Barriers to Blood Pressure Control: A STITCH Substudy

Despite improvements in blood pressure (BP) control, a substantial percentage of patients do not achieve target. The relative importance of determinants of poor BP control is unclear. Therefore, the authors conducted a post hoc exploratory analysis to assess determinants of BP control. Data were collected in 45 general practices, which enrolled patients with uncontrolled hypertension. Antihypertensive medication changes throughout the 6‐month follow‐up period were documented. Baseline and 6‐month BPs were recorded. Of the 2030 patients analyzed, 320 had diabetes. Overall, 42% of patients did not achieve BP control. In multivariate analysis, failure to intensify therapy was identified as a significant independent predictor of lesser BP reduction. Of patients unable to reach target after 6 months, only 25% were prescribed ≥3 drugs. Patients with diabetes were significantly less likely to reach target than those without (26% vs 64%, P<.001). Antihypertensive therapy prescribed to patients with diabetes was only marginally more intensive than to those without. In patients with hypertension, whether with or without coexisting diabetes, poor BP control appears to be at least partially due to failure to uptitrate antihypertensive therapy. Clinical inertia is likely an important barrier to BP control. J Clin Hypertens (Greenwich). 2011;13:73–80. © 2010 Wiley Periodicals, Inc.

[1]  G. Booth,et al.  Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Methods. , 2013, Canadian journal of diabetes.

[2]  B. Egan,et al.  US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. , 2010, JAMA.

[3]  M. Vandervoort,et al.  A Simplified Approach to the Treatment of Uncomplicated Hypertension: A Cluster Randomized, Controlled Trial , 2009, Hypertension.

[4]  V. Basevi.  Standards of medical care in diabetes--2007. , 2009, Diabetes care.

[5]  M. Moser.  Physician or Clinical Inertia: What Is It? Is It Really a Problem? And What Can Be Done About It? , 2009, Journal of clinical hypertension.

[6]  A. Classification,et al.  Standards of Medical Care in Diabetes—2009 , 2009, Diabetes Care.

[7]  G. Bakris,et al.  Mechanistic insights into diuretic-induced insulin resistance. , 2008, Hypertension.

[8]  G. Fodor,et al.  Antihypertensive medication use and blood pressure control: a community-based cross-sectional survey (ON-BP). , 2008, American journal of hypertension.

[9]  G. Ogedegbe.  Barriers to Optimal Hypertension Control , 2008, Journal of clinical hypertension.

[10]  G. Fodor,et al.  Results of the Ontario Survey on the Prevalence and Control of Hypertension , 2008, Canadian Medical Association Journal.

[11]  A. Karter,et al.  Why Don’t Diabetes Patients Achieve Recommended Risk Factor Targets? Poor Adherence versus Lack of Treatment Intensification , 2008, Journal of General Internal Medicine.

[12]  J. Rumsfeld,et al.  Importance of therapy intensification and medication nonadherence for blood pressure control in patients with coronary disease. , 2008, Archives of internal medicine.

[13]  W. Elliott.  What Factors Contribute to the Inadequate Control of Elevated Blood Pressure? , 2008, Journal of clinical hypertension.

[14]  B. Nightengale,et al.  Relationship of Blood Pressure Control to Adherence With Antihypertensive Monotherapy in 13 Managed Care Organizations , 2006, Journal of managed care pharmacy : JMCP.

[15]  V. Durkalski,et al.  Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals , 2006, Hypertension.

[16]  J. Laragh,et al.  Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial , 2004, The Lancet.

[17]  Daniel W. Jones,et al.  The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. , 2003, JAMA.

[18]  B. Davis,et al.  Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). , 2002, JAMA.

[19]  P. Lapuerta,et al.  Physician-related barriers to the effective management of uncontrolled hypertension. , 2002, Archives of internal medicine.

[20]  G. Bakris.  A practical approach to achieving recommended blood pressure goals in diabetic patients. , 2001, Archives of internal medicine.

[21]  Allan Donner,et al.  Design and Analysis of Cluster Randomization Trials in Health Research , 2001 .

[22]  A Donner,et al.  Design considerations in the estimation of intraclass correlation , 1982, Annals of human genetics.

[23]  Lawrence A Leiter,et al.  Canadian Diabetes Association Clinical Practice Guidelines Expert Committee , 2013 .

[24]  W. Elliott.  US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-2008 , 2011 .

[25]  Kevin A Peterson,et al.  Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus , 2011 .

[26]  W. Elliott.  A Simplified Approach to the Treatment of Uncomplicated Hypertension: A Cluster-Randomized Controlled Trial , 2010 .

[27]  B. Davis,et al.  Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). , 2002, Journal of clinical hypertension.

[28]  J. Wofford.  Clinical inertia. , 2002, Annals of internal medicine.