Treatment Intensification for Hypertension in US Ambulatory Medical Care

Abstract

Background: Hypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all-cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.

Methods and results: Using the nationally representative National Ambulatory Medical Care Survey (2005-2012) and National Hospital Ambulatory Medical Care Survey (2005-2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005-2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2-7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.

Conclusions: US hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension-related morbidity and mortality nationwide.

Keywords: blood pressure; hypertension medication; medication addition; medication initiation.

Figure 1

Prevalence of hypertension treatment intensification in the United States 2005–2012.

Figure 2

Weighted prevalence of hypertension treatment intensification at different systolic blood pressure levels by patient characteristics in NAMCS and NHAMCS visits 2005–2012. Data are color‐coded based on weighted prevalence from the lowest (red) to the highest (green). The minimum (6.9%) and the maximum (38.4%) are indicated with dark squares. Numbers are calculated among adult primary care visits with diagnosed hypertension and measured blood pressure at or above listed systolic blood pressure levels. CHIP indicates Children's Health Insurance Program; NAMCS, National Ambulatory Medical Care Survey; NHAMCS, National Hospital Ambulatory Medical Care Survey.