Is Enough Being Done to Control Hypertension? An Evaluation of Blood Pressure Control Patterns in a Community‐Based Setting

To the Editor: Articles and editorials have highlighted the problem of inadequate hypertension control in the United States.1–4 Recent surveys suggest that rates are improving but are still not as good as they could be.5 The reasons for this lack of control are likely to be multifactorial. Recent recommendations and studies highlight the importance of early aggressive treatment to shorten the time to reach blood pressure goals and the favorable effects of early control of blood pressure on clinical outcomes.6 In our study, we examined factors associated with the likelihood of achieving a blood pressure goal, as outlined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines7 (<140/90 mm Hg and for individuals with a diagnosis of diabetes or renal disease, <130/80 mm Hg), and the time distribution of blood pressure goal attainment in a group of patients with newly diagnosed hypertension who were receiving a combination of ≥2 antihypertensive medications. Individuals who were members of a large Northeastern managed care organization (MCO) and who began antihypertensive therapy with the combination of an angiotensin-converting enzyme inhibitor and a calcium channel blocker between July 1, 2000, and December 31, 2003, were included in this study. Patients must have been continuously enrolled in the MCO for a minimum of 12 months subsequent to the initial prescribing event (IPE) (ie, date of first prescription). Study data were extracted from medical claims data and primary medical chart review. The medical claims data were used to identify the IPE and to determine the existence of a hypertension diagnosis (using International Classification of Diseases, Ninth Revision [ICD-9] code 401.x, 402.x, 403.x, 404.x or 405.x). The charts of patients who satisfied the study criteria were reviewed by a trained nurse abstractor. Data collected from the charts included baseline and follow-up blood pressure readings (up to 12 months post-IPE), body mass index, and medication regimens. The primary outcome measure was the proportion of patients in whom blood pressure goal was attained. Reaching goal was defined as having 2 blood pressure readings at least 2 weeks apart at goal, with no change in medication for a minimum of 30 days after the initial reading. Independent variables included patient characteristics (Table). Medication modifications and time to reach blood pressure goal were examined. A total of 497 individuals were included in the study (mean age, 64.2 years; 44.9% female [223/497]) (Table). All study participants satisfied the inclusion criteria of a new hypertension diagnosis and blood pressure value higher than the recommended guidelines. BP goal was reached during the 12-month follow-up in only 22.3% (111/497) of those in whom antihypertensive therapy was initiated. However, only 37.3% (144/386) of individuals in whom BP goal was not reached had a medication modification. Of the individuals in whom BP goal was reached, in approximately half (49.6%) it occurred in the first 3 months of therapy. Our results, consistent with prior studies, show that hypertension was not adequately controlled in this study population. The Harris Survey also reported that only 30% of patients in whom BP was not controlled had medication changes. Furthermore, the apparent lack of medication therapy modification among those in whom blood pressure goal was not reached represents a lost opportunity for a more aggressive approach to control blood pressure. This is particularly troubling given the evidence that patients who reach goal are likely to do so early in their course and that this can have a beneficial effect on clinical outcomes. This opportunity should be highlighted to patients and providers in the hope that it would result in more aggressive and effective management of hypertension. The limitations of the study that merit consideration are the limited sample size and the inability to investigate reasons for lack of modifications among individuals in whom goal was not reached. This study reports a lack of blood pressure control in a group of ambulatory adults. This may be partly due to the selection of the drugs used as first-line therapies. However, the detected problems (lack of control and proper follow-up) are significant enough that the real cause(s), whether patient, provider, and/or system factors, require further investigation. Study concept and design: Saleh, Szebenyi Carter, Rocha, and Dastani. Acquisition of data: Szebenyi and Saleh. Analysis: Saleh and Carter. Interpretation of findings: Szebenyi, Saleh, and Carter. Drafting of manuscript: Saleh, Carter, Szebenyi, and Dastani. Obtained funding: Szebenyi and Saleh. Study supervision: Saleh and Szebenyi. Dastani and Rocha are employees of Novartis Pharmaceuticals Corporation. This study was funded by Novartis Pharmaceuticals Corporation.