005 and 2009 for patients already diagnosed with high BP. Some patients were on BP medications, whereas others may have been told to bring their BP under control by other means, including lifestyle changes.

“Empowering patients to discuss BP with their physicians may help us gain better control of the hypertension problem in the U.S.”

According to our results, about 20% of the 7,153 visits by patients with uncontrolled hypertension— defined as 140/90 mm Hg and higher in the setting of a diagnosis of hypertension—resulted in new medications during doctors’ office visits. People with very high BP and those who specifically came to their doctor for hypertension were more likely to get a new prescription. Patients already on BP medications were less likely to get a new one. These factors remained highly significant in multivariable regression.

Likelihood of New BP Medication

Our findings demonstrate that the low likelihood of new BP medication prescription for uncontrolled hypertension is a national problem, and that empowering patients to discuss BP with their physicians may help us gain better control of the hypertension problem.

Several tools have been studied as strategies to achieve better BP control through patient engagement and empowerment, including pre-visit forms, patient portals, education, and incentives. The key is for physicians to utilize these tools and make conscious efforts to remind patients about the importance of controlling their BP at every opportunity.

It should be noted that NAMCS does not record medication dose, so our study only speaks to new medication prescription and not to overall intensification. If NAMCS physicians escalated medication dose without adding a new medication in the same ratio to overall intensification as in other studies, the likelihood of intensification overall in our sample would have been 26%. However, new medication prescription was often the only option or the best option. In addition, NAMCS doesn’t record the reasons that new medications are or are not prescribed. Some of these factors might be clinically appropriate. However, despite these limitations, our data clearly show that we’re missing many opportunities for new BP medication prescription. Taking advantage of these teachable moments could result in improved BP control among patients throughout the country.

Readings & Resources (click to view)

Khanna RR, Victor RG, Bibbins-Domingo K, et al. Missed opportunities for treatment of uncontrolled hypertension at physician office visits in the United States, 2005 through 2009. Arch Intern Med. 2012;172:1-2. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1307566.

Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303:2043-2050.

Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.

Schmittdiel JA, Uratsu CS, Karter AJ, et al. Why don’t diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification. J Gen Intern Med. 2008;23:588-594.

Roumie CL, Elasy TA, Greevy R, et al. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Ann Intern Med. 2006;145:165-175.

Law MR, Wald NJ, Morris JK, Jordan RE. Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ. 2003;326:1427.

Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med. 2009;122:290-300.

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