Primary Care Research

Clinical distractions and care continuity affect antihypertensive treatment for patients with diabetes and hypertension

Tight control of high blood pressure (hypertension) is critical for reducing the vascular complications of diabetes. Yet, a new study shows that primary care providers (PCPs) often fail to intensify antihypertensive medications to maintain blood pressure (BP) control in patients with diabetes. Clinical distractions and shortcomings in continuity and coordination of care seem to underlie this oversight, notes T. Alafia Samuels, M.D., M.P.H., Ph.D., of the Pan American Health Organization.

Dr. Samuels and coinvestigators followed 254 adults in a managed care plan, who had type 2 diabetes and hypertension, over a 2-year period. They looked for intensification of antihypertensive medications (upping the dose of a medication or prescribing a new medication) at the 1,374 visits when patients' blood pressure was suboptimally controlled (systolic BP of 140 mmHg or more or diastolic BP of 90 mmHg or more).

PCPs intensified antihypertensive treatment in only 13 percent of these visits. Clinicians were twice as likely to intensify therapy at visits that were "routine," (and thus may have lacked other clinical distractions, such as a new medical problem). Clinicians were nearly twice as likely to intensify therapy at visits in which patients were seeing their usual primary care provider (suggesting the benefit of continuity of care).

Several factors were linked to failure to intensify antihypertensive treatment. For example, co-management of the patient by a cardiologist accounted for 39 percent of the failure in medication intensification, suggesting problems in continuity and coordination of care. Also, clinicians were half as likely to intensify treatment if the patient's blood-sugar level was high (more than 150 mg/dl) and 40 percent less likely to do so if the patient had coronary heart disease.

The study was supported in part by the Agency for Healthcare Research and Quality (HS11946).

More details are in "Failure to intensify antihypertensive treatment by primary care providers: A cohort study in adults with diabetes mellitus and hypertension," by Shari Danielle Bolen, M.D., M.P.H., Dr. Samuels, Hsin-Chieh Yeh, Ph.D., and others, in the May 2008 Journal of General Internal Medicine 23(5), pp. 543-550.

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