characteristics of blood‐pressure control in treated hypertensive patients in croatia

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: [email protected]

Blood Pressure. 2005; 14 (Suppl 2): 33–41

ISSN 0803-7051 print/ISSN 1651-1999 online # 2005 Taylor & Francis

DOI: 10.1080/08038020500465809

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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.

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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

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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.


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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.


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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.


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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).


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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.

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characteristics of blood‐pressure control in treated hypertensive patients in croatia

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