Abstract
ObjectivesThe purpose of this study is to describe trends in the utilization of antihypertensive medications, overall and by type of medication, specifically thiazide diuretics, as well as uncontrolled hypertension, in the Palestine refugee population in Jordan between 2008 and 2012.MethodsWe analyzed aggregate procurement data on antihypertensive medications derived from the United Nations Relief and Works Agency (UNRWA) pharmacy records between 2008 and 2012. Antihypertensive medications were aggregated and utilization was calculated overall and for specific types of antihypertensive medications (e.g. β-blockers, diuretics). We used the WHO (World Health Organization) defined daily dose (DDD) methodology, often used to evaluate drug utilization patterns using aggregate data, to calculate utilization defined as DDDs per 100 persons with hypertension. In addition, UNRWA medical records were used to measure the prevalence of uncontrolled hypertension in the primary care setting. Uncontrolled hypertension was defined as a systolic/diastolic blood pressure ≥140/90 in at least 2 out of 3 readings, one of which is the most recent reading, during the year for a patient diagnosed with hypertension.ResultsOverall, total utilization of antihypertensive medications has not changed between 2008 and 2012; hypertensive patients persistently used at least 2 antihypertensive medications daily (range 200–280 DDDs/100 patients with hypertension) during this five-year period. However, there is significant variation in utilization patterns by type of antihypertensive medication. While Angiotensin Converting Enzyme Inhibitors (ACE-I) were persistently the most commonly used antihypertensive medication, there utilization significantly (P < 0.05) declined by 26%. However, there was a statistically significant increase of 124% in the utilization of thiazide diuretics. Further, the prevalence of uncontrolled hypertension has also declined at a rate of 3% annually between 2008 and 2012.ConclusionOur findings indicate that the STGs for hypertension management implemented in 2009 as part of UNRWA's essential drug program have increased the utilization of thiazide diuretics, and potentially contributed to improvements in hypertension control. This study also demonstrates that feasibility of drug utilization studies in monitoring and evaluating trends in the use of essential medications in low-resource settings.
Highlights
Hypertension is a persistent and leading risk factor for cardiovascular morbidity and mortality globally [1], including countries in the Middle East for which there is a substantial, yet often overlooked, population of Palestine refugees [2]
Understanding whether trends and patterns of antihypertensive medication utilization align with standard treatment guidelines (STGs), but are effective in improving hypertension control is critical in reducing complications and costs associated with uncontrolled hypertension
In order to better characterize patterns of antihypertensive medication use in the Palestine refugee population, we leverage existing data derived from United Nations Relief and Works Agency (UNRWA) pharmacy procurement records for Jordan to describe trends in the utilization of antihypertensive medications between 2008 and 2012, and discuss the potential impact of STG implementation on utilization patterns as hypertension control We focus on Jordan because it has more than 2 million UNRWA Palestine refugees, which, aside from Palestine, is the largest population of Palestine refugees in the Middle East [4]
Summary
Hypertension is a persistent and leading risk factor for cardiovascular morbidity and mortality globally [1], including countries in the Middle East for which there is a substantial, yet often overlooked, population of Palestine refugees [2]. Hypertension is increasingly prevalent in an aging refugee population, [3] and information on whether patterns in the utilization of antihypertensive medications align with treatment guidelines is imperative for ongoing efforts to improve hypertension management. This is important considering UNRWA’s 2009 implementation of evidence-based standard treatment guidelines (STGs) which relied on the hypertension treatment recommendations of the Joint National Commission-VII (JNC-7) [5] that have since been updated to JNC-VIII [6]. Ensuring the essential medicines program, anchored in human rights principles, [8,9] effectively promotes better health in an under-recognized and often ignored population of Palestine refugees is a humanitarian imperative
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