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Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

Patients with multiple cardiovascular risk factors benefit from having them all controlled, but this rarely occurs. Fifty-seven primary care providers were enrolled in a program to monitor cardiovascular risk factor control. Data were obtained on 7315 hypertensives. This analysis focuses on 3460 high-risk hypertensives including 2199 with diabetes and 1261 with clinical cardiovascular disease. Blood pressures were <140/90 mm Hg and <130/80 mm Hg in only 44.3% and 20.4% of diabetics and 49.6% and 26.6% nondiabetics, respectively, despite the use of an average of 2.7±1.8 anti-hypertensive medications. Among high-risk dyslipidemic hypertensives, the low-density lipoprotein cholesterol level was <100 mg/dL in only 34% of diabetic and 33% of nondiabetic patients. Among 1696 diabetic hypertensives, the most recent glycosylated hemoglobin value averaged 7.5%, with 46.6% less than 7%. Among 805 diabetic, dyslipidemic hypertensives, all three risk factors were controlled to goal in only 6.6% with higher rates in whites than in African Americans (14.8% vs. 1.6%, p<0.001). An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or both were prescribed in 89.9% of diabetic and 70.8% of nondiabetic patients, p<0.05. Primary care providers use evidence-based combination therapy in high-risk hypertensive patients with and without diabetes. These findings confirm the low rates of multiple risk factor control and highlight challenges of reaching evidence-based goals in primary care.

Hypertension is frequently accompanied by other cardiovascular risk factors and comorbidities.1 Blood pressure control is especially important in preventing cardiovascular and renal complications for hypertensive patients at highest risk.2,3 In the sixth1 and seventh4 reports of the Joint National Committees on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI, JNC 7), an even lower blood pressure goal of <130/85 mm Hg has been recommended for hypertensive patients with diabetes and/or target organ damage and clinical cardiovascular disease (Risk Group C) compared to a goal of <140/90 mm Hg in other patients. In the JNC 7, a goal of <130/80 mm Hg is recommended in the same diabetic high-risk patients. Among these high-risk patients, control of blood pressure to goal is even lower5 than the 34% in the overall hypertensive population.3

Better blood pressure control reduces the vascular complications of diabetes.6–13 Long-term follow-up of 3642 subjects in the United Kingdom Prospective Diabetes Study (UKPDS) indicated that each 10 mm Hg decrease in systolic blood pressure lowered risk for diabetes-related complications by 12%, diabetes-related death by 15%, and myocardial infarction and microvascular complications by 11%.11 Based on UKPDS11 and other trials,7,11,12,13 a treatment goal of <130/85 mm Hg14 or <130/80 mm Hg is recommended4 for diabetics. Diabetics and other high-risk hypertensive patients derive additional cardioprotective benefits from a regimen that includes angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and β blockers.12,13,17,18

Several trials also indicate that diabetic and other high-risk patients benefit from lipid-lowering therapy,19–22 which led to a low-density lipoprotein (LDL) cholesterol goal of <100 mg/dL.23 Evidence supports multiple risk factor control in diabetic and other high-risk hypertensive patients. However, recent reports5,24 indicate that only ≊3% of diabetic hypertensive patients in teaching hospitals reach target goals for blood pressure, LDL-cholesterol, and glycosated hemoglobin (HbA1c); use of agents that interrupt the renin-angiotensin system appeared suboptimal.

