Consistency of Blood Pressure Control: a Useful Tool of Hypertension Assessment in a Vulnerable Population
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Department of Internal Medicine, Loyola University of Medical Center, Maywood, IL, USA; 2Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05299-7 © Society of General Internal Medicine 2019
INTRODUCTION
There is strong evidence that treatment of hypertension reduces cardiovascular morbidity and mortality.1 National Health and Nutrition Examination Survey (NHANES) and a national quality program, the Health Plan Employer Data and Information Set (HEDIS), use point prevalence of blood pressure with a cut point of less than 140/90 mmHg to assess control for the population and for clinical practices, respectively.2, 3 There is compelling data showing that the proportion of visits with blood pressure control below 140/90 is a graded predictor of hypertension-related outcomes.4 The implication of this study is that beyond point prevalence of hypertension control, consistency of control below 140/90 may be an important patient-centered goal of care.
METHODS
We conducted an electronic medical record (EMR) review of patients in a primary care clinic at John H. Stroger, Jr. Hospital of Cook County approved by our institutional review board. Patients seen over a 2-week period of a random month of the year were selected using a random sampling method. An established primary care patient was defined as one with five or more clinic visits in the three preceding years. A diagnosis of hypertension was determined from the problem list. The last five clinic blood pressures recorded by the clinic nursing staff were abstracted for established clinic patients with hypertension. Blood pressure control was defined as < 140/90 mmHg. For each participant, we evaluated the number of visits with blood pressure control and control at the last visit. Consistent control was defined as control on 4 or 5 of the visits. We defined inconsistent control as those with 3 or fewer of the five visits with controlled blood pressure. The distribution of clinical predictors was compared between subjects with consistent and inconsistent control with chi-square tests. Independent predictors were identified using multivariate logistic regression. We developed multivariate
models defining the race/ethnicity as a dichotomous variable (African-American vs. other race/ethnicity) because the sample size of each non-African-American race/ethnicity was small. We used the number of visits during the 3-year timeframe as a dichotomous variable with a cut-point of 9 visits, as this bivariate association with consistency of Table 1 Baseline Characteristics of Patients with Inconsistent and Consistent BP Control Inconsistent control (n = 87) Demographics Age ≤ 54 31 (35.63%) 55–64 16 (18.39%) 65–74 22 (25.29%) ≥ 75 18 (20.69%) Gender Female 49 (56.32%) Male 38 (43.68%) Race/ethnicity African67 (77.01%) American Others 20 (22.99%) Current smoking Yes 8 (9.2%) No 79 (90.8%) BMI (CDC categories) Normal 18 (20.69%) Overweight 26 (29.89%) Obese 43 (49.43%) Comorbidities Diabetes mellitus 52 (5
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