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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

J Clin Hypertens(Greenwich). 2010;12:570–577. © 2010 Wiley Periodicals, Inc.

Factors influencing hypertension (HTN) control in the United States are not well understood. The authors utilized a newly designed survey instrument to interview patients presenting to a diverse, general cardiology practice at a tertiary care center in order to identify factors associated with HTN control. The study was completed in 154 participants, and 121 (78.6%) had HTN. Of those, 111 (91.7%) had awareness of HTN, and 72 (59.5%) had HTN control, defined as <140/90 mm Hg. In a multivariate analysis, race/ethnicity was not associated with HTN control, but private insurance (odds ratio [OR] 3.40, 95% confidence interval [CI] 1.25–9.28), nonsmoker status (OR 4.36, CI 1.22–15.51), and number of medications used (OR 1.32, CI 1.12–1.56) were associated with HTN control. Correct recognition of systolic blood pressure goal and knowledge of one’s current state of HTN control were also associated with control. In conclusion, in a general cardiology practice where patients had a high degree of healthcare access, race/ethnicity was not associated with HTN control, while type of insurance, nonsmoker status, and increased number of medications used were associated. In addition, 2 novel predictors of HTN control, recognition of systolic blood pressure goal and knowledge of HTN control, were identified that can be utilized in creating new HTN treatment interventions.

Hypertension currently affects 29% of American adults.1 It is a well described risk factor for cerebrovascular disease, heart disease, and renal disease, and many effective treatment options exist for this common medical condition.2 Despite this, hypertension control rates are poor in the United States. Recent National Health and Nutrition Examination Survey data suggest that only 35% of American adults with hypertension have controlled blood pressure.1

The reasons for poor hypertension control rates in the Unites States are not fully understood. There are many suggested barriers to hypertension control, such as poor medication adherence,3 failure of providers to adequately treat hypertension,4,5 and inadequate access to medical care.6 However, data supporting these hypothesized barriers are conflicting and successful interventions to target them are limited.7 One important example is the interaction of race/ethnicity on hypertension control. Previous studies8–12 identified improved rates of hypertension control in non-Hispanic whites compared to African Americans. However, this has not been demonstrated in all research settings,13–15 and the reasons for this are unknown. There is still much to learn about predictors of hypertension control, and given the complex nature of this problem, these may be easier to identify in small patient samples as opposed to large population surveys. Therefore, we designed a prospective, observational study to examine predictors of hypertension control among patients presenting to a racially, ethnically, and economically diverse general cardiology clinic in a tertiary care center. The aims of this study were to determine the awareness and control of hypertension in this population, to examine the interaction of race/ethnicity on hypertension control, and to identify novel predictors of hypertension control with a newly designed survey instrument.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

Design and Population

This study was conducted from March 1, 2006 to August 10, 2006 at the General Cardiology Clinic of the University of Chicago Medical Center, Chicago, IL. Study participants were randomly selected from a list of patients with scheduled appointments with general cardiologists. Patients presenting to see cardiovascular specialists, such as electrophysiology or heart failure cardiologists, were excluded. Once patients arrived for their appointment, they were approached to be included in the study. Study participants gave written informed consent and the University of Chicago Institutional Review Board approved the study protocol.

During the study period 188 patients with appointments were screened for inclusion. Of those, 25 patients (13%) did not show for the scheduled appointment and were not included in the study. Of the patients that were approached for the study, 154 (95%) agreed to participate and only 9 (5%) patients approached for the study declined participation.

Data Source

Data were collected from 2 sources, medical records and a newly designed survey instrument. Data abstracted from medical records included age, sex, weight, medical problems, primary insurance provider, prescribed and over-the-counter medications, and blood pressure on the day the survey interview was performed. Blood pressures were measured by an experienced nurse or physician with a manual blood pressure cuff and the participant seated in a chair. These measurements were taken after the participant rested in the clinic waiting room and prior to the visit with the physician. If multiple blood pressure measurements were recorded for any participant, the mean systolic blood pressure and mean diastolic blood pressure were used. These measurements were utilized in the study as they were also used by treating physicians to titrate therapies. The newly-designed survey instrument was administered during a one-on-one interview. A senior medical student with survey administration experience performed both the medical chart abstractions and survey interviews. The survey instrument included questions from previously validated studies, including the National Health and Nutrition Examination Survey,16 and questions that were designed specifically for this study. The original questions utilized in this study were created to identify novel predictors of hypertension control. These questions were selected by experienced cardiologists and tested on groups of clinic patients prior to the study. The survey instrument can be viewed in Appendix S1.

