Hypertension-related Visits Research Articles

Assessing Primary Care Blood Pressure Documentation for Hypertension Management During the COVID-19 Pandemic by Patient and Provider Groups

BackgroundPrimary care electronic medical record (EMR) data can be used to identify, manage, and screen hypertension cases. However, this approach relies on completeness and accessibility of documented blood pressure (BP) values. With the large switch to virtual care due to the COVID-19 pandemic, we assessed BP documentation in primary care EMRs during the pandemic, across patient and physician groups. MethodsHypertension-related visits were identified during the pre-pandemic (January 2017 to February 2020) and pandemic (March 2020 to December 2021) periods from a primary care EMR database in Ontario, Canada. Clustered logistic regression models were used to analyze the relationship of physician and patient characteristics with an outcome variable of documented BP. A chart review of 3200 hypertension visits without a BP recorded in structured data fields was conducted to determine if BP was recorded in progress notes. ResultsPre-pandemic, 75.7% of hypertension-related visits (113,966 of 150,511) had a BP recorded in structured documentation, but this significantly decreased to 36.4% (26,660 of 73,239) during the pandemic (odds ratio [OR] = 0.18, 95% confidence interval [CI]: 0.18-0.19). For virtual visits, 14.3% (6357 of 44,572) had a documented BP, vs 74.0% (20,056 of 27,089) for in-person visits. Chart review found that 55.9% of hypertension visits had no associated BP in structured documentation, but did have a BP recorded in the progress note. Male providers, compared to female providers, were less likely to record BPs pre-pandemic (OR = 0.45, 95% CI: 0.32-0.63) and during the pandemic, for both virtual visits (OR = 0.48, 95% CI: 0.32-0.71) and in-person visits (OR = 0.46, 95% CI: 0.33-0.64). ConclusionsBP documented in primary care EMRs declined during the pandemic, most likely due to high rates of virtual visits impacting hypertension detection and management.

National patterns in intensity and frequency of outpatient care for apparent treatment-resistant hypertension

Apparent treatment-resistant hypertension (aTRH) is associated with an increased risk of adverse cardiovascular outcomes. We studied the frequency and intensity of care for aTRH among participants aged 65 years and older in the US-based REGARDS study linked with Medicare claims. Blood pressure (BP) was measured twice and averaged. aTRH was defined by the use of ≥3 classes of antihypertensive medication and uncontrolled BP (UaTRH, systolic/diastolic BP ≥140/90 mmHg), or ≥4 classes with controlled BP (CaTRH). Participants were categorized as not having aTRH (no aTRH), CaTRH or UaTRH. Among 4650 participants with hypertension, 468 (10.1%) had UaTRH, 247 (5.3%) had CaTRH, and 3935 (84.6%) had hypertension but did not have aTRH. For hypertension-related visits, those with UaTRH saw primary care physicians and cardiologists more frequently than those without aTRH (mean primary care visits per year: 2.77 vs 2.27, P<.001; cardiologists: 0.50 vs 0.35, P=.014). Among those with UaTRH, CaTRH, and no aTRH, respectively 73.5%, 68.0%, and 67.5% had >1 hypertension-related visit per year. Among those with UaTRH, males vs females (prevalence ratio=0.78; 95% CI 0.69-0.89), whites vs blacks (0.88; 95% CI 0.78-0.99), and current smokers vs non-smokers (0.66; 95% CI 0.48-0.89) were less likely to receive >1 hypertension-related visit per year. Diagnostic intensity, measured by testing for end organ damage and secondary hypertension, was similar between groups. Many people with UaTRH are not seen more than once per year for hypertension and may benefit from increased care.

Incidence of Hypertension-Related Emergency Department Visits in the United States, 2006 to 2012

Hypertension is a common chronic condition, but the burden of emergency department (ED) visits due to hypertension and associated patient and hospital characteristics are not well described. The goals of this study were to (1) establish the burden of hypertension-related ED visits, estimated by the total number, proportion of adult visits, and population-based rate, (2) evaluate for change over time, and (3) identify associated patient and hospital characteristics. The Nationwide Emergency Department Sample from 2006 to 2012 was used to identify hypertension-related ED visits (International Classification of Diseases, Ninth Revision, Clinical Modification codes 401 to 405, inclusive, and 437.2), and this was linked to US Census Bureau July population estimates to determine population-based rates for each study year. Negative binomial regression was performed to determine whether rates of hypertension-related ED visits changed over time. A total of 165,946,807 hypertension-related ED visits occurred during the 7-year study period (23.6% of all adult ED visits), and hypertension was the primary diagnosis for 6,399,088 (0.9% of all adult ED visits). The estimated yearly incidence rate increased 5.2% per year (incident rate ratio, 1.052; 95% confidence interval, 1.044 to 1.061; p <0.001) for hypertension-related visits and 4.4% per year (incidence rate ratio, 1.044; 95% confidence interval, 1.038 to 1.051; p <0.001) for ED visits with a primary diagnosis of hypertension. Over the same time, the proportion hospitalized decreased and the proportion of visits increased at safety net hospitals and among uninsured patients. In conclusion, these data indicate that hypertension-related ED visits are common and increasing.

