Blood Pressure Control in Private Practice: A Case Report ANN L. ENGELLAND, BS, MICHAEL H. ALDERMAN, MD, AND HUGH B. POWELL, BA
Abstract: High blood pressure is most commonly treated in the offices of private physicians. We have attempted to evaluate the efficacy of such care through review of all patient charts of a Board Certified, University Medical Center affiliated internist in New York City. Seventeen per cent had elevated (, 160/95) blood pressures or were taking antihypertensive medication at the time of their last visit. A selected group of 206 charts was examined to determine attendance and blood pressure outcome. Over one-half of these patients were lost to follow-up within a year of their ini-
tial visit. Of those who persisted in therapy, 55 per cent achieved good blood pressure control. Blood pressure outcomes among medicated patients were not different from those of patients who received no prescription. These results suggest that this conventional pattern of ambulatory medical care, characterized by a high attrition rate and a failure to adequately control blood pressure, may not be suitable to the long-term management of high blood pressure. (Am. J. Public Health 69:25-29, 1979.)
Introduction
Methods
Since 83 per cent of all ambulatory care is provided in the offices of privately practicing physicians,' and since treatment of hypertension is the most likely reason for adults to visit these doctors,2 it is clear that primary care physicians already expend enormous time and effort in the treatment of this single disease. A vigorous national campaign to detect and treat hypertension now promises to propel even more patients into these offices. Surprisingly, however, the process and outcome of antihypertensive treatment in the physician's office has been the subject of little systematic review or critical analysis,3'4 and studies that do exist have often focused on process without linking performance to outcomes.' By contrast, the shortcomings of hospital clinics where considerably fewer hypertensives receive care have been repeatedly detailed, and the data generated have sometimes been used as a basis for improving effectiveness.6-8 The purpose of this report is to describe an analysis of the treatment of hypertension undertaken in a private physician's practice. The outcome of treatment was similar to that observed in hospital clinics and was compatible with the results of many community surveys.
During 1976, permission was obtained for a third-year medical student to review the 4,403 charts in the office files of a New York City physician. This 46-year-old internist, affiliated with a major university medical center and Board Certified in 1962, was chosen because of his expertise in the field of hypertension. All charts were reviewed, and patients meeting the following criteria were classified as hypertensive: a) blood pressure 2 160/95 at the last visit if over 30 years of age; b) blood pressure 2 140/90 mm Hg. at the last visit if under 30 years of age; or, c) antihypertensive medications prescribed at least by the time of the last visit. This selection process yielded 750 hypertensive patients or 17 per cent of the entire practice (Figure 1). In order to obtain a workable but still sufficiently large sample, alternate charts (375) were examined. Of these, 169 were then eliminated from further analysis (Figure 1). A remaining group of 206 was thus defined to include patients who had made more than one office visit, who had high blood pressure at the time of their last visit, and/or for whom antihypertensive medication was prescribed within the last ten years and was being continued at their last visit. The charts of these 206 patients were reviewed in detail. Age and sex were determined, and dates of visits with associated blood pressure and medications prescribed were entered on prepared forms. Of the charts reviewed, 31 per cent had at least one visit with no associated blood pressure indicated in the record. Blood pressure outcomes and patient status were deter-
From the Department of Public Health, The New York Hospi-
tal-Cornell Medical Center. Address reprint requests to Dr. Michael H. Alderman, Associate Professor of Medicine and Public Health, Department of Public Health, Cornell University Medical College, 411 East 69th Street, New York, NY 10021. This paper, submitted to the Journal April 3, 1978, was revised and accepted for publication July 6, 1978.
AJPH January 1979, Vol. 69, No. 1
25
ENGELLAND, ET AL.
physician. Furthermore, female hypertensives as a group were significantly older than male hypertensives (p < .001). During a two-year period (1974-75) about 1,500 different patients were seen by this physician. The number of visits per year by all patients is approximately 2,600. Patients as a whole averaged 2.7 visits annually. However, 34 per cent of all patients made only single visits while 14 per cent of the hypertensive group was seen once (p < .001). In addition to having a greater tendency to return for at least a second visit, hypertensive patients, making 3.7 visits per year, were likely to be seen more frequently than the general patients (p < .001).
