Blood Pressure Control and Pharmacotherapy Patterns in the United States Before and After the Release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment

James H. Jackson, PharmD, MPH; John Sobolski, MD, PhD; Russ Krienke, MD; Ken S. Wong, PharmD; Feride Frech-Tamas, PharmD, MPH; Brian Nightengale, PhD

Disclosures

J Am Board Fam Med. 2008;21(6):512-521. 

In This Article

Abstract and Introduction

Abstract

Objectives: Despite recommendations from the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), only 36.8% of patients were at target blood pressure (BP) in 2003 and 2004. The objective of this study was to assess improvements in BP control and treatment patterns before and after the publication of JNC 7.
Methods: This was a retrospective, time series analysis of 27 provider groups and managed care organizations from 1998 through 2006. Patients with hypertension were identified from more than 4000 physicians. Medical charts were collected and clinical data were evaluated using prevailing JNC criteria during the time period before and after JNC 7.
Results: A total of 19,258 patients were identified with hypertension: 15,258 included in the before-JNC 7 cohort and 4,000 in the after-JNC 7 cohort. BP control in the before-JNC 7 cohort was 40.8% compared with 49.3% in the after-JNC 7 cohort (P < .0001). After controlling for demographic and clinical covariates, patients in the before-JNC 7 cohort were 45% less likely to achieve BP control compared with the after-JNC 7 cohort (odds ratio, 0.551; P < .0001).
Conclusion: Although findings indicate BP control is improving, a significant need for further improvement remains.

Introduction

Hypertension is a prevalent medical condition that affected nearly 1 in 3 adults (72 million) in the United States in 2004.[1] Termed "the silent killer" because of its asymptomatic nature, hypertension contributed to approximately 54,186 deaths in 2004 and is expected to result in $69.4 billion in direct and indirect costs in 2008.[1]

Because hypertension is a precursor to multiple disease conditions, maintaining blood pressure (BP) control and adherence to goals are imperative to reducing morbidity and mortality, especially in patients with high risk.[2,3] Since its first report in 1977, the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) has guided the medical community in the awareness, prevention, and treatment of hypertension.[4] Seven published reports (JNC 1 to JNC 7) define acceptable BP level and recommend treatment strategies based on a patient's comorbid disease states and level of BP control. Each successive report has been updated based on new clinical evidence about hypertension and its treatment.

The acceptable BP level has become more rigorous through the years, with normal diastolic blood pressure (DBP) defined as <90 mm Hg in JNC 1 versus <80 mm Hg in JNC 7; normal systolic blood pressure (SBP) was defined as <140 mm Hg in JNC 3 versus <120 mm Hg in JNC 7 (Figure 1). Until the 1980s, SBP was listed separately from DBP. However, beginning with JNC 5 (1993), hypertension was defined as a systolic/diastolic reading of at least 140/90. To better guide evaluation and treatment, in JNC 5 the categorization of BP ranges changed from a severity classification to a staging classification. JNC 7 reduced the staging categories from 3 to 2 but added "prehypertension," defined as those patients at risk of developing hypertension. Most notably, JNC 7 recognizes the increased risk of cardiovascular events in individuals with diabetes and chronic kidney disease and recommends more aggressive BP control (<130/80 mm Hg).

Classification of diastolic and systolic blood pressure according to JNC Guidelines 1 to 7.

Each JNC report has also provided drug therapy recommendations. Although diuretics have consistently been recommended as first-line therapies, notable modifications have been made over the years. For example, angiotensin converting enzyme inhibitors (ACEIs) and calcium channel blockers were added to diuretics and beta-blockers as recommended first-line drug therapy options in JNC 5, but were removed as first-line in JNC 6 because of evidence suggesting that diuretics and beta-blockers reduced cardiovascular morbidity and mortality.

Released in May 2003, the JNC 7 report focuses on greater awareness for at-risk patients, lower BP goals for people with diabetes, the use of multiple agents, and specialized treatment recommendations for compelling indications. For example, ACEIs and angiotensin II receptor blockers (ARBs) are recommended for patients with diabetes because they have been shown to also provide cardiovascular protection and slow the progression of nephropathy.[5] Beta-blockers were moved to second-line treatment after results from a meta-analysis that demonstrated superiority of diuretics on all outcomes of cardiovascular heart disease, stroke, congestive heart failure, major cardiovascular events, and cardiovascular and total mortality. In addition, 2-drug combination therapy is recommended as initial therapy for patients with stage 2 hypertension.[5,6]

Despite significant JNC efforts, a majority of patients are not reaching their BP goals. A 2003 study conducted in 8 managed care organizations in the United States concluded that less than 50% of plan members diagnosed with hypertension met their BP goal (JNC 6). This conclusion held even after various educational and awareness campaigns were initiated.[7] In addition, data from the National Health and Nutrition Examination Survey (NHANES) revealed that only 36.8% of patients (including those undiagnosed) were at their target BP.[8]

Given the significant changes in JNC 7 and the fact that the most recent data on BP control in the United States was obtained before its release, an updated investigation of hypertension treatment patterns and control after JNC 7 is warranted. This study was conducted to 1) assess improvements in BP control since publication of the JNC 7 guidelines, and 2) examine patterns of drug therapy regarding recommended best practices within the JNC guidelines.

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