Hypertension Management in Patients With Diabetes

Berlowitz, Dan R.; Ash, Arlene S.; Hickey, Elaine C.; Glickman, Mark E.; Friedman, Robert H.; Kader, Boris

doi:10.2337/diacare.26.2.355

Cited by 132 publications

(97 citation statements)

References 29 publications

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“…Because intense provider management may be associated with improved patient compliance, we measured diabetes management intensity (12,13). Berlowitz et al (12,13) defined diabetes treatment intensity as the likelihood of receiving an increase (increased dose, addition of a medication in another drug class, or a change of drug within the same class), decrease (lower dose, discontinuation of medication), or no change in treatment, accounting for variables believed to influence treatment decisions (e.g., HbA 1c , cholesterol levels, comorbidities). Observed changes were subtracted from these expected changes in treatment and divided by the number of visits.…”

Section: Research Design Andmentioning

confidence: 99%

The Influence of Insulin Use on Glycemic Control

2005

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OBJECTIVE -The purposes of this study were to determine the relationship between insulin self-management and glycemic control and to identify patient characteristics associated with better control. RESEARCH DESIGN AND METHODS-A Department of Veterans Affairs regional database was used to identify patients with diabetes on chronic insulin therapy (n ϭ 6,222) with dose defined as number of units and doses. The rate of insulin use during a 2-year period was calculated using pharmacy data. Regression analyses were used 1) to predict compliance with prescribed insulin regimens using demographic variables, HbA 1c levels, and a measure of diabetes management intensity and 2) to predict HbA 1c levels using demographic variables and rates of insulin use.RESULTS -Insulin use was 77.44 Ϯ 17% of prescribed amounts, including wastage; HbA 1c levels were 7.98 Ϯ 1.66%. Concomitant oral hypoglycemic agent use (84.89 Ϯ 16%) was higher than insulin use (P Ͻ 0.0001) but correlated with insulin use (r ϭ 0.189, P Ͻ 0.0001). Ordinary least-squares regression showed that race, HbA 1c levels, and intensity of diabetes management were significant predictors of insulin use. Age, race, and insulin use were significant predictors of HbA 1c levels.CONCLUSIONS -Adults prescribed a specific insulin regimen averaged using 77% of prescribed doses, demonstrating good intention to follow the prescription. However, HbA 1c higher than the recommended level suggested that the rate of insulin use, the prescribed regimen, or both were inadequate to achieve good glycemic control in patients with long-term insulin use. Diabetes Care 28:78 -83, 2005

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Section: Research Design Andmentioning

confidence: 99%

The Influence of Insulin Use on Glycemic Control

2005

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“…30,31 One prior study suggested that the complexity of simultaneously managing multiple risk factors in diabetics did not explain higher rates of TI, because increases in antihypertensive medications were no less likely for those visits in which diabetic medications were also changed. 30 In contrast, other studies on the management of chronic medical conditions in patients with comorbidities have implicated competing demands 32 and burden of comorbid illness. 33 Lack of knowledge of medical guidelines, for example, the lower BP goal in patients with diabetes or nephropathy, 34,35 probably does not explain the differences in TI in this study between patients with diabetes mellitus or nephropathy and those without.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals

et al. 2006

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Abstract-Therapeutic inertia (TI), defined as the providers' failure to increase therapy when treatment goals are unmet, contributes to the high prevalence of uncontrolled hypertension (Ն140/90 mm Hg), but the quantitative impact is unknown. To address this gap, a retrospective cohort study was conducted on 7253 hypertensives that had Ն4 visits and Ն1 elevated blood pressure (BP) 1999 -2000. 2,3 Despite an increase in the number and tolerability of antihypertensive medications, goal BP has been difficult to attain. Clinical trials, including the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack trial, 4 with 66% control rates and the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints study 5 with 70% control rates have shown that the BP control rates reported in national data can be substantially improved. Of note, the majority of uncontrolled hypertensive subjects in the United States are older individuals with systolic BP (SBP) 140 to 159 mm Hg who are seen an average of 6 times annually in a primary care setting. 6 Even with substantial reductions in the number of unaware and untreated hypertensive patients, controlling BP in Ն70% of treated patients is a vital component of reaching the Healthy People 2010 goal of controlling hypertension in 50% of all affected patients. 7 Hypertension control rates nearly tripled from 10% in 1976 -1980 to 29% in 1988 -1991. 8 The improvements in hypertension control coincided temporally with a large decline in the age-adjusted rates for stroke and coronary heart disease (CHD).Unfortunately, BP control rates have changed little in the past 15 years, especially in women. Patient factors, such as compliance, 9,10 knowledge, 11 and lack of insurance, 12 and system factors, such as limited access to care and medications 13 and lack of appointment reminders, 14 have been cited for the low rates of BP control. Of note, BP control remains suboptimal in systems such as the Veterans Administration where financial barriers to health care are less. 15,16 Physician factors, such as therapeutic inertia (TI), that is, failure of providers to begin new medications or increase dosages of existing medications when an abnormal clinical parameter is recorded, are becoming more evident. TI represents a significant barrier to better hypertension control. TI impacts not only control of BP but of other chronic diseases, including diabetes mellitus and hyperlipidemia. [17][18][19][20][21][22][23][24] Although data suggest that TI contributes to the high prevalence of uncontrolled hypertension, the quantitative impact is not clear. This article examines the impact of TI on

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“…Unfortunately, blood pressure control in these settings is frequently suboptimal (10 -12) and may be even worse in those with diabetes and hypertension compared with those with hypertension alone (13).…”

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confidence: 99%

Action or Inaction? Decision Making in Patients With Diabetes and Elevated Blood Pressure in Primary Care

Hicks¹,

Westfall

Vorst

et al. 2006

Diabetes Care

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OBJECTIVE -Hypertension increases micro-and macrovascular complications of diabetes. The goal for blood pressure is Ͻ130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure.RESEARCH DESIGN AND METHODS -Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action.RESULTS -Completed surveys totaled 778. Blood pressure was 130/74 Ϯ 18.8/12.0 mmHg (mean Ϯ SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS -No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction. Diabetes Care 29:2580 -2585, 2006T here is extensive clinical evidence linking hypertension with microand macrovascular complications of diabetes, including randomized controlled trials and a meta-analysis (1-6). Until 2000, the target blood pressure for individuals with diabetes was the same as that for individuals without diabetes (Ͻ140/90 mmHg). However, because of the demonstrated clinical benefit of lower blood pressure specifically for diabetes, national guidelines, established by the American Diabetes Association and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), call for more intensive management, with a target of Ͻ130/80 mmHg (7,8).Of the care provided to patients with type 2 diabetes, ϳ90% takes place in primary care practices (9). Unfortunately, blood pressure control in these settings is frequently suboptimal (10 -12) and may be even worse in those with diabetes and hypertension compared with those with hypertension alone (13).An essential component of lowering blood pressures to goal is the clinical decision made by the primary care provider at the visit in which blood pressure is elevated. Multiple factors may influence this decision. For example, it has been found that optimal blood pressure control often requires three or more medications (8), leading to increas...

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Hypertension Management in Patients With Diabetes

Cited by 132 publications

References 29 publications

The Influence of Insulin Use on Glycemic Control

The Influence of Insulin Use on Glycemic Control

Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals

Action or Inaction? Decision Making in Patients With Diabetes and Elevated Blood Pressure in Primary Care

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