characteristics of blood‐pressure control in treated hypertensive patients in croatia
Post on 09-Mar-2017
215 Views
Preview:
TRANSCRIPT
ORIGINAL ARTICLE
Characteristics of blood-pressure control in treated hypertensivepatients in Croatia
DINKO VITEZIC1,2, THOMAS BURKE3, JASENKA MRSIC-PELCIC1, ZARKO MAVRIC1,2,
LUKA ZAPUTOVIC1,2, GORDANA ZUPAN1 & ANTE SIMONIC1
1University of Rijeka Medical School, Brace Branchetta 20, 51000 Rijeka, Croatia, 2University Hospital Centre Rijeka,
Kresimirova 42, 51000 Rijeka, Croatia, 3Worldwide Outcomes Research, Merck & Co., Inc., One Merck Drive – WS-2E65,
Whitehouse Station, NJ 08889-0100, USA
AbstractThe aim of our study was to investigate blood pressure (BP) control and different factors with possible influence on BPcontrol in Croatian hypertensive patients. In this cross-sectional investigation, a representative sample of target populations(primary care physicians and patients) from different parts of Croatia was included according to the study protocol. DuringDecember 2003 and January 2004, we included, according to correctly completed questionnaires, 141 physicians and 814hypertensive patients. A controlled BP (BPv140/90 mmHg) in this hypertensive population treated with antihypertensivedrugs was in 23% of patients. The analysis of BP control according to risk factors showed that significantly related withhigher levels of systolic or diastolic BP were the age (poorer systolic BP control in patients older than 60 years), leftventricular hypertrophy, changes of the eye retina, smoking and diabetes mellitus. Furthermore, patients from towns closerto the hospital, from urban centers, with higher education and employed had significantly lower average BP. According toour results of hypertension control in Croatia, there is a need and a possibility for the improvement of the quality ofhypertension care. The relationship between demographic and cardiovascular risk factors with poor BP control should betaken into account when treating patients.
Key Words: Demographic aspects, hypertension control, questionnaire survey, risk factors
Introduction
Cardiovascular diseases (CVD) have been con-
firmed as the leading cause of death throughout
the world as well as in Croatia (1,2). Croatia is a
middle European and Mediterranean country with
4.5 million inhabitants. The percentage of overall
mortality in Croatia in 2001 related to CVD
was 53.6% (every second death), and CVD was
the leading cause for hospital admittance (2).
Hypertension is generally acknowledged as one of
the most important risk factors for CVD and it is
accepted that improving the quality of hypertension
care is a general priority that will result in a
diminished number of patients with CVD, i.e.
coronary artery disease, congestive heart failure,
stroke, peripheral vascular disease, and renal insuffi-
ciency (3,4). Despite the increased awareness of the
importance of lowering blood pressure (BP) to
values below 140/90 mmHg, the outcome of achiev-
ing this target still remains disappointing (3–7). The
reasons for inadequate management of BP in a
hypertensive population could be connected with
patients (e.g. drug adverse effects, compliance with
treatment, financial reasons – reimbursement, etc.)
and with physicians (knowledge–adherence to guide-
lines; 8–12). For an adequate improvement of
hypertension treatment, it is important to know
characteristics of treated population and factors that
could influence BP control as well as current BP
control. This information is insufficient in Croatia,
but antihypertensive drugs are the most frequently
prescribed drugs, according to the financial con-
sumption data from the Croatian National Health
Insurance (CNHI). The CNHI also reimburses all
Correspondence: Prof. Dinko Vitezic, MD, PhD, University of Rijeka Medical School and University Hospital Centre Rijeka, Brace Branchetta 20, 51000
Rijeka, Croatia. Tel: + 385 51 651 139. Fax: + 385 51 651 174. E-mail: vdinko@medri.hr
Blood Pressure. 2005; 14 (Suppl 2): 33–41
ISSN 0803-7051 print/ISSN 1651-1999 online # 2005 Taylor & Francis
DOI: 10.1080/08038020500465809
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
antihypertensive drugs, so a considerable amount of
resources is invested in hypertension treatment, but
there are no relevant data about the outcome, quality
or the impact of this costly treatment.
Therefore we prepared a cross-sectional study
using a questionnaire survey of pharmacologically
treated hypertensive patients and their physicians.