Age Differences in Treatment and Control of Hypertension in US Physician Offices, 2003-2010: A Serial Cross-sectional Study

BackgroundEvidence-based and age-appropriate antihypertensive pharmacotherapy in outpatient settings is essential for optimal treatment outcomes. Recent guidelines, although controversial, recommended different blood pressure goals using age cutoff of 60 years. We describe recent age-specific national trends in antihypertensive prescribing patterns and blood pressure control in US office-based practices. MethodsWe analyzed all hypertension-related visits to physician offices from the latest available National Ambulatory Medical Care Survey (2003-2010). We identified trends of antihypertensive prescribing overall and by class, trends of hypertension control, age differences in antihypertensive prescribing patterns and hypertension control, predicted probabilities of hypertension control in subgroups, and correlates of hypertension control. ResultsThere were 16,729 physician office visits included in the analysis. Overall, the prescription of antihypertensive medication increased from 69.2% in 2003-2004 to 78.8% in 2009-2010 (Ptrend = .001), and the increased trend was consistent in both age groups (<60 and ≥60 years). This was accompanied by an improvement in the overall hypertension control (from 39.1% to 48.8%, Ptrend <.001). Antihypertensive prescribing patterns differ significantly between the 2 age groups. The proportions of visits with β-blocker (from 25.4% to 34.7%, Ptrend <.001) and angiotensin receptor blocker prescriptions (from 17.0% to 22.1%, Ptrend = .042) increased for older patients. The increased trend of β-blocker use persisted after excluding patients with compelling indications. Among treated patients, lower odds of blood pressure control were associated with African American race, presence of comorbidities, younger age, and insufficient insurance coverage. ConclusionsIn office-based practices, antihypertensive medication prescribing among US adults with hypertension increased significantly in recent years, which was accompanied by improvement in hypertension control. The prescribing patterns differed among younger and older patients, but continuous use of β-blockers without other compelling indications raises concerns.

Missed Opportunities? Improving the Care of Patients With High Blood Pressure

Hypertension is the most prevalent and modifiable cardiovascular disease risk factor in the United States. In light of data suggesting that the prevalence rate of hypertension is increasing, concerted efforts to control high blood pressure are indicated.1 Helping hypertensive patients adopt healthier lifestyles is part of a comprehensive approach to achieving adequate blood pressure control. Physicians have an important role in helping patients engage in healthy behaviors and counseling is effective in motivating behavior change.2 In the current issue of the American Journal of Hypertension, Lopez et al. examine the frequency with which physicians counsel patients to modify their lifestyle and explore whether receipt of advice varies by patient characteristics.3 In this population-based study (NHANES 1999–2004), lifestyle counseling was high (84% received advice); however, there was considerable variability across groups. Hypertensive adults who were overweight or obese, diabetic, or had high cholesterol were more likely to receive lifestyle modification advice as were blacks, males, and adults with Medicare insurance. The findings by Lopez et al. are intriguing and consistent with a study that found that hypertensive adults with two cardiovascular comorbidities were more likely to receive lifestyle modification advice than hypertensive adults with just one or no additional cardiovascular medical concerns.4 In one respect, these findings are encouraging—lifestyle modification counseling is high, particularly for those who are medically complex. These data, however, also raise an important question: Do physicians routinely miss opportunities to counsel lower-risk patients? The pattern of more counseling for higher-risk patients is robust. This has also been demonstrated in smokers and in overweight/obese adults (i.e., smoking cessation and weight loss advice, respectively, is more common in patients with comorbidities). The higher rate of counseling in high-risk patients may merely reflect health-care utilization patterns (e.g., high-risk patients have more physician visits and thus, more opportunities to receive counseling). Interestingly, a recent study supports this hypothesis. When just one physician visit per hypertensive patient was considered, rates of lifestyle counseling did not differ in low vs. high-risk patients.5 Alternatively, variability in physician counseling may reflect physician attitudes—counseling may be viewed as having greater benefit to the high-risk patient, and accordingly, low-risk patients are not counseled. With the documented gaps in lifestyle counseling, studies should explore the factors that underlie physician practice patterns. We must also remain cognizant of how we think about lifestyle counseling. This single phrase has been applied widely to behaviors that in fact are very different (e.g., a single recommendation to alter behavior vs. a structured discussion that includes behavior change principles). A common vernacular is needed. Attention must also be paid to the quality of lifestyle counseling. Setting behavioral goals, assessing barriers and facilitators to behavior change, assessing patient motivation and confidence, and planning for follow-up visits to assess progress toward behavioral goals are quality indicators recently assessed in a study of hypertension-related visits.6 This framework which includes evidence-based behavior change principles can serve as a model for lifestyle counseling.

Lifestyle counseling in hypertension-related visits – analysis of video-taped general practice visits

BackgroundThe general practitioner (GP) can play an important role in promoting a healthy lifestyle, which is especially relevant in people with an elevated risk of cardiovascular diseases due to hypertension. Therefore, the aim of this study was to determine the frequency and content of lifestyle counseling about weight loss, nutrition, physical activity, and smoking by GPs in hypertension-related visits. A distinction was made between the assessment of lifestyle (gathering information or measuring weight or waist circumference) and giving lifestyle advice (giving a specific advice to change the patient's behavior or referring the patient to other sources of information or other health professionals).MethodsFor this study, we observed 212 video recordings of hypertension-related visits collected within the Second Dutch National Survey of General Practice in 2000/2001.ResultsThe mean duration of visits was 9.8 minutes (range 2.5 to 30 minutes). In 40% of the visits lifestyle was discussed (n = 84), but in 81% of these visits this discussion lasted shorter than a quarter of the visit. An assessment of lifestyle was made in 77 visits (36%), most commonly regarding body weight and nutrition. In most cases the patient initiated the discussion about nutrition and physical activity, whereas the assessment of weight and smoking status was mostly initiated by the GP. In 35 visits (17%) the GP gave lifestyle advice, but in only one fifth of these visits the patient's motivation or perceived barriers for changing behavior were assessed. Supporting factors were not discussed at all.ConclusionIn 40% of the hypertension-related visits lifestyle topics were discussed. However, both the frequency and quality of lifestyle advice can be improved.

Inadequate management of blood pressure in a hypertensive population.

Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care. We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure. Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.