\
206 206 HYPERTENSIVE
SAMPLE STUDIED
169 Eliminated: 69 - No visits after 1966 54 - Single visit 1 7 - tBP not sustoined at 2nd chort reading 10 - Charts illegible
19 - Other
FIGURE 1-Patient Sample Selection Process
mined. A patient was considered "lost during the first year" if he/she made no visit after the first anniversary of the initial visit. "Excellent" blood pressure control was defined as a SBP < 160 and DBP < 95. A 10 per cent decline in mean arterial pressure (MAP) was considered "good" control. Patients who achieved a decline of less than 10 per cent MAP and had blood pressure exceeding 160/95 were considered under "poor" control. In order to place the findings regarding hypertensive patients in a broader context, the entire patient population (hypertensive and non-hypertensive) was reviewed. Every twentieth chart was selected and the age, sex, and visit dates of these 215 patients were recorded. All data were keypunched and stored on computer tapes.
Characteristics of Hypertensive Patients The 206 hypertensive patients were thus a group more likely to be older, female, and make more visits than members of the practice as a whole. Forty-five patients (22 per cent of the 206 hypertensive patients selected for study) were taking antihypertensive drugs at the time of their first visit. The mean initial pressure of this medicated group (175 + 28/105 ± 18) was significantly higher (p < .02 for diastolic BP) than that of hypertensive patients who were not on medications (168 ± 28/98 ± 17). Over one-third of the 206 patients had systolic pressures exceeding 180 mm Hg., and 20 per cent had diastolic pressures above 115 mm Hg. Outcome
Fifty-one percent of the 206 patients were lost during the first year, leaving 101 who made at least one visit after the first anniversary of their initial visit.' Figure 2 shows the outcomes for these 206 studied patients. Patients lost during the first year did not differ with respect to their initial blood pressures from other hypertensive patients. In no age, sex, or blood pressure category did more than 55 per cent persist in therapy for one year, and for all groups, attrition was higher in the first year than in succeeding years. Only 55 per cent of the 101 patients who completed one year in therapy achieved "excellent" or "good" blood pressure control (Table 1). Results of the 76 patients in treatment at two years were similar, but for those 58 in therapy for at least three years, the percentage achieving "excellent" or "good" control was somewhat higher (62 per cent). A significantly larger percentage (p < .01) of patients with high initial blood pressures (diastolic 2 105 or systolic 2 180) compared to those below these levels achieved good results (70 percent vs. 50 per cent). In fact, patients with mnitial pressures less than 105 mm Hg. had only a 50-50 chance of achieving satisfactory control at one, two, or three years.
Results Characteristics of the Practice All but one of the patients were white, and they were drawn largely from the affluent "upper east side" population of Manhattan. Both the male (mean age = 54 years) and female (mean age = 63 years) hypertensive groups were significantly (p < .01 and p < .001, respectively) older than the general patient population (mean age = 45 years) of this 26
Drug Regimens and Blood Pressure Control The drug regimens prescribed for the 206 hypertensive patients are shown in Table 2. Forty-three per cent of patients with DBP < 105 were untreated, while only 12 per cent of those with diastolics - 105 received no drug prescription (p < .01). Table 3 illustrates one-year outcomes for 101 treated and untreated patients with varying initial blood pressure AJPH January 1979, Vol. 69, No. 1
BP CONTROL IN PRIVATE PRACTICE
206 Hypertensive sample studied
105 (51 %)
made
was found in the proportion of treated or untreated patients at goal. *
no
anniversary visit
Discussion
FIGURE 2-Outcomes of Hypertensive Study Patients
In this private practice, long-term success in the treatment of patients with high blood pressure was the exception rather than the rule. Since patients who made only one visit may have included a large number of referrals, this group was eliminated from the outcome study. Excluding these patients, only one-half of all others who began therapy were still under the care of this physician after one year. Attrition may be accounted for by the urban setting, patients returning to previous physicians after hypertensive work-up, the general mobility of the American population, or other unknown factors. The ultimate goal of antihypertensive therapy is the reduction of cardiovascular morbidity and mortality. Blood pressure control, the focus of this investigation, can be viewed as an intermediate outcome measure. Of those patients who remained in therapy for a year, only one-half achieved blood pressure control. These results might merely reflect a single physician's treatment of a self-selected population and therefore be of limited value. Although a tempting conclusion, available evidence suggests that this situation is
levels. In no category of diastolic pressure did treatment significantly affect the likelihood that patients would achieve improved or controlled blood pressure levels. Treated patients tended to have higher initial pressures and did achieve a significant reduction in mean blood pressure. Nevertheless, after one year of treatment, no significant difference
*Since rigid blood pressure criterion for the initiation of drug therapy was not followed, subjective factors may have influenced placement of patients who had not experienced illness into the no treatment group; hence, the two groups may be medically different. Alternately, the fact that all five untreated patients with initial DBP a 105 mg Hg, achieved satisfactory control may reflect the tendency of blood pressure to regress toward the mean overtime.
TABLE 1-Outcomes of 101 Patients after One Year N
Excellent*
Good"
Poor"*
5%
Age
Abstract: High blood pressure is most commonly treated in the offices of private physicians. We have attempted to evaluate the efficacy of such care through review of all patient charts of a Board Certified, University Medical Center affiliated internist in New York City. Seventeen per cent had elevated (, 160/95) blood pressures or were taking antihypertensive medication at the time of their last visit. A selected group of 206 charts was examined to determine attendance and blood pressure outcome. Over one-half of these patients were lost to follow-up within a year of their ini-
tial visit. Of those who persisted in therapy, 55 per cent achieved good blood pressure control. Blood pressure outcomes among medicated patients were not different from those of patients who received no prescription. These results suggest that this conventional pattern of ambulatory medical care, characterized by a high attrition rate and a failure to adequately control blood pressure, may not be suitable to the long-term management of high blood pressure. (Am. J. Public Health 69:25-29, 1979.)
Introduction
Methods
Since 83 per cent of all ambulatory care is provided in the offices of privately practicing physicians,' and since treatment of hypertension is the most likely reason for adults to visit these doctors,2 it is clear that primary care physicians already expend enormous time and effort in the treatment of this single disease. A vigorous national campaign to detect and treat hypertension now promises to propel even more patients into these offices. Surprisingly, however, the process and outcome of antihypertensive treatment in the physician's office has been the subject of little systematic review or critical analysis,3'4 and studies that do exist have often focused on process without linking performance to outcomes.' By contrast, the shortcomings of hospital clinics where considerably fewer hypertensives receive care have been repeatedly detailed, and the data generated have sometimes been used as a basis for improving effectiveness.6-8 The purpose of this report is to describe an analysis of the treatment of hypertension undertaken in a private physician's practice. The outcome of treatment was similar to that observed in hospital clinics and was compatible with the results of many community surveys.
During 1976, permission was obtained for a third-year medical student to review the 4,403 charts in the office files of a New York City physician. This 46-year-old internist, affiliated with a major university medical center and Board Certified in 1962, was chosen because of his expertise in the field of hypertension. All charts were reviewed, and patients meeting the following criteria were classified as hypertensive: a) blood pressure 2 160/95 at the last visit if over 30 years of age; b) blood pressure 2 140/90 mm Hg. at the last visit if under 30 years of age; or, c) antihypertensive medications prescribed at least by the time of the last visit. This selection process yielded 750 hypertensive patients or 17 per cent of the entire practice (Figure 1). In order to obtain a workable but still sufficiently large sample, alternate charts (375) were examined. Of these, 169 were then eliminated from further analysis (Figure 1). A remaining group of 206 was thus defined to include patients who had made more than one office visit, who had high blood pressure at the time of their last visit, and/or for whom antihypertensive medication was prescribed within the last ten years and was being continued at their last visit. The charts of these 206 patients were reviewed in detail. Age and sex were determined, and dates of visits with associated blood pressure and medications prescribed were entered on prepared forms. Of the charts reviewed, 31 per cent had at least one visit with no associated blood pressure indicated in the record. Blood pressure outcomes and patient status were deter-
From the Department of Public Health, The New York Hospi-
tal-Cornell Medical Center. Address reprint requests to Dr. Michael H. Alderman, Associate Professor of Medicine and Public Health, Department of Public Health, Cornell University Medical College, 411 East 69th Street, New York, NY 10021. This paper, submitted to the Journal April 3, 1978, was revised and accepted for publication July 6, 1978.
AJPH January 1979, Vol. 69, No. 1
25
ENGELLAND, ET AL.
physician. Furthermore, female hypertensives as a group were significantly older than male hypertensives (p < .001). During a two-year period (1974-75) about 1,500 different patients were seen by this physician. The number of visits per year by all patients is approximately 2,600. Patients as a whole averaged 2.7 visits annually. However, 34 per cent of all patients made only single visits while 14 per cent of the hypertensive group was seen once (p < .001). In addition to having a greater tendency to return for at least a second visit, hypertensive patients, making 3.7 visits per year, were likely to be seen more frequently than the general patients (p < .001).
\
206 206 HYPERTENSIVE
SAMPLE STUDIED
169 Eliminated: 69 - No visits after 1966 54 - Single visit 1 7 - tBP not sustoined at 2nd chort reading 10 - Charts illegible
19 - Other
FIGURE 1-Patient Sample Selection Process
mined. A patient was considered "lost during the first year" if he/she made no visit after the first anniversary of the initial visit. "Excellent" blood pressure control was defined as a SBP < 160 and DBP < 95. A 10 per cent decline in mean arterial pressure (MAP) was considered "good" control. Patients who achieved a decline of less than 10 per cent MAP and had blood pressure exceeding 160/95 were considered under "poor" control. In order to place the findings regarding hypertensive patients in a broader context, the entire patient population (hypertensive and non-hypertensive) was reviewed. Every twentieth chart was selected and the age, sex, and visit dates of these 215 patients were recorded. All data were keypunched and stored on computer tapes.