The objectives were to determine the characteristics
of a selected group of patients with hypertension and
to evaluate the BP control. Different factors and
their influence on BP level in patients with pharma-
cologically treated hypertension were analyzed.
We also investigate physicians’ and hypertensive
patients’ subjective point of view (satisfaction) about
BP control.
Materials and methods
Subjects
Subjects included in this cross-sectional study were
primary care physicians and patients with pharma-
cologically treated hypertension.
Target population. The physician target population
was defined as the general population of family
medicine doctors working on a permanent basis in
Croatian primary/ family medicine services in the
beginning of December 2003. The total target
population size was 2260.
The patient target population was defined as the
general adult (18+) population of non-institutiona-
lized Croatian citizens, with physician-diagnosed
hypertension, treated with antihypertensive drugs
for at least 6 months and able to visit the doctor’s
office in person because of regular medical examina-
tion (inclusion criteria). Hospitalized patients and
patients who had not taken antihypertensive medi-
cations for at least 6 months prior to the study were
excluded (exclusion criteria).
Sample of physicians. The primary care physicians’
database of the Croatian National Institute of Public
Health was used as the sample frame. We used a
disproportionate, stratified, random sample of
physicians. First, the total population of physicians
was stratified according to Croatian regions. The
maximum planned number of physicians’ sample
size was 153. Then, a random digit generator was
applied on the population list and the required
number of physician names was drawn. For each
name, two additional names were drawn, in order to
replace the eligible respondents who would refuse or
would not be able to participate.
Sample of patients. The patients sample was also
stratified according to region and inclusion criteria.
Each physician was instructed and requested to
include the first 10 of her/his eligible patients
entering the office the day after the distribution of
the questionnaires. A disproportionate sample was
used because of the prior determination of the size of
each physician’s sample of patients. The final
maximal patients’ sample size was planned to be
1530 patients (10 patients per physician).
Sample size. Significance level of pv0.05 was
chosen as appropriate for the main findings. The
desired level of precision was set to¡5%. Under the
worst-case assumption of population proportion
of p50.5, the required final patients’ sample size
in each of the main four strata was n5385. For
the minimum power (probability that statistical
significance will be indicated if it is present) of 0.9,
with a given significance level of p(0.05, desired
level of precision (5%), and the ‘‘expected average’’
effect size for mean systolic BP of 140 mmHg (with
standard deviation of 20 mmHg), the required
sample size was n5150. Final physicians’ sample
size was planned to n5153, respecting the needed
power and disproportionate correction for samples
from the smallest stratum [n(minimum)51]. Final
patients’ sample size was planned to n51530,
respecting the rule of 10 patients per physician,
which is set up in respect to the budget and
physicians’ efforts constraints. The initial number
of contacts was calculated to be n5248, respecting
the theoretically expected prevalence rate of correct
names and addresses (within the sample frame) of
0.95, and 0.65 expected rate of ‘‘first-contact–
finished interview’’.
Recruitment
All physicians who were selected for the main sample
were sent a detailed invitation letter with the
explanation that the study was approved by the local
ethical committee (Ethical Committee of the Rijeka
University School of Medicine). A week later,
trained interviewers (medical students) called them
by phone and scheduled meetings. Finally, they
visited them in person, explained the purpose of the
study again, asked them to participate and gave the
explanation letter. All interviewers were medical
school students.
Patients who appeared eligible according to
inclusion criteria and who agreed to participate were
given detailed information on the study and were
asked by their physicians to sign the informed
consent prior to inclusion.
34 D. Vitezic et al.
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
Total physicians’ recruitment time took 3 weeks
and the study was carried out during December
2003 and January 2004.
Instruments
A combination of three different questionnaires was
used:
(i) Physician questionnaire: medical specialization,
working experience, patients’ population, town
and county, familiarity with hypertension
guidelines usage in everyday practice, etc.;
(ii) Patient medical data questionnaire: sex, age,
height, weight, education, employment, medi-
cal history (risk factors and comorbidity),
relevant data from physical and laboratory
examinations, detailed data about BP and
pharmacotherapy;
(iii) Patient self-administered questionnaire: perception
of the disease and satisfaction with treatment
and hypertension control.
