Association Between Pain, Blood Pressure, and Medication Intensification in Primary Care: an Observational Study
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Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic 9500 Euclid Avenue, G10, Cleveland, OH, USA; Department of Internal Medicine, Brigham and Women’s Hospital/Harvard Medical School Boston, MA, USA.
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BACKGROUND: Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain. OBJECTIVE: To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit. DESIGN: Retrospective cohort SETTING: Integrated health system PARTICIPANTS: Adults seen in primary care EXPOSURE: Pain status based on numerical scale: mild (1–3), moderate (4–6), or severe (≥ 7). MAIN MEASURES: We defined elevated BP as ≥ 140/ 80 mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well. KEY RESULTS: Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28–1.48) for severe pain, 1.06 (95% CI: 0.99–1.14) for moderate pain, and 1.02 (95% CI: 0.93–1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54– 0.80) for mild pain, 0.61 (95% CI: 0.52–0.72) for moderate pain, and 0.55 (95% CI: 0.47–0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit. CONCLUSIONS: When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit. KEY WORDS: hypertension; quality of care; pain; medications; primary care.
Received February 14, 2020 Accepted August 31, 2020
J Gen Intern Med DOI: 10.1007/s11606-020-06208-z © Society of General Internal Medicine 2020
BACKGROUND
Pain and elevated blood pressure (BP) are both highly prevalent in the USA.1, 2 Since the nervous and cardiovascular systems interact within the human body, managing hypertension in the setting of pain may be challenging.3, 4 Acute pain causes a rise in BP, probably as a survival mechanism allowing humans to escape immediate harm.5 In experimental settings, normotensive individuals’ systolic BP increased up to 30 mmHg6, 7 while being subjected to an acute painful stimulus.8 This experimental evidence may underlie the widespread belief that pain can be responsible for elevated BP in the office setting.9 However, subje
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