There are multiple barriers to implementing treatment guidelines and achieving control goals in clinical practice.25,26 Physicians are often unaware of treatment patterns and control rates in their patients, and providing feedback can be effective, at least in some settings.27 Moreover, the Institute of Medicine identified the need for better information and data in outpatient settings to drive quality improvements in health care.28 To address these issues, we developed a monitoring and reporting system for multiple cardiovascular risk factors in hypertensive patients as a joint effort of the Hypertension Initiative of South Carolina29 and the American Society of Hypertension (ASH) Carolinas-Georgia Chapter.30

Purpose and Provider Enrollment

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

The Hypertension Initiative of South Carolina29 and ASH Carolinas-Georgia Chapter30 were initiated to support and facilitate improvement in cardiovascular risk factor treatment and control in the three-state area. The two main components of the Initiative are the Experts in Hypertension Seminar Series and the data monitoring and feedback program. The Experts Series is accredited for continuing medical education, and several programs are held each year in various locations throughout the state. At each program, attendees are invited to participate in the data audit and feedback program and several elect to do so. Some primary care physicians joined the audit and feedback program on the recommendation of colleagues who were active participants.

Fifty-seven different primary care providers contributed information on 7315 patients to the database during the period included in this report: January 1, 2001–July 31, 2002.

Regulatory Review

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

The data monitoring and reporting procedures were reviewed and approved by the Office for Research Protection and Integrity at the Medical University of South Carolina (MUSC) to ensure that appropriate safeguards for patient confidentiality were in place and that the project was in compliance with the Health Insurance Portability and Accountability Act. The data systems manager/programmer and data entry clerk had access to the unique patient, provider, and site identifiers that were required to facilitate reports to the primary care physician of record. The data manager and data entry clerk signed a confidentiality agreement reviewed and approved by the Office of Research Protection and Integrity and legal counsel at MUSC.

Data Acquisition

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

Providers participated in the monitoring and feed-back program by one of two methods. One option utilized a 3×5-in report card completed by the provider and/or office staff at each visit by a hypertensive patient.29,30 The variables captured on the card included age, gender, race, height, weight, blood pressure; LDL cholesterol level (mg/dL), dose and frequency of antihypertensive and lipid-lowering medications; presence of type 2 diabetes mellitus, HbA1c value; and the presence of cardiovascular risk factors and comorbidities (e.g., smoking, menopausal status, family history of cardiovascular disease, nephropathy, congestive heart failure, hypercholesterolemia). The cards were batched and mailed in a pre-addressed, postage-paid envelope to the data management center at MUSC. The cards did not include any personal identifiers such as name, address, phone number, social security number, or zip code. Unique patient and provider identifiers were obtained to facilitate the generation of summary reports and flow sheets to each provider on his or her own patients. The main purpose of these reports was to enhance the quality of patient care.

The second method used the electronic medical record (EMR) for practices with this technology. The data export function of the EMR was used to obtain the same data as the cards. Personal identifying information (except for a unique patient, provider, and site identifier) was not obtained. The identifiers were required to generate reports and flow sheets that were given only to the health care provider of record for the patient. For analytical purposes, another database devoid of the patient, provider, and site identifiers was used.

Data Management

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

The information obtained from the data card and EMR were entered into a Microsoft Access database (Microsoft Corp., Redmond, WA) and examined using a series of programmed queries established by our group. Patients were stratified into Risk Group A, B, and C based on criteria established in JNC VI.1

Data Reporting

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

Providers received quarterly summary reports for their patients on the JNC VI Risk Group distribution as well as the percentage of hypertensive patients achieving blood pressure control targets, dyslipidemic patients reaching LDL cholesterol goals, and diabetic patients meeting target HbA1c values. Providers also received a summary of medications used to treat hypertension for all of their patients combined and for each risk group. For comparison purposes, each physician/provider received a summary report for all patients in the monitoring program without any identifiers by patient, provider, or site.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

Data were obtained from 57 primary care providers on 7315 patients from January 1, 2001 through July 31, 2002. These patients were stratified according to the risk classification scheme proposed in JNC VI.1 The distribution of the three JNC VI Risk Groups in our database compared with a previous representative national sample2 is depicted in the Figure 1. Our sample was skewed toward a larger proportion in Risk Group C, which is the focus of this report.

image

Figure 1. Percent of individuals in Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Risk Groups A—C in the National Health and Nutrition Examination Survey (NHANES) and the Hypertension Initiative of South Carolina (HTN Initiative of S.C.)