Hypertension prevalence and awareness were assessed in a manner similar to the method used in the National Health and Nutrition Examination Survey,16 and utilized information from the medical chart and survey instrument. Participants were recorded as having hypertension if it was listed as a problem in the medical chart, if participants were on antihypertensive medications for the purpose of lowering blood pressure, or if participants answered yes to the following question, “Were you told on 2 or more different visits that you had hypertension, also called high blood pressure?” Awareness of hypertension was documented if the participant had hypertension and answered yes to the following question, “Have you ever been told by a doctor or other health professional that you have hypertension, also called high blood pressure?” For all study participants with hypertension, control was defined as <140/90 mm Hg. This value was chosen so that results could be compared to similar studies using the same definition.1,4,5,8,9,12,13,15,17,18

All study participants were assessed for hypertension prevalence and awareness. In addition, the survey instrument included questions for all study participants to assess tobacco use, highest level of education achieved, religiousness, frequency of use of religious services, support system at home, dog ownership, exercise habits, Internet use, home blood pressure machine ownership, and salt intake. Self-reported race/ethnicity was also recorded for all participants. In order to assess trust of physicians, participants were also specifically asked, “On a scale of 1 to 5, with 1 being not at all and 5 being very much, how much do you trust the advice of your doctors?” To assess knowledge of hypertension treatment goals, all participants were also asked to state his/her ideal or goal blood pressure.

In order to assess predictors of hypertension control, the survey instrument included additional questions specifically for participants recognized as having hypertension. These questions assessed hypertension management and consequences of hypertension. For example, participants were asked what physician specialty (cardiology, primary care doctor, etc) manages his/her hypertension, frequency of blood pressure checks in last 12 months, knowledge of friends and family with hypertension and how that condition affected their overall health, self-perceived medication adherence, and medication copayments. In order to assess participant perception of hypertension control, they were also asked how well his/her blood pressure was currently controlled on a 1 to 5 scale, with 1 being very poorly controlled and 5 being perfect.

Statistical Analysis

Analysis was performed using Stata IC version 10.0 (StataCorp LP, College Station, TX). All continuous variables were expressed as means ± standard deviations while categorical variables were expressed as percentages. Differences in continuous variables were assessed using unpaired Student t tests. The unpaired student t test was also used to compare the reported ideal/goal systolic and diastolic blood pressures between participants who had controlled vs uncontrolled hypertension. Differences in dichotomous variables were assessed using chi-square tests or Fischer exact tests as appropriate. In order to determine independent predictors of hypertension control, a logistic regression was performed. Variables that had a significant univariate association with hypertension control were included in the model. A 2-tailed P value <.05 was considered statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

Baseline Characteristics

A total of 154 participants were included in the study. Table I summarizes characteristics of the study participants. The average age of study participants was 66.4±13.8 years and 48.1% of participants were women. With respect to race/ethnicity, 50.0% identified themselves as Caucasian, 42.2% identified themselves as African American, and the remainder (3.9%) identified themselves as either Hispanic or Asian. Most participants had either Medicare insurance (55.2%) or private insurance (36.4%) as their primary insurance provider. The most common medical condition was hypertension (78.6%). Other common medical conditions included dyslipidemia (51.9%), coronary artery disease (42.9%), diabetes (22.7%), and congestive heart failure (13.0%). The average body mass index of participants was 29.3 kg/m2.

Table I.   Study Participant Characteristics
VariableFrequency (%)
Age 66.4±13.8
Sex (female)74/154 (48.1)
Race/ethnicity
 Caucasian77/154 (50.0)
 African American65/154 (42.2)
 Hispanic/Asian6/154 (3.9)
Primary insurance
 Medicare85/154 (55.2)
 Private56/154 (36.4)
 Medicaid11/154 (7.1)
Body mass index (kg/m2)29.3±5.9
Waist circumference (in)40.3±7.6
Medical conditions
 Hypertension121/154 (78.6)
 Dyslipidemia80/154 (51.9)
 Coronary artery disease66/154 (42.9)
 Diabetes35/154 (22.7)
 Congestive heart failure20/154 (13.0)
 Chronic kidney disease14/154 (9.1)
 Cerebrovascular disease12/154 (7.8)
 Peripheral arterial disease11/154 (7.1)
Mean number of medications  6.0±0.28
Antihypertensive medication use
 Mean number prescribed  2.1±0.12
 β-Blocker73/121 (60.3)
 Angiotensin-converting enzyme inhibitor43/121 (35.5)
 Calcium channel blocker42/121 (34.7)
 Thiazide diuretic42/121 (34.7)
 Angiotensin receptor blocker30/121 (24.8)
 Loop diuretic26/121 (21.5)
 Diuretic, other9/121 (7.4)
 Nitrates6/121 (5.0)
 Clonidine4/121 (3.3)
 Hydralazine3/121 (2.5)