Analysis and classification of the data
For categorical variables, frequencies and percen-
tages were calculated. For approximately normally
distributed continuous variables, analysis of variance
with Duncan post-hoc test was used to assess the
differences between subgroups. Kolmogorov–
Smirnov was used as the test of deviations from
theoretical normal distribution. The Levene test of
homogeneity of variance was used and whenever the
test indicated statistically significant results at
pv0.05, non-parametric Mann–Whitney (for two
groups) or Kruskal–Wallis (for three or more
groups) was used. The differences for all analyses
are regarded as statistically significant if p(0.05.
BP measurements were standardized and per-
formed as described in WHO MONICA Manual,
which was translated in Croatian and given to all
physicians participating in the study (13). BP data
were classified according to WHO/ISH definitions
and classification of BP levels and on ESH/ESC
guidelines (14,15). Controlled BP was defined at
levels v140/90 mmHg.
Before the analysis, more variables were recoded
into new aggregated forms. For the purpose of the
data analysis, Croatia was divided into four tradi-
tional regions, and two global areas: Continental
Croatia (the Zagreb and Osijek regions) and Coastal
Croatia (the Rijeka and Split regions; Table I).
Results
Characteristics of the sample
The final sample consisted of 141 physicians (92%
of the planned sample); 214 physicians were initially
contacted. The refusal rate out of all contacted
physicians was 34%. A predominant reason for
refusal was the other physicians’ obligations in the
planned data collection period. Those physicians
who were selected for the main sample and properly
contacted, but who refused to take a part in the
study were asked about (i) the total number of
hypertensive patients examined the day before the
contact with the interviewer, (ii) about their total
clinical experience, (iii) about the lowest level of
systolic BP when starting pharmacotherapy. In
addition, their (iv) sex, (v) age estimated by the
interviewer, (vi) size of the town/village, and (vii) the
region were recorded. On none of these seven
statistics did the participants differ significantly from
those who refused to participate. This strongly
indicates that refusal rate did not significantly affect
structural quality of the final sample. That is, the
final sample structure is not statistically significantly
different from the population structure, meaning
that it is representative for the targeted population in
terms of these seven parameters and that the results
can be generalized according to the population.
The planned physicians’ sample (n5153) stan-
dard error for the particular response distribution of
50% was¡7.65% at p50.05 significance level. Final
physicians’ sample (n5141) standard error under
the same conditions was¡7.99%. This strongly
indicates that the change in the planned and final
physicians’ sample size did not significantly jeopar-
dize the reliability of the results.
The regional distribution of the final sample
did not differ significantly from the population
parameters.
The completed questionnaires were obtained for
814 of the patients. The average number of included
patients per physician was 5.9. The planned
patients’ sample (n51530) standard error for the
particular response distribution of 50% was¡2.5%
at p50.05 significance level. The final patients’
sample (n5814) standard error under the same
conditions was¡3.43%. This strongly indicates that
the change in the planned and final patients’ sample
size did not significantly jeopardize the reliability of
the results. The physicians were explained and
reminded three times (in the invitation letter,
explanation letter and in person by the interviewer)
that the patients should be selected systematically
one after another. The dates of the exams and the
inclusion of the patients were later on controlled.
Characteristics of blood-pressure control 35
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
This control proved no significant deviations
from the inclusion sequence plan. Several runs
tests have been done, analysis of variance tests
and chi-square tests with independent variables:
BP, physicians’ estimation of the hypertension
level of control, patient’s sex and age, while the
dependent variable was the day of inclusion. The day
of inclusion was defined as the number of days
passed from the day when physician had included
the first patient. No test shown any statistically
significant (at pv0.05) correlation of ‘‘the day of
inclusion’’; and mentioned independent variables.
This indicates that the patients actually were chosen
without omissions, that is, by a requested sequence.
If it is so, the structural quality of the final patients’
sample was not jeopardized by the shrinkage in its
total size.
In the final physicians’ sample, there were 105
(75%) women. The average physicians’ age was 46
(SD57.4); 98% of physicians (137) had clinical
experience of more than 6 years in primary care
practices. Regional distribution of participating
physicians closely matched the population regional
distribution.