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Descriptive characteristics of the entire group and of Risk Group C patients are provided in Table I. Patients in Risk Group A (premenopausal women) were significantly younger. Among 3460 hypertensive patients in JNC VI Risk Group C, 2199 patients were diabetic and 1261 were not diabetic (Table II). Nondiabetic patients in Risk Group C were the oldest (p<0.05), with a mean age of 71.4±14.4 years. Blood pressure control rates in the three different JNC VI Risk Group strata are provided at the various cut points indicated. In general, control rates were relatively comparable across the three risk groups at the various cut points shown. Among Risk Group C patients, 34.3% of nondiabetics and 25.6% of diabetic hypertension patients were controlled to <130/85 mm Hg, whereas control to <130/80 mm Hg occurred in only 26.5% of nondiabetics and 20.3% of diabetic hypertensive patients (Table II).

Table I.  Demographic Characteristics of Hypertensive Patients Stratified by JNC VI Risk Group
   Risk Group CRisk Group C
Demographic CharacteristicRisk Group A (n=484)Risk Group B (n=3371)Nondiabetic (n=1261)Diabetic (n=2199)
Age (years)*44.3±8.764.3±14.471.4±14.466.0±12.8
Gender (n [%])    
 Male01451 (43.0)480 (38.0)798 (36.3)
 Female484 (100)1869 (55.4)736 (58.4)1370 (62.3)
 Unknown051 (1.5)45 (3.6)31 (1.4)
Ethnicity (n[%])    
 White100 (20.7)1143 (33.9)471 (37.4)602 (27.4)
 African American202 (41.7)1036 (30.7)542 (43.0)850 (38.6)
 Hispanic11 (232)35 (1.0)5 (0.4)17 (0.8)
 Other4 (0.8)8 (0.2)3 (0.3)1 (<0.1)
 Unknown167 (34.7)1149 (34.1)239 (19.0)729 (33.2)
JNC VI=Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; *mean±SD
Table II.  Differences in Risk Factor Control by JNC VI Risk Group*
Risk FactorGroup A (n=484)Group B (n=3371)Group C Nondiabetic (n=1261)Group C Diabetic (n=2199)
SBP (mm Hg)139±20140±20137±23141±22
DBP (mm Hg)87±1183±1279±1379±12
BP control to (n [% of those measured]):    
<150/95322 (64.0)2222 (66.2)879 (69.7)1453 (65.8)
<140/90213 (42.4)1442 (43.0)626 (49.6)979 (44.3)
<130/85113 (23.3)812 (24.1)432 (34.3)564 (25.6)
<130/8067 (13.3)542 (16.2)334 (26.5)449 (20.3)
Lipids**    
No. with dyslipidemia 16607571371
No. with LDL 12245411069
LDL-C, (mg/dL) 130±37116±42117±39
LDL-C control to: (mg/dL, n [%])    
LDL <130 586 (47.9)346 (64.0)694 (64.9)
LDL <100 251 (20.5)178 (32.9)363 (34.0)
Diabetes    
HbA1C measured   7.5±1.9
No.   1696
HgbA1C measured    
<7.0 (n [% of those measured])   790 (46.6)
JNC VI=Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; SBP=systolic blood pressure; DBP=diastolic blood pressure; BP=blood pressure; LDL=low-density lipoprotein; LDL-C=low-density lipoprotein cholesterol; HbA1c=gylcosated hemoglobin; *data are mean±SD unless noted; **values provided only for patients with diagnosis of and/or on treatment for a lipid disorder

Mean LDL cholesterol was lower in Risk Group C than B and may be explained in part by the lower LDL cholesterol goal of <100 mg/dL for many patients in the highest risk group.23 LDL cholesterol control was comparable among diabetic (34.0%) and nondiabetic (32.9%) patients in Risk Group C with a diagnosis and/or treated lipid disorder.