On average, study participants were taking 6.0±0.28 medications, including over-the-counter and prescribed medications. In participants with hypertension, antihypertensive medications were commonly used, and participants were prescribed an average of 2.1±0.12 antihypertensive medications. The most common antihypertensive medications used were β-blockers (60.3%), angiotensin-converting enzyme inhibitors (35.5%), calcium channel blockers (34.7%), thiazide diuretics (34.7%), angiotensin receptor blockers (24.8%), and loop diuretics (21.5%).

Hypertension Prevalence, Awareness, and Control

Hypertension prevalence, awareness, and control in the study population are described in Table II. Of the 154 study participants, 121 (78.6%) had hypertension. Among participants with hypertension, 111 (91.7%) were aware of their diagnosis and 72 (59.5%) had controlled hypertension.

Table II.   Hypertension Prevalence, Awareness, and Control
VariableFrequency (%)
Hypertension prevalence121/154 (78.6)
Hypertension awareness111/121 (91.7)
Hypertension control72/121 (59.5)

Variables Associated With Hypertension Control

Table III lists selected variables hypothesized to be associated with hypertension control. Variables that were associated with hypertension control included nonsmoker status, higher level of education achieved, having private insurance, and higher number of medications used. Of note, race/ethnicity was not associated with hypertension control. Other factors such as comorbid conditions and patient trust of physicians were also not associated with hypertension control. Other variables that were not associated with hypertension control included religiousness, frequency of use of religious services, support system at home, dog ownership, exercise habits, Internet use, home blood pressure machine ownership, salt intake, frequency of blood pressure checks in last 12 months, and self-perceived medication adherence.

Table III.   Hypothesized Predictors of Hypertension Control
VariableControlled (n=72)Uncontrolled (n=49)P Value
  1. Abbreviations: BMI, body mass index; CAD, coronary artery disease; CKD, chronic kidney disease; HMO, health maintenance organization; OSA, obstructive sleep apnea; PPO, preferred provider organization.

  2. aSome participants reported more than one physician managing hypertension.

Age68.1±11.668.6±13.7 
Sex31 (43.1%)28 (57.1%) 
Race
 Caucasian34 (47%)21 (43%) 
 African American35 (49%)22 (45%) 
 Hispanic/ Asian3 (4%)6 (12%) 
Weight (lb)186.5±42.8184.2±41.6 
Waist (in)41.0±7.341.1±9.0 
BMI29.6±6.429.9±6.0 
Tobacco use  .01
 Current5 (7%)11 (22%) 
 Never/former67 (93%)38 (78%) 
Education  .05
 No high school5 (7%)9 (18%) 
 High school30 (42%)24 (49%) 
 College/grad school37 (51%)16 (33%) 
Comorbid conditions
 Diabetes20 (28%)14 (29%) 
 CAD35 (49%)20 (41%) 
 CKD9 (13%)5 (10%) 
 Dyslipidemia43 (60%)25 (51%) 
 OSA6 (8%)2 (4%) 
Patient trust of physicians (1–5 scale)
 Low (1–2)0 (0)2 (4%) 
 Intermediate (3–4)17 (24%)10 (20%) 
 High (5)55 (76%)37 (76%) 
Physician managing hypertensiona
 Cardiologist57 (79%)35 (71%) 
 Primary care doctor44 (61%)29 (59%) 
 Other7 (10%)9 (18%) 
Primary insurance.02
 Medicare39 (54.9%)34 (69.4%) 
 Medicaid2 (2.8%)5 (10.2%) 
 Private (HMO/PPO)30 (42.3%)10 (20.4%) 
Number of medications.02
 0–22 (2.8%)7 (14.3%) 
 3–515 (20.8%)8 (16.3%) 
 5–724 (33.3%)24 (49.0%) 
 ≥831 (43.1%)10 (20.4%) 

Multivariate Analysis

Results of a multivariate analysis are listed in Table IV. The following factors were significantly and independently associated with hypertension control: nonsmoker status, private insurance, and higher number of medications used. Higher level of education was a univariate predictor of hypertension control but was not an independent predictor of control in this model. Current nonsmokers were 4.4 times more likely to have hypertension control, and participants with private insurance were 3.4 times more likely to have hypertension control than those with other forms of insurance. Interestingly, use of more medications was associated with hypertension control, with each additional medication providing a 1.3-fold increase in the likelihood of hypertension control.

Table IV.   Univariate and Multivariate Predictors of Hypertension Control
VariableUnivariate AnalysisMultivariate Analysis
OR (95% CI)P ValueOR (95% CI)P Value
  1. Abbreviations: CI, confidence interval; OR, odds ratio.

Nonsmoker status3.88 (1.25–12.00).024.36 (1.22–15.51).02
Education
 No high school(Reference)
 High school2.25 (0.67–7.61).192.19 (0.58–8.24).25
 College/graduate school4.16 (1.2–14.39).023.23 (0.83–12.64).10
Private insurance2.79 (1.20–6.44).023.40 (1.25–9.28).02
Number of medications
 Each additional medication1.25 (1.08–1.44)<.011.32 (1.12–1.56)<.01

Novel Predictors of Hypertension Control

The Figure and Table V describe 2 novel predictors of hypertension control identified in this study. All participants were asked, “What do you think is your ideal or goal blood pressure?” Results are displayed in the Figure. Reported ideal/goal systolic blood pressures are clustered around 120 mm Hg for participants with controlled hypertension (left panel) while results are quite variable and range from 110 to 180 mm Hg for participants with uncontrolled hypertension (right panel). The mean reported ideal/goal systolic blood pressure goal was lower and closer to actual target systolic blood pressures2 for participants with controlled hypertension than for those with uncontrolled hypertension (P<.01).

image

Figure Figure.  Novel predictor of hypertension (HTN) control: What do you think is your ideal or goal blood pressure? The panel on the left has participant responses with controlled HTN, and the panel on the right has participant responses with uncontrolled HTN. Answers in red indicate goal systolic blood pressures (SBP) and answers in blue indicate goal diastolic blood pressures (DBP). Average reported SBP goals (red) were lower and closer to actual target SBP for participants with controlled HTN (P<.01).

Download figure to PowerPoint

Table V.   Novel Predictor of Hypertension Control
VariableOdds RatioP ValueConfidence Interval (95%)
How well is your blood pressure currently controlled? (1–5 scale)
 1–3 
 4–55.6(2.5–12.6)

The participants with hypertension were asked, “On a scale of 1 to 5, with 1 being very poorly controlled and 5 being perfect, in your opinion, how well is your blood pressure currently controlled?” Results are displayed in Table V. Participants with responses of 4 or 5 on the 1 to 5 scale were 5.6 times more likely to have actual hypertension control. This finding was also an independent predictor of hypertension control in a multivariate model for all variables listed in Table IV (P<.001).

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

This study examined predictors of hypertension control among patients presenting to a diverse, general cardiology clinic in a tertiary care center. Our results included many key findings. We identified high rates of hypertension awareness and control in our population. For predictors of hypertension control, race/ethnicity was not associated with control, while type of insurance, nonsmoker status, and increased number of medications were independent predictors of control. We also identified 2 novel predictors of hypertension control, correct recognition of one’s systolic blood pressure goal and knowledge of one’s current state of hypertension control.

A unique aspect of our study is that unlike previous studies assessing hypertension awareness and control, we recruited participants from a general cardiology clinic that was known to serve a diverse patient population. Patients served by this clinic travelled from various locations in the Chicago metropolitan area and were composed of different races, ethnicities, and socioeconomic backgrounds. This allowed us to study a diverse population with established access to medical care yet still at substantial risk for complications from hypertension. To our knowledge, no previous study has utilized this patient setting to assess predictors of hypertension control. In this population, we found high rates of hypertension awareness and control, 91.7% and 59.5%, respectively. Both of these rates exceed rates described in large epidemiological surveys. For instance, recent National Health and Nutrition Examination Survey data1,19 suggest that 71.8% of Americans had hypertension awareness, 35.1% of all Americans with hypertension had hypertension control, and 56.6% of Americans with treated hypertension had control. However, our rates of hypertension control did not achieve rates reported in clinical trials, such as 66% in the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints (CONVINCE)20 or 68% in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).21 It is important to note that our findings included patients with both treated and untreated hypertension as not all patients were necessarily under treatment at the time of study. For instance, 21% of the participants were new to the clinic.

One of the most remarkable findings in our study was, in contrast to previously published studies, hypertension control rates were independent of race/ethnicity. Previous data on the association between African-American race/ethnicity and hypertension control are quite variable.8–15,22 Together, these data suggest the impact of race/ethnicity on health is complex and interacts with other factors, such as access to care. Unlike previous studies, all of our study participants had a high degree of access to medical care. Specifically, all participants had some form of medical insurance, the opportunity to seek a cardiovascular specialist, and the ability to attend the clinic visit.

Our results underscore the importance of disease awareness and education in the control of hypertension. We found that participant awareness of disease, measured by knowledge of one’s current state of hypertension control on a 1 to 5 scale was associated with actual control. In addition, we found that correct recognition of one’s systolic blood pressure goal was predictive of having hypertension control. This second finding is consistent with results of a previous study of ambulatory patients by Knight and colleagues.17 Similar to our findings, in that study awareness of systolic blood pressure goal but not diastolic was associated with improved hypertension control. This suggests that systolic blood pressure targets alone may be an efficient educational objective for patients with hypertension. Interestingly, while disease awareness and education were important variables in our study, home blood pressure machine ownership was not associated with improved control. Previous work has demonstrated that home blood pressure monitoring programs improve hypertension control.23 However, in our study we were only able to collect data on machine ownership and were not able to assess participant use of home blood pressure machines. Thus, we speculate that the lack of association identified in our study may be due to the fact that not all participants with blood pressure machines regularly used them.

Another predictor of hypertension control in our study was nonsmoker status. Of participants with nonsmoker status, 45/105 (42.9%) were never smokers and 60/105 (57.1%) were former smokers. With this in mind, our results are somewhat surprising given previous reported findings on smoking and blood pressure. Nicotine is known to acutely raise blood pressure,24 but smoking cessation actually increases blood pressure, even when controlling for potential confounders.25,26 One potential explanation is that smoking cessation may improve 24-hour ambulatory blood pressure measurements but not physician clinic measurements.27,28 However, our findings, using physician office measurements, suggest that not smoking predicts improved hypertension control. One reason for our contradictory results may be that we were not able to control for potential confounders such as time to last cigarette and quantity of cigarettes typically smoked. Regardless, our findings support recommendations2 that smoking cessation be a part of cardiovascular risk reduction in hypertensive patients. However, given our small sample size, additional studies are needed to confirm our findings.

Interestingly, participants taking an increased number of medications had improved control in our study. Although not displayed in Table III, this was not true for increased antihypertensive medications, only medications in general. This was not explained by other diagnoses that may require increased medications and have associated lower blood pressure, such as systolic heart failure. The reason for this finding is not entirely clear, but may be related to an increased number of interactions with the healthcare system, allowing for more opportunities for blood pressure measurement and hypertension management, underscoring the need for access to medical care in the management of hypertension.

This study had several potential limitations worth highlighting. First, because we studied patients in a single cardiology practice our findings may not be similar to those in other settings. Second, some questions were not previously validated in research studies. However, all questions were reviewed by a number of cardiovascular specialists and tested on clinic patients prior to their use. Utilizing this methodology, we were able to identify 2 novel predictors of hypertension control. Third, our study population was small and may not have been powered to detect a difference in hypertension control for all assessed variables. One benefit to the small sample size was that we were able to conduct a prospective, observational study and provide detailed assessments of each study participant.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

This study established hypertension awareness and control rates in a tertiary cardiology clinic, a setting that has previously not been well studied. Race/ethnicity did not impact hypertension control in this population with a high degree of access to medical care, and additional research is necessary to further understand the interactions of race/ethnicity and healthcare access on hypertension control. This study also highlights the importance of disease awareness and education on hypertension control and suggests target systolic blood pressure goal is an efficient educational goal. These findings should be further investigated in the form of educational interventions to improve hypertension control.

Disclosure:  This study was funded by a Calvin Fentress Research Fellowship through the University of Chicago Pritzker School of Medicine. The authors declare no financial conflict of interest related to this study.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
  8. Supporting Information

Appendix S1. Predictors of hypertension control in a diverse, general cardiology practice: patient questionnaire form (PQF).

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JCH_298_sm_AppS1.pdf160KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.