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Retrospective analysis of comorbid hypertension and dyslipidemia management in a primary care practice
Catherine E. Cooke, PharmD, BCPS, PAHM; Teisha A. Robertson, PharmD, MBA
KEYWORDS: Hypertension, Dyslipidemia, Treatment
DISCLOSURES
Funding for this study was received from Pfizer, Inc.
ABSTRACT
BACKGROUND: Cardiovascular disease remains the leading cause of morbidity and mortality in the United States. Several cardiovascular risk factors increase the risk of coronary heart disease (CHD). Two of the most prevalent and asymptomatic risk factors for CHD are hypertension and dyslipidemia and they commonly co-exist. The CHD risk in patients with co-morbid hypertension and dyslipidemia is greater than the sum of CHD risks for hypertension and dyslipidemia when they occur alone. Although there are more treatment options available today, achieving control of these diseases is challenging. Previous studies have found control rates for hypertension around 25% while control of dyslipidemia is around 33%.
OBJECTIVE: To describe the (1) demographic and clinical characteristics (2) blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) goal attainment and (3) use of antihypertensive and lipid-lowering therapy in patients with comorbid hypertension and dyslipidemia in a primary care setting.
METHODS: This retrospective study used administrative and clinical data from an urban mid-Atlantic primary care medical group. Patients with at least one ICD-9-CM code for hypertension (401.xx) and hypercholesterolemia (272.xx) were identified from January 1, 2005 to June 30, 2005. Data abstracted from medical chart review included: age (as of January 1, 2005), sex, ethnicity, risk factors for CHD (documentation of hypertension, dyslipidemia, diabetes mellitus, tobacco abuse and family history of premature CHD), renal disease, clinical diagnosis of any depression and/or prescription for anti-depressant medication, antihypertensive and lipid-lowering therapy and BP and lipid profiles (including dates). Blood LDL-C values were classified as at goal based on NCEP ATP III. BP was classified as at goal if BP was < 130/80 mmHg for patients with diabetes and/or renal dysfunction and < 140/90 mmHg for the remaining patients.
RESULTS: The final cohort consisted of 378 evaluable patients with an average age of 56.7 +/- 11.8 (range 25-82) years and 43.4% (n=164) male. The largest demographic group was African American women, n=178 (47.1%). The most common additional risk factors were age (81.7% of men were 45 years or older and 59.4% of women were 55 years and older) and diabetes (43.9%). Hypertension was controlled in 194/378 (51.3%) patients. