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Risk factors for uncontrolled hypertension in Italy E Degli Esposti1, M Di Martino2, A Sturani3, P Russo4, C Dradi5, S Falcinelli5 and S Buda2Received 26 June 2003; Revised 18 September 2003; Accepted 29 September 2003.

Top of pageAbstractTo identify factors related to poor control of blood pressure in primary care, we designed a retrospective case analysis of clinical and demographic data recorded in the General Practitioners (GP) database. Study data were provided on a voluntary basis by 21 GPs from a practice based network in primary care. The study included 2519 hypertensive patients enrolled between January 1 and December 31, 2000. The interventions were antihypertensive medication, and the main outcome measures were control of systolic and diastolic blood pressure (BP). The independent variables considered were: age of patient and GP; patient gender, body mass index, history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction or heart failure, and number of admissions for surgery; length of patient follow up, type of antihypertensive medication, mean daily dosage, adherence to the drug regimen, and number of other medications currently being taken by the patient. Blood pressure was uncontrolled (>140/90 mmHg) in 1525 (60%) of the 2519 hypertensive patients enrolled. The presence of diabetes mellitus, increasing patient age, and increasing GP age significantly increased the risk of uncontrolled BP. Factors significantly associated with a reduced risk of uncontrolled BP were the number of other medications currently being taken by the patient and a prior history of MI. We conclude that the failure of antihypertensive medication to adequately control BP is determined by both the patient's characteristics and factors related to the patient relationship. Failure to achieve the targeted BP control is a global problem. In the United States, fewer than 30% of hypertensive patients have BP values lower than 140/90 mmHg,5 while, in the United Kingdom, only 6% of hypertensive patients have attained these target BP levels.6 Even with less stringent levels of BP control of 160/95 mmHg, data from Australia, Canada, Finland, India, Scotland, and Spain suggest that no more than 20% of the population would achieve this goal.7 The identification of factors related to poor control of BP can help to target populations in need of medical attention, and to aid in the development of effective treatment strategies for specific subpopulations.7 The objective of the present case study was to identify risk factors for uncontrolled BP among those patients enrolled in the Pandora project, a prospective ongoing global outcomes study begun in 1996 to organize a database for epidemiological assessments and to improve the management of hypertension in primary care. Top of pageMethodsData collection and patientsOf 330 general practitioners (GPs) in the Ravenna, Italy area, 21 voluntarily participated in the PANDORA project. In Italy, the GP is the doctor working outside the hospital, who is delegated by the National Health System to provide care for a known number of subjects. Each GP was asked to enrol two hypertensive patients per week in the study, starting on 01/01/1996. When this study was carried out, the GPs participating in the Pandora project had a cohort of about 33 000 beneficiary subjects representing 9.3% of persons living in the Ravenna area. The Pandora project was approved by the Local Ethics Committee, and informed consent was obtained from each patient enrolled. The remote server is also linked to the Local Health Unit database (patient, GP, prescription, hospital, and death records) and to the hypertension unit. At the remote station, a team of different specialists (computer scientist, economist, statist, epidemiologist, pharmacologist) produces a variety of reports which are regularly returned to the various operators. software controlled the operation of the BP device, which was connected to the computer. The BP value recorded and entered into the database at each visit represented the average of three consecutive readings obtained at 1 min intervals after the patient had remained seated for 5 min. BP was measured in the dominant upper arm during the daytime, morning or afternoon, in accordance with conventional clinical practice. A tube 3.6 m in length and a cuff of 23 cm for normal subjects or 31 cm for obese subjects were used. Clinical and laboratory data were gathered and stored either by the GPs themselves or through links with Health Service databases, as already documented.8 At the enrolment visit, the GP recorded the patient's currently prescribed antihypertensive regimen, defining the drug(s), active ingredient(s), and the number of tablets the patient was instructed to take daily. At the end of each visit, the antihypertensive treatment was again prescribed by the GP, who had complete discretion to decide the type of drug and the dosage for an individual patient, and the frequency with which BP would be measured. The antihypertensive drugs purchased by each patient were identified from the pharmaceutical database kept by the Local Health Unit of Ravenna, which logs each prescription, records the code number of the prescribing physician, the national pandora bracelet jared health number of the patient, the date dispensed, the Anatomical classification (ATC), the number of packs, and the number of tablets per pack. All drug prescriptions considered in this study are fully reimbursed by the National Health System. The completeness and coherence of the information recorded for each patient were periodically checked at the remote station and only those patients whose recorded data which satisfied the inclusion criteria of the study were considered in the analysis. Patient characteristics and outcome measuresThe main outcome measure for this case study was BP control (yes/no). Adequate control was defined as a representative SBP of less than 140 mmHg and a DBP of less than 90 mmHg; for patients with diabetes, BP control was defined as a representative SBP british pandora charms of 4 Eligible patients were at least 18 years of age, and had been enrolled in the Pandora project for at least 1 year prior to the BP measurement period from 1 January to 31 December 2000. Patients were excluded if they had end stage renal disease or malignant systemic disease (ie lupus erythematosus). The representative BP was the BP reading from the most recent visit during the measurement period. Only those patients whose records included at least one BP value measured at least 365 days before the representative value were included in the study. The control group consisted of those patients with diagnosed hypertension whose BP was adequately controlled at the end of the measurement period. Cases were those patients with diagnosed hypertension whose BP was not adequately controlled at the end of the follow up measurement period. A patient follow up period was defined retrospectively as the interval, in days, between the representative BP and the earliest BP value present in the patient's record. The independent variables considered in this study included the age of the patient and GP; patient gender, body mass index (BMI); history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction (MI) or heart failure; number of admissions for surgery; and length of patient follow up, type of antihypertensive medication, mean daily dosage (MDD), utilization of antihypertensive drugs and number of other medications currently being taken by the patient (antiaggregants, anti inflammatories, anithypolipaemia drugs, antiasthmatics, and drugs for the treatment of heart diseases). Utilization of antihypertensive drugsUtilization of antihypertensive agents was defined for the purpose of this study as the MDD of the drugs purchased during the follow up period, expressed as the number of tablets per day. The formula utilized was: number of tablets prescribed from the first to the penultimate prescription, divided by the number of days from the first to the last prescription. The duration pandora sale charms (expressed in days) of the antihypertensive treatment (DT) was then calculated as the number of days from the first to the last prescription plus the number obtained by dividing the number of tablets indicated in the final prescription by the MDD. The calculations were based on the total number of tablets purchased by each patient, regardless of the active principle that each contained. Three categories for use of antihypertensive medication were defined, regardless of the type and number of active ingredients taken: patients were defined as (1) occasional users if they received only one prescription of antihypertensive medication during the study period; (2) interrupted users if, during the study period, they interrupted the use of any antihypertensive drug; (3) continuous users if, during the study period, they continuously took antihypertensive drugs (by maintaining, combining or switching the active ingredient) without interrupting the pharmacological therapy. In the case of nonoccasional users, four types of antihypertensive treatment were identified on the basis of MDD: patients with MDD 0.5 tablets/day and 1 tablet/day and 2 tablets/day. Statistical analysisContinuous variables are presented as mean values plus or minus the standard deviation. Statistical significance between means was calculated by independent samples t test or, alternatively, by paired samples t test. Association between categorical variables and BP control was tested using the Pearson's 2 test.9 For all analyses, P values of less than 0.05 were considered significant. Unadjusted odds ratios were obtained to identify factors predictive of not achieving adequate control of BP, the outcome variable. A multivariable logistic regression model10 was then developed, identifying factors predictive of not achieving adequate BP control while simutaneously adjusting for potential confounders. A forward stepwise approach was undertaken setting entry/removal criteria for each independent variable at (P value(in)=0.05, P value(out)=0.10) using the Wald test statistic. The fit of the model was assessed jewelry seattle with the Hosmer goodness of fit test statistic,10 with P 11 Top of pageResultsPatient characteristicsThere were 6392 hypertensive patients in the Pandora project population from 1 January to 31 December 2000, representing 19.4% of the total beneficiaries in the care of the 21 GPs. Of these, 2519 met the inclusion criteria for the present study, including 1525 cases (60.5%) and 994 controls (39.5%). All the subjects included in the study were white. The characteristics of the patients enrolled are shown in Table 1. Compared with controls, cases were significantly older and less likely to smoke. The percentage of patients who had diabetes mellitus was significantly greater among cases than controls. The percentage of patients with previous hospital admissions for cardiovascular reasons and the percentage of patients taking two or more co medications were higher in the controls than in the cases. Compared with controls, cases also had a slightly higher BMI, which was statistically significant, and a significantly shorter duration of follow up. Adherence to the antihypertensive regimen was significantly higher among cases compared with controls (83.4 vs 77.7%, P blockers was greater among controls, whereas the use of calcium channel blockers was greater among cases. at the end of the follow up period. At the end of the follow up period, 22.3% (222 patients) of the control group had a representative BP of vs controls at enrolment (15320 vs 14021 mmHg, respectively) and at the end of follow up (15313 vs 12610 mmHg, respectively) was significantly higher (P11 vs 8011 mmHg, respectively) and at the end of follow up (8112 vs 748 mmHg, respectively) (Figure 1). Among cases, there was a significant decrease in DBP from enrolment to the end of follow up (8211 vs 8112 mmHg, respectively, P20 vs 15313 mmHg, respectively). By contrast, the controls showed a significant decrease from enrolment to the end of follow up in both SBP (14021 vs 12610 mmHg, respectively) and DBP (8011 vs 748 mmHg) (P4 at the end of follow up, 71.

9% (1096 patients) cases had stage I hypertension, 23.1% (352 patients) had stage II hypertension, and 5.0% (77 patients) had stage III hypertension.


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