Diagnosis and Treatment of Incident Hypertension Among Patients with Diabetes: a U.S. Multi-Disciplinary Group Practice Observational Study

Abstract

BACKGROUND: Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes mellitus. There is a need to improve hypertension management among patients with diabetes mellitus. OBJECTIVE: We aimed to evaluate rates and associations of hypertension diagnosis and treatment among patients with diabetes mellitus and incident hypertension. DESIGN: This was a 4-year retrospective analysis of electronic health records. PARTICIPANTS: Adults ≥18 years old (n=771) with diabetes mellitus, who met criteria for incident hypertension and received primary care at a large, Midwestern academic group practice from 2008 to 2011 were included MAIN MEASURES: Cut-points of 130/80 and 140/ 90 mmHg were used to identify incident cases of hypertension. Kaplan-Meier analysis estimated the probability of receiving: 1) an initial hypertension diagnosis and 2) antihypertensive medication at specific time points. Cox proportional-hazard frailty models (HR; 95 % CI) were fit to identify associations of time to hypertension diagnosis and treatment. KEY RESULTS: Among patients with diabetes mellitus who met clinical criteria for hypertension, 41 % received a diagnosis and 37 % received medication using the 130/ 80 mmHg cut-point. At the 140/90 mmHg cut-point, 52 % received a diagnosis and 49 % received medication. Atrial fibrillation (HR 2.18; 1.21-4.67) was associated with faster diagnosis rates; peripheral vascular disease (HR 0.18; 0.04-0.74) and fewer primary care visits (HR 0.93; 0.88-0.98) were associated with slower diagnosis rates. Atrial fibrillation (HR 3.07; 1.39-6.74) and ischemic heart disease/congestive heart failure (HR 2.16; 1.24-3.76) were associated with faster treatment rates; peripheral vascular disease (HR 0.16;) and fewer visits (HR 0.93;) predicted slower medication initiation. Diagnosis and treatment of incident hypertension were similar using cut-points of 130/80 and 140/90 mmHg. CONCLUSIONS: Among patients with diabetes mellitus, even using a cut-point of 140/90 mmHg, approximately 50 % remained undiagnosed and untreated for hypertension. Future interventions should target patients with multiple comorbidities to improve hypertension and diabetes clinical care.

Levels of detection of hypertension in primary medical care and interventions to improve detection: a systematic review of the evidence since 2000

“…Some studies also investigated diagnostic delay, that is, the first time between defined criteria for hypertension being met and a diagnosis being made. Among those whose hypertension had been diagnosed, the delay was 8.9 months in one study 21 and 1.9 months in another, 32 although 60% or more of hypertensive patients in these studies had not been detected during the period of follow-up. In a third study of delay, 34% of adults aged 18–39 years meeting criteria for hypertension were detected after 20 months of follow-up (44% among those 40–59 years old and 56% among those aged 60 or older).…”

A Comparison of the Use of Clinical-Guideline–Recommended Antihypertensive Regimens in Mexican American, Non-Hispanic Black, and Non-Hispanic White Adults With Type 2 Diabetes and Hypertension in the United States

“…Pharmacoepidemiologic studies usually measure antihypertensive medication use as whether a patient is taking a specific drug or is on a particular drug class, or they count the number of antihypertensive drug classes in a patient regimen. 6,[11][12][13][14][15][16][17] For example, ACEi or ARB use has been reported to be 35% to 53% nationally, and as high as 75% in the primary care setting or particular states in the country. 6,14,15 Minority studies report that blacks with or without diabetes are usually more likely than whites to be on ACEi and/or ARBs and require a greater number of antihypertensive drug classes.…”

The importance of frequent return visits and hypertension control among US young adults: a multidisciplinary group practice observational study

“…JNC 7 criteria were used because they were the established US hypertension guidelines during the reporting period. A patient was determined as meeting hypertension eligibility criteria based on electronic health record data if there were: (1) three or more elevated outpatient BP measurements from three separate dates, ≥30 days apart, but within a 2‐year span (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) or (2) two elevated BPs (systolic BP ≥160 mm Hg or diastolic BP ≥100 mm Hg), ≥30 days apart within a 2‐year period . If more than one BP was taken at a visit, the average was used .…”