What is the clinical evidence from this study?

Study design: Cohort. Population: Hypertension. Intervention: Antihypertensive medications vs. Temporal trends (Period 1 vs Period 2 vs Period 3). Primary outcome: Proportion initiating therapy on diuretics.

May 10, 1995

Temporal patterns of antihypertensive medication use among older adults, 1989 through 1992. An effect of the major clinical trials on clinical practice?

Key Result

Following the publication of major clinical trials, the proportion of older adults initiating antihypertensive therapy with diuretics increased from 35.9% to 47.5%.

Study Design

Type

Cohort

Structured PICO

Does the publication of major clinical trials influence the temporal patterns of antihypertensive medication use in older adults?

Population

Adults 65 years or older receiving antihypertensive therapy, categorized as continuous users (n=1667, 1643, and 1605 across three periods) or starters (n=157, 142, and 120 across three periods).

Intervention

Antihypertensive therapy (diuretics, beta-blockers, vasodilators, calcium channel blockers, angiotensin-converting enzyme inhibitors)

Comparator

Temporal comparison across three study periods (June 1989 to May 1992) before and after the publication of major clinical trials

Outcome

Proportion of patients initiating or continuing specific classes of antihypertensive medications

The publication of major clinical trials demonstrating the efficacy of low-dose diuretics in older adults coincided with a significant increase in diuretic initiation and a halt in the decline of their continuous use in clinical practice.

Main Result

Absolute Event Rate: 47.5% vs 35.9%

Limitations

Other factors such as cost may have been important in influencing temporal trends

Abstract

Objective. —To describe the changing patterns of antihypertensive medication use in the years immediately before and after the publication of the results of three major clinical trials of the treatment of hypertension in older adults. Design. —In this cohort study, adults 65 years or older were examined annually on four occasions between June 1989 and May 1992, and the use of antihypertensive medications was assessed by inventory at each visit. The four visits defined the boundaries of three study periods. For each study period, participants receiving antihypertensive therapy were either continuous users (n = 1667, 1643, and 1605, respectively) or starters (n = 157,142,120) of hypertensive therapy. The large clinical trials that convincingly proved the efficacy and safety of low-dose diuretic therapy in older adults were published during the latter parts of period 2 and the early parts of period 3. Results. —Among starters, the proportion initiating therapy on diuretics increased from 35.9% in period 2 to 47.5% in period 3, significantly so among women (P=.04). The proportions initiating other drugs displayed no significant trends. Among continuous users, the use of diuretics, β-blockers, and vasodilators generally decreased over the 3-year period, while the use of calcium channel blockers and angiotensin-converting enzyme inhibitors increased significantly in each of the three periods (PP=.03) to almost a complete halt during period 3 (0.2% decline). The rate of increase in the use of calcium channel blockers slowed significantly (P=.01) between period 1 (+6.7%) and period 3 (+2.8%). Conclusions. —Although other factors such as cost may have been important, the temporal trends in antihypertensive drug therapy coincided in time with and may have reflected in part the influence of the major clinical trials on the patterns of clinical practice. (JAMA. 1995;273:1436-1438)

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