Treatment Intensification for Hypertension in US Ambulatory Medical Care

Abstract

BackgroundHypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all‐cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.Methods and ResultsUsing the nationally representative National Ambulatory Medical Care Survey (2005–2012) and National Hospital Ambulatory Medical Care Survey (2005–2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005–2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2–7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.ConclusionsUS hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension‐related morbidity and mortality nationwide.

Clinical inertia in the pharmacological management of hypertension

“…Importantly, medication initiation in diagnosed hypertensive patients occurred in only 26.4% of visits. [ 24 ] Thus, appropriate guideline-adherent treatment initiation and intensification of antihypertensive medication is a major opportunity to improve HTN control and reduce CVD risk.…”

A Flexible Regimen of Combination Antihypertensive Therapy for Lower Blood Pressure to the Lower Target Level. Viewpoint of Cardiologist and Clinical Pharmacologist

“…Возможно, увеличение приверженности было связано с более быстрым снижением АД при использовании 2-х антигипертензивных препаратов и с подтверждением эффективности назначенной терапии, что обусловливало согласие больного выполнять предписания врача [16]. Другое объяснение преимуществ начальной комбинированной терапии может состоять в преодолении так называемой терапевтической инертности, которая выражается в низкой частоте перевода больного с приема 1 антигипертензивного препарата на комбинированную терапию при недостижении целевого уровня АД [17,18].…”

Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control

“…One factor in suboptimal hypertension control rates is clinical inertia among primary care physicians. [10][11][12] The Swedish Stroke Prevention Study (SSPS) was developed as a health care intervention to overcome this inertia. 13 Through an electronic decision support system, lectures on antihypertensive treatment, and feedback on hypertension control, the SSPS aimed to improve the initiation and intensification of BP-lowering treatment by primary care physicians in Västerbotten County, Sweden.…”