A total of 1696 diabetic hypertensive patients had an HbA1c value taken during the past year in the database. Using the most recent value for each of these patients showed a mean HbA1c value of 7.5%±1.9% with 46.6% having a last reading <7%.

The classes of antihypertensive medications used in the diabetic and nondiabetic patients in JNC VI Risk Group C are shown in Table III along with comparable data on Risk Group A and B patients. Diuretic use was the most consistent across all three risk groups at approx56%–60%. Compared with patients in Risk Groups A and B, patients in Risk Group C were more likely to receive ACE inhibitors and calcium channel blockers. Utilization of different antihypertensive drug classes was similar in diabetic and nondiabetic Risk Group C patients except for greater use of β blockers (p<0.05) in nondiabetics and greater use of ACE inhibitors (p<0.05) in diabetics. Within Risk Group C, patients with a diagnosis of cardiovascular disease including congestive heart failure were more likely to receive a β blocker than patients without these conditions (37.5% vs. 23.3%; p<0.01). When patients on β and/or αβ blockers were added together, the respective percentages rose slightly to 40.6% vs. 27.7% (p<0.01).

Table III.  Hypertensive Medication Use by JNC VI Risk Group
 Group C NondiabeticGroup C Diabetic
 Group A (n=484)Group B (=n3371)(n=1261)(n=2199)
Medication Classn (%)n (%)n (%)n (%)
Antihypertensives    
 ACE inhibitors129 (26.7)1180 (35.0)624 (49.5)1434 (65.2)
 ARB83 (17.1)788 (23.4)268 (21.3)544 (24.7)
 ACE inhibitor+ARB17 (3.5)210 (6.2)95 (7.5)256 (11.6)
  β blocker123 (25.4)841 (24.9)434 (34.4)586 (26.6)
  α β blocker5 (1.0)46 (1.4)48 (3.9)78 (3.5)
 Diuretic272 (56.2)1907 (56.6)725 (57.5)1323 (60.2)
 DHP–CCB73 (15.1)826 (24.5)416 (33.0)710 (32.3)
 NDHP–CCB34 (7.0)375 (11.1)189 (15.0)291 (13.2)
 Blood pressure*1.82±1.152.14±1.412.72±1.762.77±1.81
Lipid medications    
 Statins 610 (18.1)410 (32.5)789 (35.9)
 Other antilipidemics 274 (8.1)135 (10.7)251 (11.4)
JNC VI=Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; ACE=angiotensin-converting enzyme; ARB=angiotensin receptor blocker; DHP=dihydropyridine; NDHP=nondihydropyridine; CCB=calcium channel blocker; *blood pressure medications reported as mean±SD (number of antihypertensive medications per patient)

The frequency of clinical cardiovascular disease and congestive heart failure comorbidities in Risk Group C patients subdivided by the presence or absence of diabetes mellitus is shown in Table IV. Nondiabetics were more likely than diabetics in Risk Group C to have a comorbid diagnosis of cardiovascular disease and congestive heart failure.

The percentages of diabetic and nondiabetic hypertensive patients in Risk Group C with dyslipidemia who had blood pressure and/or LDL cholesterol controlled to goal are shown in Table V. The top of Table V provides control rates for blood pressure, LDL cholesterol level, and HbA1c value in the subgroup of 805 patients with the triad of hypertension, diabetes, and dyslipidemia. The percentage rates for control of these risk factors are at variance with the data shown in Table II because only patients with all risk factors are included. The control rates for cardiovascular risk factor singly and in combination are further stratified by ethnicity and gender.

Table V.  Percentage of Patients With Multiple Risk Factors Controlled Among Diabetics and Nondiabetics, Stratified by Ethnicity and Gender Among JNC VI Risk Group C
Diabetic Hypertensive Patients With Dyslipidemia
Risk Factor (Group)BP <130/80 mm HgLDL <100 mg/dlHgbA1C <7%Two at GoalThree at Goal
All (n=805)24.0%35.4%48.6%31.8%7.6%
White (n=263)35.4%58.2%58.9%51.0%14.8%
African American (n=379)17.2%21.9%39.1%18.7%1.6%
Women (n=511)21.9%31.3%47.9%29.0%4.9%
Men (n=278)26.6%41.7%49.3%35.3%9.3%
Nondiabetic Hypertensive Patients With Dyslipidemia
Risk Factor (Group)BP <130/80 MM HgLDL <100 MG/DlBothat Goal
All (n=541)32.7%32.9%15.6%
White (n=233)45.5%53.6%27.9%
African American (n=234)26.0%15.0%4.7%
Women (n=296)39.7%24.7%10.1%
Men (n=209)37.3%45.0%23.4%
JNC VI=Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; BP=blood pressure; LDL=low-density lipoprotein; only patients with values in the past year for all risk factors are included

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

This study was carried out in community-based practice settings throughout South Carolina and included a diverse population of patients (Table I). The findings demonstrate the feasibility of obtaining data on cardiovascular risk factor control rates and treatment patterns in primary care settings that can be used to facilitate continuing medical education programs and other interventions aimed at improving health outcomes and reducing health disparities. This initiative was successful in enlisting the cooperation of 57 primary care providers serving a high-risk population of hypertensive patients with diabetes and/or major target organ damage or clinical cardiovascular disease. In fact, 47.3% of the hypertensive patients in this database met criteria for inclusion in JNC VI Risk Group C compared with 19% in a previous report from an earlier nationally representative sample.2 The higher risk of hypertensive patients in our database is consistent with evidence that stroke, total cardiovascular disease, and end-stage renal disease are higher in South Carolina than the US average.31

African Americans comprised about half of the patient sample for which ethnicity was identified (ethnicity was not available on patients in some practices using EMRs). Although approx30% of the South Carolina population is African American, this ethnic group is more likely to have hypertension, diabetes mellitus, and target organ damage than whites, which would contribute to relative over-representation, especially in the highest risk group. Although hypertensive patients in this database do not reflect a random sample, it is likely that the ethnic characteristics of our hypertensive patient sample are generally representative of those in the state.

Blood pressure <140/90 mm Hg was achieved in 44.3% of diabetic hypertensives; a target blood pressure of <130/85 mm Hg was attained in 25.6%. Blood pressure was controlled to goal in a larger proportion of non- diabetic than diabetic hypertensive patients to <140/90 mm Hg (49.6%) and <130/85 mm Hg (34.3%) in Risk Group C (Table II). Among patients who achieved blood pressure <130/85 mm Hg, 72.4% were prescribed a combination of two or more antihypertensive medications. Of note, the number of antihypertensive medications used was comparable in diabetic and nondiabetic Risk Group C patients with a mean of 2.7–2.8 agents each. The number of antihypertensive mediations was similar in Risk Group C patients with and without blood pressure control to goal (not shown).

Utilization of various classes of antihypertensive compounds was similar in Risk Group C patients with and without diabetes, except for greater β blocker use in nondiabetics and greater ACE inhibitor use among diabetics. Diuretics were the most commonly prescribed antihypertensive class in all hypertensive patients combined and, unlike the other major classes of antihypertensive medications, frequency of use was very similar across the three JNC VI Risk Groups. The relatively high use of diuretics compared with other classes of antihypertensive agents is consistent with the JNC VI management guidelines and appears greater among providers in this database than in a recent report from a national Veterans Administration sample.32

Beta and αβ blocker use was also relatively flat across risk groups except for higher use among nondiabetic Group C. Beta and αβ blocker use was greater among Risk Group C patients than those without known cardiovascular disease or congestive heart failure at 40.6% vs. 27.7% (p<0.01), which is consistent with the evidence.17,18 The use of the other classes of antihypertensive agents rose as the JNC VI Risk Group increased from A to C (Table III).

The increasing use of ACE inhibitors across the various risk strata was most striking in absolute terms, rising from ≊27% in Risk Group A to 49% of nondiabetics and 65% of diabetics among Risk Group C. The sharp increase in ACE inhibitor use among the highest risk patients likely reflects adherence by their primary care providers to evidence-based treatment guidelines. Several reports document the cardio- and renoprotective benefits of ACE inhibitors and ARBs in diabetics and in other high-risk patients.1,6,12,13 In fact, ≊90% of diabetics and 71% of nondiabetic Risk Group C patients were receiving an ACE inhibitor and/or an ARB usually with another therapy, diuretics.

Although providers in this database were using combination therapy in most Risk Group C and many Risk Group B patients, blood pressure was controlled to <140/90 mm Hg in only ≊50% of hypertensives. Failure of providers to titrate medications,33 reluctance to use diuretic therapy in 4% of patients (a positive predictor of blood pressure control in combination regimens34), and patient nonadherence with medication and lifestyle advice are major barriers to better blood pressure control rates.35

While blood pressure control was somewhat better in nondiabetic than in diabetic patients in Risk Group C, control of LDL cholesterol level to <100 mg/dL was similar in these two groups. The proportion of high-risk patients with two cardiovascular risk factors controlled to goal occurred in 31.8% of diabetics but in only 15.6% of nondiabetics. The difference largely reflects the fact that all of the diabetics in this comparison had three risk factors and a combination of any two met the criteria. Nevertheless, the major point remains that only a very small proportion of nondiabetic hypertensive Risk Group C patients with dyslipidemia had both risk factors controlled to goal.

With regard to multiple risk factor management in diabetics, McFarlane and colleagues5 assessed control rates among 1247 outpatients with hypertension and type 2 diabetes followed at two academic centers, including Veterans' Affairs clinics in two major urban medical centers (Brooklyn, NY, and Detroit, MI). In that study, 26.7% of patients with diabetes and hypertension met the JNC VI blood pressure target of <130/85 mm Hg, which was comparable to the 25.6% rate in our database. The average blood pressure was 143/78 mm Hg among diabetic hypertensives in the McFarlane study and 141/79 mm Hg for diabetic hypertensives in our database. In that previous study,5 the mean number of antihypertensive medications required to achieve blood pressure <130/85 mm Hg was 3.1, while those with blood pressure >130/85 mm Hg were receiving 3.3 medications. In our study, Risk Group C patients with and without blood pressure control received an average of 2.7–2.8 antihypertensive medications each. Also of note, nearly 75% of patients were men in the previous report, which reflects the demographics of Veterans' Affairs medical centers. However, in our database, men were somewhat more likely than women to obtain control of the hypertension, dyslipidemia, and diabetes triad (Table V).

Goal LDL cholesterol level of <100 mg/dL was met in 35.5% of patients in the earlier report,5 which is similar to our results of 34.0% <100 mg/dL among all dyslipidemic diabetics and 35.4% among those with current values for all three risk factors (Table V). In the previous study,5 26.7% had an HbA1c value <7% compared with a higher rate of 46.6% in our study for all diabetics and 48.6% among those with all three risk factors.

Another study by Singer and coworkers36 evaluated blood pressure control rates in a hypertension clinic staffed primarily by clinical hypertension specialists certified by ASH. The specialist clinic saw patients referred mainly for difficult-to-manage high blood pressure. Of 437 consecutive treated patients studied, 87 (20%) had diabetes. Blood pressure control <140/90 mm Hg was achieved in 52% of the patients with diabetes. Only 22% of diabetic hypertensives reached the more stringent goal of <130/85 mm Hg, although more than half of them received three or more drugs. An ACE inhibitor or ARB was included in the regimen of 76% of diabetic patients and a diuretic in ****55%, compared with ****90% for ACE inhibitor and/or ARB and 60% diuretic in our sample. Blood pressure control rates were similar, whereas use of ACE inhibitor, ARB, and diuretics in patients managed by specialists in the previous report36 were somewhat lower than for comparable patients managed by primary care providers in this database. The explanation for these differences is unknown but may reflect recent changes in practice patterns.

Ethnic differences represent an important variable affecting health status and outcome for individuals with type 2 diabetes.37 Disease burdens vary by region, and regional differences in demographic patterns and disease profiles emphasize the importance of developing action plans tailored to the needs of local communities.30 The burden of disease is particularly high among African Americans in the southeastern United States.30,31 In this regard, it is of interest to note that control of hypertension, LDL cholesterol, and HbA1c to goal was not only disappointingly low overall but also significantly poorer among African Americans than whites in our report. Control of two risk factors was significantly less common among African-American than white patients both with and without diabetes (Table V). Among 805 hypertensive, dyslipidemic diabetics with recent values in our database, control of blood pressure to <130/80 mm Hg, LDL cholesterol level to <100 mg/dL, and HbA1c value to <7% among patients diagnosed with all three risk factors to goal was a relatively rare occurrence overall at 6.6%. A significant ethnic difference was observed for controlling all three risk factors to goal (African Americans 1.6% vs. whites 14.8%; p<0.01).

One of the challenges confronting medicine today is the need to improve the quality of care. Meeting this challenge can be facilitated by a dynamic audit and feedback process, which is in compliance with federal regulations. The approach outlined addresses both priorities and provides the basis for further initiatives to enhance the relevance of continuing medical education programs and strategic interventions to improve the quality of care and the outcomes achieved. Such progress is especially important for patients at highest risk, including ethnic minorities and patients with multiple risk factors and comorbidities, who have the greatest burden of adverse outcomes.

The findings in this report are indicative of the challenges in controlling blood pressure to goal in primary care settings, despite the relatively high use of combination, evidence-based therapy. These observations emphasize the difficulty in simultaneously controlling multiple cardiovascular risk factors. These data are a reminder to physicians that cardiovascular risk factor control is suboptimal and that there are many opportunities for improvement. It is our desire that the database will guide the design, implementation, and evaluation of continuing medical education programs and novel interventions aimed at enhancing risk factor control and reducing the burden of disease and health disparities.

Acknowledgments and disclosure:

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References

The authors thank Kim Edwards and Donna Jordan for their administrative assistance, Melanie Giese, RN, for support with the continuing medical education programs, Sheryl Mack for excellence in medical site recruitment and management, and the providers and office staff at medical sites throughout South Carolina for their active participation in the Hypertension Initiative. This work was supported in part by grant No. P01HS1087-03 (EXCEED) from the Agency for Healthcare Research and Quality, the Duke Foundation, and grants No. HL04290 and No. P60-MD00267 (EXPORT) from the National Heart, Lung, and Blood Institute and the South Carolina Department of Health and Environmental Control.