In the final patients’ sample, there were 452
(56%) women. The average patients’ age was 61
(SD511.5; 21–89 years). The final sample consisted
of 9% (72) patients who did not finish their primary
school, 32% (257) who finished primary school,
41% (331) who finished secondary school, and 18%
(146) with a college or university degree. Education
level was not recorded for eight (1%) patients. At the
time of the inclusion into the study 30% (238) of the
patients were employed, 14% (111) were unem-
ployed and 56% (452) were retired. The work status
was not recorded for 2% (13) of the patients.
Normal body mass index was present in 17%
(128) of the patients, and the rest were overweight
(51%; 397), and obese (32%; 250). The data needed
for BMI calculation were not recorded for 5% of the
patients (39). The average patient had hypertension
diagnosed 7.4 (SD56.9) years before the study. For
90% of patients, hypertension was diagnosed more
than 1 year before the inclusion in the study.
Table I. Blood pressure by demographics.
Systolic Diastolic
n Mean (mmHg) SD p n
Mean
(mmHg) SD p
Whole sample 804 146.3 16.82 800 87.7 9.29
Region
Zagreb 372 146.9 17.30 0.024 369 87.8 9.21 0.740
Osijek 140 146.4 17.07 140 87.6 9.71
Rijeka 123 149.7 19.88 123 87.0 9.87
Split 169 142.4* 11.79 168 88.2 8.72
Distance to the hospital
Up to 30 min 500 144.7 16.23 0.000 499 88.1 9.30 0.760
31 min or more 231 150.1 17.94 230 87.9 8.81
Urbanization
Urban center 367 144.4 15.69 0.042 366 88.2 8.96 0.570
Small town or village 364 148.5 17.94 362 87.9 9.34
Sex
Male 360 145.0 16.79 0.066 360 87.7 9.46 0.909
Female 438 147.2 16.63 434 87.8 9.19
Age (years)
Up to 59 342 144.9 17.90 0.004 341 88.8 9.52 0.041
60 and more 440 147.3 15.63 437 86.9 9.01
Education
Primary school 299 150.5* 17.03 0.000 295 88.9 9.56 0.013
Secondary school 346 144.0 17.07 346 87.3 9.23
College 85 143.8 12.77 85 87.7 8.35
University 65 141.9 15.30 65 85.1* 9.17
Work
Employed 233 142.6* 16.46 0.000 233 88.6 9.19 0.162
Unemployed 92 148.6 19.17 91 88.3 10.85
Retired 464 147.8 16.24 462 87.2 9.00
*Categories of particular variable whose means differ at p50.05 from means of other categories of the same variable (in the case of three or
more subgroups). Bold5all demographic factors with statistically significant (at pv0.05) variations of blood pressure.
36 D. Vitezic et al.
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
BP control and demographics data
Controlled BP was found in 186 patients (23%),
grade 1 or mild hypertension (140–159/90–
99 mmHg) in 366 patients (46%), grade 2 or
moderate (160–179/100–109 mmHg) in 174
patients (22%), and grade 3 or severe (>180/
>110 mmHg) in 73 patients (9%) (Figure 1). The
data on BP were not recorded for only 31 patients
(4%). Isolated systolic hypertension was detected
among 221 (28%) patients.
BP according to demographics data is shown in
Table I.
Systolic BP (SBP), as showed in Table I, varied
statistically significantly by:
N Region (n5786, Kruskal–Wallis x259.462, df53,
p50.024), in a way that the average SBP was
lowest in the Split region (142.4 mmHg) and not
statistically significantly different within the other
three regions;
N Distance to the hospital (F515.922, dfb51,
dfw5728, pv0.000), in a way that patients who
are treated in more distant general practitioners’
offices have higher average SBP (150.1 mmHg);
N Urbanization (n5723, Mann–Whitney U5
55,565, Z522.03, p50.042), in a way that
patients treated in small town or village general
practitioners’ offices have higher average SBP
(148.5 mmHg);
N Age (F58.541, dfb51, dfw5775, p50.004), in a
way that older patients have higher average SBP
(147.3 mmHg);
N Education (F58.1, dfb54, dfw5789, pv0.000),
in a way that patients with unfinished or finished
primary school have higher average SBP
(150.5 mmHg) than those with higher education;
N Work (F58.295, dfb52, dfw5786, pv0.000), in
a way that unemployed (148.6 mmHg) and
retired patients (147.8 mmHg) have higher aver-
age SBP.
