Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records

Abstract

Background: Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design.

Methods and results: Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017 Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines (9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC 8 report (6% lower in 2018-2019 compared to 2010-2014).

Conclusions: Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Keywords: antihypertensive drugs; electronic health records; guideline adherence; prescriptions.

Figure 1. Study flow chart.

EHR indicates electronic health record; and PCORnet, National Patient‐Centered Clinical Research Network.

Figure 2. Crude proportions of antihypertensive treatment regimens (A) and monotherapy subclasses (B) among adults with hypertension in the PCORnet MedWeight study from 2010 to 2019.

The proportion of FDC reflected prescription episode of using FDC alone and not in combination with other pills. ACE indicates angiotensin‐converting‐enzyme; ARB, angiotensin receptor blocker; CCB, calcium‐channel blocker; EHR, electronic health record; FDC, fixed‐dose combination; and K‐sparing, potassium‐sparing.

Figure 3. Likelihood of antihypertensive treatment regimen in adults with hypertension in the PCORnet MedWeight study from 2011 to 2019, with 2010 as reference.

Odds ratio estimated using generalized estimating equations with the binary variable of treatment regimen (monotherapy, polytherapy, or any FDC) as a dependent variable, and year of prescription as an independent variable. All models considered clustering by study site, repeated measures by patients, and adjusted for the order of prescription episode, sex, race, ethnicity, blood pressure control, body mass index, and other chronic disease histories. FDC indicates fixed‐dose combination; OR, odds ratio; and PCORnet, National Patient‐Centered Clinical Research Network.

Figure 4. Trends of antihypertensive treatment regimen in response to change in treatment guideline.

Odds ratio is interpreted as the odds of receiving beta blocker as first‐line therapy (A) or CCB and thiazide directics as first‐line therapy for Black patients (B) among all treatment episodes during the specified period compared with the reference period 2010–2014 or receiving dual therapy and FDC for patients with BP ≥140/90 mm Hg compared with the reference period 2015–2017 (C), controlling for order of prescription episode, site, age, sex, race, ethnicity, hypertension control, body mass index, and other chronic disease histories. ACC/AHA indicates American College of Cardiology/American Heart Association; BP, blood pressure; CCB, calcium‐channel blocker; FDC, fixed‐dose combination; JNC 8, Eighth Joint National Committee; OR, odds ratio; and PCORnet, National Patient‐Centered Clinical Research Network.