ADA: Clinicians Found Remiss in Blood Pressure Control for Diabetics

WASHINGTON, June, 10 - For every five visits to primary care physicians by diabetic patients with blood pressure that's too high, only once will the antihypertensive regimen be intensified, according to researchers here.

Chalk it up to clinical inertia, researchers reported at the American Diabetes Association meeting here, a tendency on the part of physicians to stay the course even in the face of abnormal findings, said endocrinologist Alexander Turchin, M.D., M.S., of Brigham and Women's Hospital in Boston.

More dramatic spikes in systolic pressure-10 mm Hg and up-tend to spur even complacent clinicians into action, and younger physicians are more likely to make a change in therapy than older physicians, Dr. Turchin said.

"It could be that the younger physician, having just completed a residency, is more aware of the current American Diabetes Association guidelines," Dr. Turchin said.

About two-thirds of patients with diabetes have blood pressures above the maximum level recommended by the ADA, and two of five have pressures that are more than 10 mm Hg above that level, Dr. Turchin said.

He and his colleagues used computer analysis technology to examine more than 172,357 outpatient progress notes taken by 582 primary care physicians caring for 12,806 diabetic hypertensive patients.

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They defined elevated blood pressure according to ADA guidelines that were current at the time of the study outset (at or above 130/85 mm Hg) and analyzed documented blood pressure results and evidence of antihypertensive therapy intensification.

They found that antihypertensive regimens were stepped up in only 21.4 of visits where the patients had documented elevated blood pressure, or more than 130/85 mm Hg.

In a subanalysis, they found that those patients who had more frequent intensification of therapy were significantly more likely to have decreases in systolic pressure as measured by the average change per visit.

Higher blood pressure readings (either systolic or diastolic) were significant predictors for treatment intensification, with the likelihood of treatment increasing about 30% for every 10 mm Hg increase of systolic pressure.

Other predictors for treatment intensification were :

• Age of the treating physician.
• Gender of the patient (men were 15% more likely to have treatment intensification than women).
• Age of the patient (the likelihood of regimen intensification increased 2% with every decade of life).
• Minority status. Patients who were members of ethnic minority groups, and therefore at increased risk for hypertension, had a 15% greater chance of having treatment intensification than whites.

"While some reasons for not intensifying therapy at a given visit are valid-such as that the provider was not the individual's regular physician or that that the person has a history of stabilizing pressure by the next visit-the majority of people with diabetes with elevated blood pressure do not have treatment intensified appropriately at a given visit," Dr. Turchin said.

Better professional education and feedback can help to lessen clinical inertia and improve outcomes, he added.

"The good news is that we are getting better: for every year in the study we have found an across the board 4% increase in the likelihood of treatment intensification," Dr. Turchin said.