SBP did not vary statistically significantly by sex
(F53.386, dfb51, dfw5795, p50.066), but this
difference is highly indicative and should be checked
on the larger sample.
Diastolic BP (DBP) varied statistically signifi-
cantly by:
N Age (F52.107, dfb57, dfw5769, p50.041), in a
way that younger patients have higher average
DBP (88.8 mmHg);
N Education (F53.311, dfb54, dfw5785,
p50.013), in a way that university graduated
patients have the lowest average DBP
(85.1 mmHg) and the patients with a finished
primary school have the highest (89.3 mmHg).
DBP did not vary statistically significantly (at
pv0.05) by any other socio-demographic factor.
The relationship of defined factors used in
cardiovascular risk stratification on the level of
systolic or diastolic BP is presented in Table II.
SBP varied statistically significantly by the level
of DBP (pv0.000), in a way that higher SBP
correlates with significantly higher DBP; left ven-
tricular hypertrophy (p50.012), in a way that
patients with left ventricular hypertrophy had
higher average SBP (149.0 mmHg); and retinal
changes (p50.044), in a way that patients with
no retinal changes had higher average SBP
(146.8 mmHg). SBP did not vary statistically
significantly (at pv0.05) by any other socio-
demographic factor.
DBP varied statistically significantly by the level of
SBP (pv0.000); smoking (p50.042), in a way that
patients who smoked had the higher average DBP
(88.9 mmHg); and diabetes (p50.045), in a way
that patients with no diabetes had a higher average
DBP (88.0 mmHg). DBP did not vary statistically
significantly (at pv0.05) by any other socio-
demographic factor.
Physicians’ and patients’ subjective opinion on BP
control
Grouped results about physicians presumed BP
control in their patients (answer to question: ‘‘In
what percentage of your patients do you consider
hypertension well controlled?’’) have been summar-
ized in Figure 2.Figure 1. Blood pressure (BP) control in pharmacologically
treated hypertensive patients.
Characteristics of blood-pressure control 37
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
According to 64% of physicians, BP is controlled
in 50% or more patients. Only 13% of physicians
presume that BP is controlled in less then 25% of
their patients.
The patients’ satisfaction with BP control is
presented in Table III.
The average SBP varied statistically significantly
by the levels of subjective patients’ evaluation of
hypertension control (pv0.000). According to the
Duncan post-hoc test, the average SBP differs
significantly (at pv0.05) between all three subjective
hypertension control evaluation groups in a way that
the higher average SBP correlates positively with
patients’ dissatisfaction.
The average DBP varied statistically significantly
by the levels of subjective patients’ evaluation of
hypertension control (pv0.000). According to
Duncan post-hoc test, the average DBP
differs significantly (at pv0.05) between the sub-
jective group ‘‘bad hypertension control’’ and two
other groups, but did not differ statistically signifi-
cantly (at p50.05) between ‘‘good’’ and ‘‘satisfac-
tory’’ subjective hypertension control evaluation
groups.
Table II. Blood pressure by risk factors.
