Even though hypertension is one of the most common reasons for visits to a physician's office, many patients have poorly controlled hypertension. Data from the National Health and Nutrition Examination Survey found that only 24 percent of patients with hypertension had blood pressures of less than 140/90 mm Hg. Research has shown that management of hypertension is inadequate even among patients who receive regular medical care. Patient noncompliance has often been the focus of studies, while the role of the physician in management, particularly in prescribing different medications, has not. Berlowitz and colleagues evaluated the way physicians managed hypertension in patients who had direct access to health care and medications in an effort to develop recommendations for improving care.

Patients were eligible for this multi-center trial conducted at five Veterans Administration outpatient clinics if they had been seen by a physician at least three times at specified intervals over a two-year period. Patients' medical records were reviewed to obtain information regarding the reason for the visit, symptoms, diagnoses and physical findings, including blood pressure measurements, test results and medications prescribed. Information regarding changes in dosage or type of medication was obtained from physician orders, progress notes and pharmacy records. A blood pressure of less than 140/90 mm Hg was considered well controlled; a systolic pressure over 160 mm Hg or a diastolic pressure over 95 mm Hg was considered poorly controlled.

Eight hundred men were evaluated for the study. The mean patient age was 65 years, and approximately 90 percent of the patients were white. At baseline, the mean systolic blood pressure was 146 mm Hg; after two years of medical care, it was relatively unchanged at 145 mm Hg. Mean diastolic blood pressures were relatively unchanged as well, decreasing only slightly from 84.3 to 82.6 mm Hg during this same time. However, during this time the percentage of patients with a baseline blood pressure of greater than 160/90 mm Hg decreased from 46 to 39 percent.

Despite these rather poor results, patients, on average, visited a physician six times over the two-year study period. Antihypertensive medications were increased at 6.7 percent of the visits, most commonly when the patient's diastolic blood pressure was greater than 90 mm Hg, although changes in therapy were instituted at only 35 percent of all visits. Changes in therapy were rare if patients' blood pressure was less than 160/90 mm Hg and there was no history of coronary artery disease. An intensity score was calculated to quantify the degree of medical therapy. Patients who had the highest intensity scores had the greatest mean decreases in both systolic and diastolic blood pressures during the two years of follow-up.

The authors conclude that many patients with hypertension have inadequate control of blood pressure. In this population, fewer than 25 percent had readings of less than 140/90 mm Hg. Clearly, lack of access to care and medications were not issues in this population. Noncompliance may be to blame, at least in part, but was not specifically addressed in this study. Rather, physician prescribing behavior was examined. Physicians in this study frequently failed to change dosages or introduce new medications to better control hypertension. Data from this study suggest that physicians should continually reassess their approach to individual patients and consider more aggressive therapies to control of blood pressure.

editor's note: The message of this study is fairly straightforward: physicians are not aggressive enough in treating hypertension, despite the availability of national treatment guidelines, access to care and an almost infinite number of antihypertensive medications. Patient compliance certainly is a contributing factor, but it appears that our approach to treatment is simply not aggressive enough. Educating patients about the importance of following treatment regimens is a strength of managed care organizations. Fixed-combination therapies given once daily are reestablishing themselves and may provide at least a partial solution to this problem.—j.t.k.