Screening, Treatment, and Control of Hypertension in US Private Physician Offices, 2003–2004

Abstract

Abstract-Essential hypertension is the most common diagnosis in US primary care settings for middle-aged persons andseniors. Yet, data on hypertension screening, treatment, and control in such settings are limited. We analyzed National Ambulatory Medical Care Survey data to examine the rates of and factors associated with hypertension screening, treatment, and control during US office visits in 2003 and 2004. Blood pressure was measured in 56% (95% confidence limits: 52% to 59%) of all visits by patients Ն18 years of age and in 93% (95% confidence limits: 89% to 96%) of hypertensive patient visits. Among the latter, 62% (95% confidence limits: 55% to 69%) were treated. Diuretics were the most commonly prescribed antihypertensive agents (46%; 95% confidence limits: 41% to 50%), and combination therapy was reported in 58% (95% confidence limits: 54% to 63%) of treated visits. Only 39% (95% confidence limits: 34% to 43%) of treated visits were at recommended blood pressure goals. The odds of not being screened for hypertension were notably greater for visits with a provider other than a primary care physician or cardiologist (10.0; 95% confidence limits: 5.5 to 16.7) and for nonwell care visits (5.6; 95% confidence limits: 3.6 to 8.3). Greater odds of not being treated for hypertension were noted by geographic region (South versus Northeast: 2.6; 95% confidence limits: 1.2 to 5.6) and visit type (first time versus return visits; 1.6; 95% confidence limits: 1.1 to 2.4). The odds of not having blood pressure controlled were greater for patients with comorbidities (1.6; 95% confidence limits: 1.1 to 2.4). In conclusion, more intervention efforts are needed to further reduce the gaps and variations in routine practice in relation to evidence-based practice guidelines for hypertension screening, treatment, and control. Data from the National Health and Nutrition Examination Survey (NHANES), a long-standing survey of the US noninstitutionalized civilian population, have drawn attention to continuing gaps in the prevalence, awareness, treatment, and control of hypertension in relation to US public health objectives and clinical practice guidelines. 1,3,4 The latest article based on NHANES 1999NHANES -2004 reported that the overall prevalence of hypertension was 29% in [2003][2004], with a clear trend of increasing prevalence with age, and Ϸ1 of 4 hypertensive patients were unaware of their hypertension. 1 These findings bolster the importance of the recommendation by the US Preventive Services Task Force that clinicians routinely screen adults aged Ն18 years for high BP. 5 The same article 1 that analyzed the data from NHANES 1999 -2004 also reported that, in 2003-2004, 65% of individuals with known hypertension reported to be taking antihypertensive medications, and 37% had their BP under control, defined as BP Ͻ140/90 mm Hg for nondiabetic patients and Ͻ130/80 mm Hg for diabetic patients. The 37% control rate reflected an 8% age-adjusted increase from 1999 to 2000, making it seem feasible to reach the Healthy People 2...

Antihypertensive Medication Adherence, Ambulatory Visits, and Risk of Stroke and Death

“…This study, unlike previous studies of cohorts of patients with chronic disease, [12][13][14] found that ambulatory visits were protective for death once we controlled for the impact of comorbidity. The most notable of previous studies to assess the impact of ambulatory care showed that recently hospitalized veterans with diabetes, chronic obstructive pulmonary disease, or congestive heart failure randomized to an intensive primary care intervention actually experienced higher readmission rates.…”

“…Further research is needed to determine the optimal number and types of visits needed to maintain blood pressure control and prevent adverse events, the primary mechanisms through which ambulatory visits improve outcomes, and the most effective methods for improving adherence and control of hypertension in ambulatory settings. 13 This study also demonstrated that exposures to most major classes of antihypertensives were protective for mortality independent of adherence levels. This is consistent with clinical trials and meta-analyses of hypertension outcome trials demonstrating similar mortality benefits for these major classes.…”

“…Well-controlled studies have generally demonstrated that routine ambulatory visits do not have protective effects for the chronically ill. [12][13][14] The most notable previous study of the impact of ambulatory visits focused on patients with chronic diseases that often require hospitalization for whom increased surveillance might be expected to increase hospitalization rates. 12 Hypertension seldom leads to hospitalization, and ambulatory visits for uncomplicated hypertension are typically employed to assess and improve blood pressure control.…”

Resistant hypertension and hyperaldosteronism

“…Data from the National Health and Nutrition Examination Survey indicated that among hypertensive patients, only 53% were controlled to less than 140/90 mm Hg [2]. In addition, data from the National Ambulatory Medical Care Survey involving US offi ce visits in 2003 and 2004 determined that goal blood pressure goals were achieved in only 39% of ambulatory clinic visits [3]. These observational results emphasize that with application of routine care, a large proportion of hypertensive patients remain poorly controlled.…”

Is the Ethnic Disparity in CKD a Symptom of Dysfunctional Primary Care in the US?

“…14 Although hypertension-associated stage 5 CKD is the single most common cause of stage 5 CKD in US black individuals, 4 incident rates of hypertension did not differ among middle-class black and white individuals who had similar levels of baseline BP and basal metabolic indices and were followed for 7 yr. 15 The kidney community already recognizes the critical importance of good primary care in preventing or slowing progression of early CKD to stage 5 CKD, 16 yet this care is suboptimal in ethnic minorities. For example, good BP control is important in CKD management, yet BP control is suboptimal for US patients with hypertension in general, 17 more so in ethnic minorities, 18 and poor for patients with CKD. 19 Supporting that equivalent primary care given to black and white patients with CKD might yield equivalent and desirable outcomes, provider compliance with selected CKD targets were similar for black and white patients in Department of Defense beneficiaries for whom insurance status and access to a primary care provider were not barriers to care.…”