Systolic Diastolic
n
Mean
(mmHg) SD p n
Mean
(mmHg) SD p
Whole sample 804 146.3 16.82 800 87.7 9.29
Systolic BP
Controlled 239 129.0 5.39 0.000 236 82.9 6.19 0.000
140+ 565 153.6 14.48 564 89.8 9.62
Diastolic BP
Controlled 407 138.9 12.94 0.000 407 80.4 4.41 0.000
90+ 393 154.2 16.87 393 95.3 6.50
Smoking
No 597 146.6 16.71 0.404 594 87.3 9.27 0.042
Yes 207 145.5 17.16 206 88.9 9.30
Total cholesterol (mmol/l)
Up to 5.99 363 146.0 17.28 0.956 362 88.1 8.87 0.331
6.00 or more 330 146.1 15.92 327 87.4 9.78
BMI (kg/m2)
Up to 29 581 145.8 17.08 0.402 580 87.7 9.15 0.838
30 or more 199 146.9 15.91 197 87.8 9.74
Positive family anamnesis
No 452 146.1 16.55 0.751 451 87.3 9.09 0.111
Yes 352 146.5 17.19 349 88.3 9.52
Physical activity
Active 516 146.7 17.41 0.697 516 87.4 9.00 0.126
Not active 272 146.2 15.94 268 88.5 9.88
Diabetes
No 651 146.6 16.84 0.265 649 88.0 9.20 0.045
Yes 153 144.9 16.72 151 86.4 9.58
Left ventricular hypertrophy
No 611 145.5 16.40 0.012 608 87.6 8.71 0.394
Yes 193 149.0 17.88 192 88.1 10.94
CVI or cerebral episodes
Yes 73 147.5 16.91 0.538 72 87.9 9.52 0.870
No 731 146.2 16.82 728 87.7 9.28
Coronary disease
Yes 159 147.6 16.32 0.289 157 87.7 9.76 0.941
No 645 146.0 16.94 643 87.7 9.18
Proteinuria
No 768 146.1 16.65 0.078 764 87.7 9.32 0.491
Yes 36 151.2 19.80 36 88.8 8.69
Eye retinal changes
No 703 146.8 17.03 0.044 700 87.9 9.26 0.263
Yes 101 143.2 15.05 100 86.8 9.53
Bold5all demographic factors with statistically significant (at pv0.05) variations of blood pressure. CVI, cerebrovascular insult; BMI, body
mass index.
38 D. Vitezic et al.
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
Discussion
The methodological concept with three question-
naires used in this cross-sectional study was a
complex one. The intention was not only to retrieve
objective data about hypertension control, but also
to obtain data about a subjective impression from
the patients’ and physicians’ point of view, which are
important for an adequate BP control. The response
rate was adequate and the obtained results justified
this approach. We are aware of the potential
limitation of the study – selection bias or inclusion
of patients with poorer BP control. This problem
was minimized because all included patients were
examined by their physicians on regular monthly
basis. The explanation is in the local health system,
which allows drug prescribing for the maximal
period of 1 month.
The results of the study confirmed a low level of
BP control in outpatients with treated hypertension,
i.e. only 23% of patients have BP under the level of
140/90 mmHg. This finding is consistent with the
results of poor BP control in different countries, but
it is important to point out that our results are from
the group of pharmacologically treated patients
(3,7,16,17). In the observational, practice-based
study performed by Degli Esposti et al. in Italy
40% of hypertensive patients reached BP targeted
goal (18). The other study, also from Italy (ForLife
study), involved primary care physicians and their
hypertensive patients and controlled BP values
occurred in only 18.4% of patients (5). The average
BP of 146.3/87.7 mmHg in our study is slightly less
than in treated patients according to InterASIA
(2000–2001) study in China (148/89 mmHg) but
much higher than the results of NHANES III
(1988–1994) in the USA (139/81 mmHg; 19).
The analysis of BP control according to demo-
graphic data showed that some of them have a
significant impact on BP control. A better SBP
control was noticed in the Split region and we can
only presume the possible impact of Mediterranean
lifestyle typical of this region. The patients distant to
hospital and living in small towns and villages have
poorer SBP control, and the distance could be the
reason in less frequent control of BP in this group of
patients. The working status and education have a
significant influence on both, SBP and DBP control.
A better control was in the group of patients with
higher (e.g. university) education and also in the
group of employed versus unemployed and retired.
Patients with higher education are more aware of the
importance of BP control and generally have, such as
employed patients, better socio-economic position.
Some similar findings about the association of
education and socio-economic position on BP
control described Gulliford et al. (20). The
INTERMAP study among US participants showed
significant inverse relation of SBP and DBP levels to
years of education, i.e. the less the education, the
higher the SBP and DBP (21).
The age of the patient is a factor with the significant
influence on BP control, i.e. among our subjects older
than 60 years, SBP is poorly controlled. The Hyman
and Pavlik analysis of NHANES III data showed that
the largest relative and attributable risk of uncon-
trolled hypertension was associated with age (at least
Table III. Patients’ satisfaction with their BP control by the levels of systolic and diastolic BP.
Systolic Diastolic
n Mean (mmHg) SD p n Mean (mmHg) SD p
Whole sample 794 146.4 16.81 790 87.8 9.28
Patients’ evaluation of BP controla
Good 475 143.7* 15.43 0.000 475 86.4 8.32 0.000
Satisfactory 279 148.5* 17.22 275 88.8 9.58
Bad 40 164.1* 17.20 40 98.0* 10.88
*Categories of variable hypertension control whose means differ at p50.05. aAnswer to question: ‘‘Could you evaluate how well is your
hypertension controlled?’’.
