Clinical Decisionmaking

Physicians in HMOs should more aggressively manage hypertension

Better control of hypertension lessens a person's risk of developing coronary artery disease, stroke, congestive heart failure, renal insufficiency, and peripheral vascular disease. However, a study of a large health maintenance organization (HMO) suggests that HMOs have room to improve in this area. Their physicians should be more aggressive in the treatment of high blood pressure, particularly systolic blood pressure (SBP), whose importance has been underemphasized until recently, concludes the study, which was supported in part by the Agency for Healthcare Research and Quality (MEDTEP Research Center for Diverse Populations, HS07373).

Researchers led by Mark Alexander, Ph.D., of the University of California, San Francisco, and the Kaiser Permanente Medical Care Program, retrospectively assessed blood pressure control for a random sample of adult patients with hypertension in a large HMO. Using patients' mean and last office blood pressure measurements to evaluate hypertension control, they found that about 70 percent of hypertensive patients in the HMO had good diastolic blood pressure (DBP) control (< 90 mm Hg). However, less than 40 percent of patients had hypertension controlled to an SBP less than 140 mm Hg. About 30 percent had both DBP and SBP under control.

The proportion of patients meeting the criteria for blood pressure control was similar whether the researchers used the mean BP for all visits, the last recorded BP, or control at 50 percent or more of visits. However, the proportion of patients with combined BP control at 75 percent or more of their visits was half that of the other methods. Older patients were more apt to have elevated SBP, whereas younger patients were more likely to have elevated DBP. SBP control may be more difficult to achieve in the elderly without producing symptoms of dropped blood pressure, such as dizziness upon standing. On the other hand, doctors may simply be less inclined to push therapy aggressively to achieve this goal. Physicians also may be concerned about excessively lowering DBP while trying to achieve SBP control, explain the researchers.

See "Evaluating hypertension control in a managed care setting," by Dr. Alexander, Irene Tekawa, M.A., Enid Hunkeler, M.A., and others, in the December 13, 1999, Archives of Internal Medicine 159, pp. 2673-2677.

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