Abstract
Introduction: Hypertension control has worsened in recent years, yet trends for appropriate blood pressure intensification practices for older adults is unknown. Hypothesis: We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on anti-hypertensives over the past decade. We hypothesize that treatment intensification may not have improved over time. Methods: Data from National Ambulatory Medical Care Survey (NAMCS, 2008-2018) were used. NAMCS is a nationally representative sample of ambulatory medical visits. Adults ages 60 years or older were included. Appropriate antihypertensive intensification was defined as the addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the ACC/AHA, the ESC, and the ACP/AAFP guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all three guidelines. Results: From 2008-2018, appropriate treatment intensification by ACC/AHA guidelines occurred at 11.1% (95% CI:9.8-12.5%) of visits, decreasing from 13.6% (95% CI:15.6-28.7%) of visits in 2008-2009 to 10.4% (95% CI:10.9-26.4%) in 2015-2018. Appropriate intensification by ESC occurred at 14.2% (12.1-16.6%) of visits over 2008-2018, decreasing from 16.9% (95% CI:13.5-21.0%) in 2008-2009 to 12.5% (95% CI:7.4-20.3%) from 2015-2018. Appropriate intensification by AAFP/ACP occurred at 18.9% (16.2-22.0%) of visits over 2008-2018, decreasing from 24.7% (95% CI:20.2-29.0%) in 2008-2009 to 14.9% (95% CI:9.0-23.7%) from 2015-2018. By all-inclusive criteria, intensification trended towards worsening with time: odds ratio: 0.93 (95% CI:0.87-1.00; p=0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the US was suboptimal over the past decade despite growing trial evidence showing beneficial effects for intensive blood-pressure control in older adults. Strategies to mitigate therapeutic inertia are needed, and clinical practices should make concerted efforts to improve appropriate treatment intensification in older adults.
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