References

  1. Top of page
  2. Abstract
  3. METHODS
  4. Purpose and Provider Enrollment
  5. Regulatory Review
  6. Data Acquisition
  7. Data Management
  8. Data Reporting
  9. RESULTS
  10. DISCUSSION
  11. Acknowledgments and disclosure:
  12. References
  • 1
    Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:24132446.
  • 2
    Ogden LG, He J, Lydick E, et al. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to JNC VI risk stratification. Hypertension. 2000;35:539543.
  • 3
    Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA. 2003;290:199206.
  • 4
    Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:25602572.
  • 5
    McFarlane SI, Jacober SJ, Winer N, et al. Control of cardiovascular risk factors in patients with diabetes and hypertension at urban academic medical centers. Diabetes Care. 2002;25:718723.
  • 6
    Bakris GL. A practical approach to achieving recommended blood pressure goals in diabetic patients. Arch Intern Med. 2001;161:26612667.
  • 7
    Curb JD, Pressel SL, Cutler JA, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA. 1996;276:18861892.
  • 8
    Hansson L, Zanchetti A, Carruthers SG, et al. for the HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) trial. Lancet. 1998;351:17551762.
  • 9
    Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350:757764.
  • 10
    Tuomilehto J, Rastenyte D, Birkenhager WH, et al. for the Systolic Hypertension in Europe Trial Investigators. Effects of calcium channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med. 1999;340:677684.
  • 11
    United Kingdom Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703713.
  • 12
    Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet. 2000;355:253259.
  • 13
    Lindholm LH, Ibsen H, Devereux RB, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:10041010.
  • 14
    Bakris GL, Williams M, Dworkin L, et al. Preserving renal function in patients with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committee Working Group. Am J Kidney Dis. 2000;36:646661.
  • 15
    Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): a prospective observational study. BMJ. 2000;321:412419.
  • 16
    Estacio RO, Jeffers BW, Gifford N, et al. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care. 2000;23(suppl 2)B54B64.
  • 17
    Kario K, Pickering TG. Modification of high blood pressure after myocardial infarction. Med Clin North Am. 2000;84:121.
  • 18
    Eichhorn EJ, Young JB. Optimizing the use of beta-blockers in the effective treatment and management of heart failure: a case study approach. Am J Med. 2001;110(suppl 5A):11S20S.
  • 19
    Pyorala K, Pedersen TR, Kjekhus J, et al. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study. Diabetes Care. 1997;20:614620.
  • 20
    Koskinen P, Manattari M, Manninen V, et al. Coronary heart disease incidence in NIDDM patients in the Helsinki Heart Study. Diabetes Care. 1992;15:820825.
  • 21
    Elkeles RS, Diamond JR, Poulter C, et al. Cardiovascular outcomes in type 2 diabetes. A double-blind placebo-controlled study of bezafibrate: the St. Mary's, Ealing, Northwick Park Diabetes Cardiovascular Disease Prevention (SENDCAP) Study. Diabetes Care. 1998;21:641648.
  • 22
    Goldberg RB, Mellies JM, Sacks FM, et al. Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analysis in the cholesterol and recurrent events (CARE) trial. Circulation. 1998;98:25132519.
  • 23
    Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:24862497.
  • 24
    Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care. 1998;21:13911396.
  • 25
    Oliveria SA, Lapuerta P, McCarthy BD, et al. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med. 2002;162:413420.
  • 26
    Clark CM Jr, Snyder JW, Meek RL, et al. A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care. 2001;24:10791086.
  • 27
    Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:14581465.
  • 28
    Berwick DM. A user's manual for the IOMs ‘Quality Chasm’ report. Health Aff. 2002;21:8090.
  • 29
    Giese M, Lackland DT, Egan BM. The hypertension initiative of South Carolina. Promoting cardiovascular health through better blood pressure control. J S C Med Assoc. 2001;97:5762.
  • 30
    Egan BM, Lackland DT, Basile JN. American Society of Hypertension regional chapters: leveraging the impact of the clinical hypertension specialist in the local community. Am J Hypertens. 2002;15:372379.
  • 31
    Egan BM, Lackland DT. Strategies of prevention and the importance of public health and community programs. Ethn Dis. 1998;8:143154.
  • 32
    Siegel D, Lopez J, Meier J, et al. Changes in the pharmacologic treatment of hypertension in the Department of Veterans Affairs 1997–1999: decreased use of calcium antagonists and increased use of beta-blockers and thiazide diuretics. Am J Hypertens. 2001;14:957962.
  • 33
    Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339:19571963.
  • 34
    Materson BJ, Reda DJ, Cushman WC, et al. Results of combination anti-hypertensive therapy after failure of each of the components. J Hum Hypertens. 1995;9:791796.
  • 35
    Weir MR, Maibach EW, Bakris GL, et al. Implications of a health lifestyle and medication analysis for improving hypertension control. Arch Intern Med. 2000;160:481490.
  • 36
    Singer GM, Izhar M, Black HR. Goal-oriented hypertension management. Translating clinical trials to practice. Hypertension. 2002;40:464469.
  • 37
    Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diabetes Care. 2001;24:454459.