Patient-Reported Adherence to Guidelines
Objectives: To compare antihypertensive drug compliance with treatment guidelines established by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and to identify patient adherence to antihypertensive drugs and factors affecting prescribing patterns.
Methods: Patients filling antihypertensive drug prescriptions in metropolitan New York area pharmacies were enrolled. Pharmacy externs collected patient-reported demographics, medical and drug histories, and blood pressure measurements. Compliance with JNC VI guidelines was assessed.
Results: Eight hundred twenty-one patients from 102 pharmacies participated. Blood pressure was controlled in 61% of patients at the time of the study. The most prescribed class of antihypertensive agents was angiotensin-converting enzyme inhibitors, followed by diuretics and
-Blockers. Over the study period, compliance with JNC VI guidelines decreased significantly from 85% to 64% (p<0.05). Thirty-seven percent of patients reported consistent adherence to their antihypertensive regimens. Patients' education level was the only factor found to correlate positively with the appropriateness of antihypertensive agents prescribed.
Conclusion: Compliance with JNC VI guidelines decreased over time, and patient adherence to drug therapy was suboptimal. Continuing-education efforts to reinforce optimal blood pressure management are necessary.
Hypertension is strongly associated with cardiovascular morbidity and mortality. According to the third National Health and Nutrition Examination Survey (NHANES III) from 1991-1994, approximately 20% of adults aged 18-74 years have hypertension. Prevalence of hypertension increases with age, affecting 44% of adults aged 50-59 years and 65% of adults over 80 years. Despite its prevalence, the NHANES III data indicate that 35% of those with hypertension are unaware of their condition and, even more disturbing, optimal blood pressure control (< 140/90 mm Hg) occurs in only 27% of hypertensive patients. This is particularly disappointing as it has been 30 years since the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) published its first treatment guidelines based on research.
Many factors contribute to suboptimal blood pressure control. First, an inappropriate antihypertensive agent may be selected. As the choices of pharmacologic agents increase, selection for an individual patient becomes increasingly complicated. Other variables such as morbidity and mortality benefits, adverse effect profile, type of insurance coverage, cost, and ease of administration must be taken into consideration.
Second, nonadherence to drug therapy can result in decreased efficacy. Hypertension alone is a chronic asymptomatic disease; for patients to be compliant with a lifelong drug regimen, constant reinforcement and education are required.
Third, inadequate follow-up by health care professionals may result in suboptimal therapy management.
Finally, ineffective dissemination of information and updated national treatment guidelines to health care providers contributes to inadequate control of high blood pressure.
Since hypertension is a chronic and disabling disease, management and control of hypertension is and will continue to be a high priority in health care. The JNC issues and updates hypertension management guidelines based on new research every 3-5 years. In November 1997, the JNC published its sixth report (JNC VI) on hypertension management. In addition to recommending diuretics and
-Blockers as first-choice agents for treating patients without concurrent conditions or contraindications to these agents, four compelling indications were established in the JNC VI guidelines: the use of
-Blockers or angiotensin-converting enzyme (ACE) inhibitors in patients with histories of myocardial infarction; use of ACE inhibitors in patients with left ventricular dysfunction; use of diuretics or long-acting dihydropyridines in elderly patients with isolated systolic hypertension; and use of ACE inhibitors in patients with type 1 diabetes mellitus and proteinuria.
It is both important and interesting to study the impact of the JNC VI guidelines on hypertension management as well as antihypertensive drug prescribing patterns, which may help to identify factors leading to suboptimal blood pressure control.
Objectives: To compare antihypertensive drug compliance with treatment guidelines established by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and to identify patient adherence to antihypertensive drugs and factors affecting prescribing patterns.
Methods: Patients filling antihypertensive drug prescriptions in metropolitan New York area pharmacies were enrolled. Pharmacy externs collected patient-reported demographics, medical and drug histories, and blood pressure measurements. Compliance with JNC VI guidelines was assessed.
Results: Eight hundred twenty-one patients from 102 pharmacies participated. Blood pressure was controlled in 61% of patients at the time of the study. The most prescribed class of antihypertensive agents was angiotensin-converting enzyme inhibitors, followed by diuretics and
-Blockers. Over the study period, compliance with JNC VI guidelines decreased significantly from 85% to 64% (p<0.05). Thirty-seven percent of patients reported consistent adherence to their antihypertensive regimens. Patients' education level was the only factor found to correlate positively with the appropriateness of antihypertensive agents prescribed.
Conclusion: Compliance with JNC VI guidelines decreased over time, and patient adherence to drug therapy was suboptimal. Continuing-education efforts to reinforce optimal blood pressure management are necessary.
Hypertension is strongly associated with cardiovascular morbidity and mortality. According to the third National Health and Nutrition Examination Survey (NHANES III) from 1991-1994, approximately 20% of adults aged 18-74 years have hypertension. Prevalence of hypertension increases with age, affecting 44% of adults aged 50-59 years and 65% of adults over 80 years. Despite its prevalence, the NHANES III data indicate that 35% of those with hypertension are unaware of their condition and, even more disturbing, optimal blood pressure control (< 140/90 mm Hg) occurs in only 27% of hypertensive patients. This is particularly disappointing as it has been 30 years since the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) published its first treatment guidelines based on research.
Many factors contribute to suboptimal blood pressure control. First, an inappropriate antihypertensive agent may be selected. As the choices of pharmacologic agents increase, selection for an individual patient becomes increasingly complicated. Other variables such as morbidity and mortality benefits, adverse effect profile, type of insurance coverage, cost, and ease of administration must be taken into consideration.
Second, nonadherence to drug therapy can result in decreased efficacy. Hypertension alone is a chronic asymptomatic disease; for patients to be compliant with a lifelong drug regimen, constant reinforcement and education are required.
Third, inadequate follow-up by health care professionals may result in suboptimal therapy management.
Finally, ineffective dissemination of information and updated national treatment guidelines to health care providers contributes to inadequate control of high blood pressure.
Since hypertension is a chronic and disabling disease, management and control of hypertension is and will continue to be a high priority in health care. The JNC issues and updates hypertension management guidelines based on new research every 3-5 years. In November 1997, the JNC published its sixth report (JNC VI) on hypertension management. In addition to recommending diuretics and
-Blockers as first-choice agents for treating patients without concurrent conditions or contraindications to these agents, four compelling indications were established in the JNC VI guidelines: the use of
-Blockers or angiotensin-converting enzyme (ACE) inhibitors in patients with histories of myocardial infarction; use of ACE inhibitors in patients with left ventricular dysfunction; use of diuretics or long-acting dihydropyridines in elderly patients with isolated systolic hypertension; and use of ACE inhibitors in patients with type 1 diabetes mellitus and proteinuria.
It is both important and interesting to study the impact of the JNC VI guidelines on hypertension management as well as antihypertensive drug prescribing patterns, which may help to identify factors leading to suboptimal blood pressure control.
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