Adequacy of blood pressure management in our hypertensive type 2 diabetic outpatient population

Abstract

Hypertension is a common co-morbid condition in Type 2 diabetes. Despite explicit guidelines, blood pressure control in diabetics remains challenging. To evaluate blood pressure control in hypertensive Type 2 diabetics receiving medical care at our outpatient clinics and to identify means by which we can improve management of hypertension in these patients. We examined the care of 180 hypertensive Type 2 diabetics receiving regular medical care at two Internal Medicine outpatient clinics over a 5-year period. All visits that could plausibly be related to hypertension were reviewed, paying close attention to BP measurements, number and type of antihypertensive medications, interventions made (if any) and the rationale for each therapeutic decision. BP measurements were compared between assigned Index visit (the first BP-related visit identified) and Outcome visit (the last such visit) spanning a management period of 1 1/2 - 2 years. We compared patient blood pressures to standards dictated by the JNC VI/VII, ADA, and by NKF. 1460 HTN-related visits were reviewed. BP was lowered between the Index and Outcome visits. The average number of antihypertensive medications prescribed increased from 1.8 to 2.4*. The mean SBP at the Index sit was 144.2 ± 1.3 mmHg which fell to 136.9 ± 1.4 mmHg* at the Outcome visit. The mean DBP at the Index visit was 82.8 ± 0.9 mmHg and 78.6 ± 0.8 mmHg* at the Outcome visit. In respect to BMI and Hg A1C, we found no significant difference between Index and Outcome visits. 62% of patients were on ACE-I/ARB at Index visit, comparing with 86% at Outcome visit. Overall, 80 (44.4%) patients achieved the JNC VI blood pressure goal of <130/85 mmHg while only 50 (27.8%) reached the more stringent ADA/NKF BP goal of <130/80 mmHg. When BP was uncontrolled at HTN-related visit, the physician in 60% of the cases made no intervention. * P< 0.05 Despite proven benefits from effective management, blood pressure was inadequately controlled in the majority of our hypertensive diabetic patients. Physicians should analyze their process of care for individual patients and identify situations where more aggressive management of hypertension would be appropriate.