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Many clinicians aren't heeding hypertension treatment guidelines.

ORLANDO, FLA. -- Many clinicians do not follow clinical guidelines for treating high blood pressure, resulting in a "disturbing pattern of poor-quality hypertensive treatment in the United States," said James Gill, M.D.

Despite the recent National Heart, Lung, and Blood Institute (NHLBI) recommendation that thiazide diuretics should be a first-line agent for most patients with high blood pressure and a second-line agent for others, fewer than 10% of nearly 13,000 hypertensive patients in a national practice network were prescribed the potassium-depleting agent to control their blood pressure, according to the results of a cross-sectional study.

Men and women included in the study were 20-80 years old and receiving medical care from providers in the Medical Quality Improvement Consortium (MQIC)--a network comprising more than 4,000 predominantly primary care providers from 23 states who use an ambulatory electronic medical record (EMR).

To be eligible for inclusion, patients had to have had an office visit for hypertension between August 1, 2002, and July 31, 2003, and a prescription for antihypertensive medication during the same calendar year as the visit. The investigators analyzed the electronic medical records of patients who met inclusion criteria to determine the proportion of patients taking each major class of antihypertensive medications as of the end of the study year.

The most common category of antihypertensives was angiotensin-converting enzyme inhibitors, taken by 36% of 12,878 study-eligible patients. Nearly 25% of the patients in the study were prescribed [beta]-blockers, 21% received calcium channel blockers, and 15% used angiotensin-II receptor diuretics, Dr. Gill reported in a presentation at the annual meeting of the North American Primary Care Research Group.

"Only 8.9% of the patients were on thiazide diuretics, even though these have been shown to provide the greatest benefit to hypertensive patients," said Dr. Gill, director of Health Services Research at the Christiana Care Family Medicine Center in Wilmington, Del. The findings are consistent with those of other studies showing that diuretics are not being sufficiently used, despite their proven effectiveness in preventing hypertension's cardiovascular complications, he said.

The NHLBI's 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends the following drug-treatment guidelines for optimal care of patients with high blood pressure:

* Thiazide-type diuretics should be the initial drug therapy for most hypertensive patients, either alone or combined alone or combined with other drug classes.

* Most patients will require two or more antihypertensive drugs to achieve goal blood pressure.

* If blood pressure is greater than 20/10 mm Hg above goal, initiate therapy with two agents, one of which should usually be a thiazide diuretic.

The causes of the prescription/guideline discrepancies cannot be ascertained from the data analyzed for this investigation. "We didn't consider comorbidities or separate out subgroups for whom thiazide diuretics might not be indicated, which certainly could affect the findings," Dr. Gill said. The objective was to determine antihypertensive prescribing patterns on a large scale.

A secondary objective was to show that the electronic medical record is a feasible tool for measuring quality of care over large networks, Dr. Gill said. In this regard, using EMRs offers advantages over other sources, such as claims information or surveys. "The clinical data are easy to access and can be used for outcomes research across various conditions, such as diabetes or urinary tract infections."

Conversely, using the EMR has some of the limits common to all secondary data sources. "The data are not always entered in a structured way and can be difficult to clean and standardize," he said. "The infrastructure needed to create a [uniform] reporting database requires time and money, which is not always available, so some information never gets into the existing database."


New England Bureau
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Title Annotation:Cardiovascular Medicine
Author:Mahoney, Diana
Publication:Internal Medicine News
Geographic Code:1USA
Date:Dec 1, 2004
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