Characteristics of Hypertensive Patients The 206 hypertensive patients were thus a group more likely to be older, female, and make more visits than members of the practice as a whole. Forty-five patients (22 per cent of the 206 hypertensive patients selected for study) were taking antihypertensive drugs at the time of their first visit. The mean initial pressure of this medicated group (175 + 28/105 ± 18) was significantly higher (p < .02 for diastolic BP) than that of hypertensive patients who were not on medications (168 ± 28/98 ± 17). Over one-third of the 206 patients had systolic pressures exceeding 180 mm Hg., and 20 per cent had diastolic pressures above 115 mm Hg. Outcome
Fifty-one percent of the 206 patients were lost during the first year, leaving 101 who made at least one visit after the first anniversary of their initial visit.' Figure 2 shows the outcomes for these 206 studied patients. Patients lost during the first year did not differ with respect to their initial blood pressures from other hypertensive patients. In no age, sex, or blood pressure category did more than 55 per cent persist in therapy for one year, and for all groups, attrition was higher in the first year than in succeeding years. Only 55 per cent of the 101 patients who completed one year in therapy achieved "excellent" or "good" blood pressure control (Table 1). Results of the 76 patients in treatment at two years were similar, but for those 58 in therapy for at least three years, the percentage achieving "excellent" or "good" control was somewhat higher (62 per cent). A significantly larger percentage (p < .01) of patients with high initial blood pressures (diastolic 2 105 or systolic 2 180) compared to those below these levels achieved good results (70 percent vs. 50 per cent). In fact, patients with mnitial pressures less than 105 mm Hg. had only a 50-50 chance of achieving satisfactory control at one, two, or three years.
Results Characteristics of the Practice All but one of the patients were white, and they were drawn largely from the affluent "upper east side" population of Manhattan. Both the male (mean age = 54 years) and female (mean age = 63 years) hypertensive groups were significantly (p < .01 and p < .001, respectively) older than the general patient population (mean age = 45 years) of this 26
Drug Regimens and Blood Pressure Control The drug regimens prescribed for the 206 hypertensive patients are shown in Table 2. Forty-three per cent of patients with DBP < 105 were untreated, while only 12 per cent of those with diastolics - 105 received no drug prescription (p < .01). Table 3 illustrates one-year outcomes for 101 treated and untreated patients with varying initial blood pressure AJPH January 1979, Vol. 69, No. 1
BP CONTROL IN PRIVATE PRACTICE
206 Hypertensive sample studied
105 (51 %)
made
was found in the proportion of treated or untreated patients at goal. *
no
anniversary visit
Discussion
FIGURE 2-Outcomes of Hypertensive Study Patients
In this private practice, long-term success in the treatment of patients with high blood pressure was the exception rather than the rule. Since patients who made only one visit may have included a large number of referrals, this group was eliminated from the outcome study. Excluding these patients, only one-half of all others who began therapy were still under the care of this physician after one year. Attrition may be accounted for by the urban setting, patients returning to previous physicians after hypertensive work-up, the general mobility of the American population, or other unknown factors. The ultimate goal of antihypertensive therapy is the reduction of cardiovascular morbidity and mortality. Blood pressure control, the focus of this investigation, can be viewed as an intermediate outcome measure. Of those patients who remained in therapy for a year, only one-half achieved blood pressure control. These results might merely reflect a single physician's treatment of a self-selected population and therefore be of limited value. Although a tempting conclusion, available evidence suggests that this situation is
levels. In no category of diastolic pressure did treatment significantly affect the likelihood that patients would achieve improved or controlled blood pressure levels. Treated patients tended to have higher initial pressures and did achieve a significant reduction in mean blood pressure. Nevertheless, after one year of treatment, no significant difference
*Since rigid blood pressure criterion for the initiation of drug therapy was not followed, subjective factors may have influenced placement of patients who had not experienced illness into the no treatment group; hence, the two groups may be medically different. Alternately, the fact that all five untreated patients with initial DBP a 105 mg Hg, achieved satisfactory control may reflect the tendency of blood pressure to regress toward the mean overtime.
TABLE 1-Outcomes of 101 Patients after One Year N
Excellent*
Good"
Poor"*
5%
Age