Figure 2. Grouped results – physicians presumed BP control in
their patients (‘‘In what percentage of your patients do you
consider hypertension well controlled?’’). (Tukey’s Biweight M-
estimator553.32; arithmetic mean553.27; SD520.720;
Median550; Standard error of mean51.757).
Characteristics of blood-pressure control 39
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
65; 22). The importance of treating and difficulties of
achieving target values of SBP, especially in older
patients, has been well known during the last decade
(18,19,23–26).
The relationships of defined risk factors used in
cardiovascular risk stratification (recognized by
current European guidelines) and their influence
on BP level have been analyzed in our study (15).
Significantly related with higher levels of systolic or
diastolic BP were left ventricular hypertrophy,
changes of the eye retina, smoking and diabetes
mellitus. ForLife study results showed also that left
ventricular hypertrophy and diabetes mellitus were
connected with lower BP control (5).
As mentioned before, BP control is poor in the
investigated population. The factors that influence a
better or worse control need more attention in future
treatment approaches. Besides these objective fac-
tors, some subjective factors could also contribute to
poor BP control. Our physicians have (subjectively)
a very high level of satisfaction with BP treatment of
the patients. The discrepancy in real BP control and
their presumption could also be one of the reasons
for not achieving target BP levels. On the other
hand, hypertensive patients are mostly satisfied with
their BP control, but the ones with high levels of
systolic or diastolic BP are aware of this fact. This
could be used as a good starting point for changing
the therapeutic approach. There are similar results in
the study of Chen et al. but concerning patient
satisfaction with antihypertensive therapy, i.e. the
patients with BP controlled to JNC 7 guidelines were
more satisfied with their medication than those with
uncontrolled BP (27).
The need for improving treatment and education
in the field of hypertension is mandatory in Croatia,
according to the results of our study, and according
to the fact that the global burden of hypertension will
increase in the future (28).
In conclusion, this is the first investigation that
confirms unsatisfactory BP control among pharma-
cologically treated patients in Croatia. The relation-
ship of some demographic and risk factors on poor
BP control has been detected, and this should be
taken into account when treating patients. Special
attention should be given to older non-urban
patients living far from the hospital. Further,
physicians’ satisfaction about BP control could be
an obstacle in adequate treatment, so more attention
should be turned to education concerning the
importance of achieving the target BP, especially
because antihypertensive drugs from all classes are
accessible for all patients through the Croatian
healthcare system.
Acknowledgements
The study was supported by MSD grant. STRATUM
Healthcare MR and Biometrika Healthcare Research
helped in conducting the study technically.
References
1. World Health Organization. World Health Report 2002.
Reducing risks promoting healthy life. World Health
Organization: Geneva, 2002.
2. Hrabak-Zerjavic V, Kralj V, Silobrcic-Radic M.
Javnozdravstvena vaznost najcescih kardiovaskularnih bolesti
(The public health importance of the most frequent cardio-
vascular diseases). Medicus. 2003;12:9–16.
3. Mancia G, Seravalle G, Grassi G. Tolerability and treatment
compliance with angiotensin II receptor antagonists.
Am J Hypertens. 2003;16:1066–1073.
4. Carretero OA, Oparil S. Essential hypertension. Part I:
Definition and etiology. Circulation. 2000;101:329–335.
5. Mancia G, Ambrosioni E, Rosei EA, Leonetti G, Trimarco B,
Volpe M. Blood pressure control and risk of stroke in
untreated and treated hypertensive patients screened from
clinical practice: results of the ForLife study. J Hypertens.
2005;23:1575–1581.
6. Carretero OA, Oparil S. Essential hypertension. Part II:
Treatment. Circulation. 2000;101:446–453.
7. Mancia G, Sega R, Milesi C, Ceasana G, Zanchetti A. Blood-
pressure control in the hypertensive population. Lancet.
1997;349:454–457.
8. Sanson-Fisher RW, Clover K. Compliance in the treatment of
hypertension. A need for action. Am J Hypertens.
