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Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension

Journal of General Internal Medicine volume 23, pages 543–550 (2008)Cite this article

Abstract

Background

Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications.

Objective

To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes.

Design

Non-concurrent prospective cohort study.

Patients

A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999–2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg).

Measurements and Main Results

Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were “routine” odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36–3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11–3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31–0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38–0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41–1.03).

Conclusions

Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.

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Acknowledgment

This work was presented at the national Society of General Internal Medicine in April 2006. Dr. Shari Bolen was supported by a T32 NRSA training grant. Dr. T. Alafia Samuels was supported by NIH training grant (HD 08487) and NIH/NHLBI Cardiovascular Epidemiology Training Grant (T32HL07024). Dr. Fred Brancati was supported by a Mid Career Award for Patient-Oriented Research in Diabetes from the NIDDK, Bethesda, MD (1K24-DK6222-01). Funding for this project was received from AHRQ Dissertation Grant (1R03HS011946-01), and from the Johns Hopkins Department of Epidemiology, Summer Epidemiology Program Fund. Funders provided financial resources only, and did not contribute to the project otherwise.

This study was reviewed and approved by the Johns Hopkins School of Public Health Institutional Review Board.

Conflict of Interest

None disclosed.

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Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Shari Danielle Bolen MD, MPH, Hsin-Chieh Yeh PhD, Spyridon S. Marinopoulos MD, MBA, Maura McGuire MD & Frederick L. Brancati MD, MHS

  2. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Shari Danielle Bolen MD, MPH, Hsin-Chieh Yeh PhD & Frederick L. Brancati MD, MHS

  3. Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA

    Hsin-Chieh Yeh PhD & Frederick L. Brancati MD, MHS

  4. Pan American Health Organization (PAHO), Washington, DC, USA

    T. Alafia Samuels MD, MPH, PhD

  5. Department of Medicine, University of Massachusetts School of Medicine, Worcester, MA, USA

    Marcela Abuid MD

  6. Welch Center for Epidemiology and Prevention, Baltimore, MD, USA

    Shari Danielle Bolen MD, MPH

Authors
  1. Shari Danielle Bolen MD, MPH
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  2. T. Alafia Samuels MD, MPH, PhD
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  7. Frederick L. Brancati MD, MHS
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Correspondence to Shari Danielle Bolen MD, MPH.

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Bolen, S.D., Samuels, T.A., Yeh, HC. et al. Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension. J GEN INTERN MED 23, 543–550 (2008). https://doi.org/10.1007/s11606-008-0507-2

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  • DOI: https://doi.org/10.1007/s11606-008-0507-2

KEY WORDS

  • diabetes mellitus
  • hypertension
  • health services
  • cohort study