1995;8:82S–88S.
9. Oliveira SA, Lapuerta P, McCarthy D, L’Italien GJ,
Berlowitz DR, Asch SM. Physician-related barriers to the
effective management of uncontrolled hypertension. Arch
Intern Med. 2002;162:413–420.
10. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH,
Abboud PA, et al. Why don’t physicians follow clinical
practice guidelines? A framework for improvement. JAMA.
1999;282:1458–1465.
11. Nelson MR, Reid CM, Krum H, McNeil JJ. Factors
influencing family physician adherence to hypertension
treatment guideline recommendations on the initiation of
pharmacotherapy. Am J Cardiovasc Drugs. 2003;3:437–441.
12. Mehta SS, Wilcox CS, Schulman KA. Treatment of
hypertension in patients with comorbidities. Results from
the Study of Hypertensive Prescribing Practices (SHyPP).
Am J Hypertens. 1999;12:333–340.
13. World Health Organization (WHO). MONICA Manual.
Available from: URL: http://www.ktl.fi/publications/monica/
manual/index.htm, .
14. Guidelines Sub-Committee. 1999 World Health Organization
– International Society of Hypertension guidelines for the
management of hypertension. J Hypertens. 1999;17:151–183.
15. Guidelines Committee. 2003 European Society of
Hypertension – European Society of Cardiology guidelines
for the management of arterial hypertension. J Hypertens.
2003;21:1011–1053.
16. Zdrojewski T, Szpakowski P, Bandosz P, Pajak A, Wiecek A,
Krupa-Wojciechowska B, et al. Arterial hypertension in
Poland in 2002. J Hum Hypertens. 2004;18:557–562.
17. Rieder A. Awareness and control of hypertension in Austria.
J Hum Hypertens. 2004;18:535–537.
40 D. Vitezic et al.
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
18. Degli Esposti E, Di Martino M, Sturani A, Russo P, Dradi C,
Falcinelli S, et al. Risk factors for uncontrolled hypertension
in Italy. J Hum Hypertens. 2004;18:207–213.
19. Muntner P, Gu D, Wu X, Duan X, Wenqi G, Whelton PK,
He J, for the InterASIA Collaborative Group. Factors
associated with hypertension awareness, treatment, and
control in a representative sample of the Chinese population.
Hypertension. 2004;43:578–585.
20. Gulliford MC, Mahabir D, Rocke B. Socioeconomic inequality
in blood pressure and its determinants: Cross-sectional data
from Trinidad and Tobago. J Hum Hypertens. 2004;18:61–70.
21. Stamler J, Elliott P, Appel L, Chan Q, Buzzard M, Dennis B,
et al. for the INTERMAP Research Group. Higher blood
pressure in middle-aged American adults with less education
– role of multiple dietary factors: The INTERMAP Study.
J Hum Hypertens. 2003;17:655–675.
22. Hyman DJ, Pavlik VN. Characteristics of patients with
uncontrolled hypertension in the United States.
N Engl J Med. 2001;345:479–486.
23. Lloyd-Jones DM, Evans JC, Larson MG, O’Donnell CJ,
Levy D. Differential impact of systolic and diastolic blood
pressure level on JNC-VI staging. Hypertension.
1999;34:381–385.
24. Black HR. The paradigm has shifted, to systolic blood
pressure. Hypertension. 1999;34:386–387.
25. Basile JN. Systolic blood pressure. It is time to focus on
systolic hypertension – especially in older people. BMJ.
2002;325:917–918.
26. Berlowitz DR, Ash AS, Hickey EC, Friedman RH,
Glickman M, Kader B, et al. Inadequate management of
blood pressure in a hypertensive population. N Engl J Med.
1998;339:1957–1963.
27. Chen K, Chiou CF, Plauschinat CA, Frech F, Harper A,
Dubois R. Patient satisfaction with antihypertensive therapy.
J Hum Hypertens. 2005;19:793–799.
28. Kearney PM, Whelton M, Reynolds K, Muntner P,
Whelton PK, He J. Global burden of hypertension: Analysis
of worldwide data. Lancet. 2005;365:217–223.
Characteristics of blood-pressure control 41
Blo
od P
ress
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
2/14
For
pers
onal
use
onl
y.
top related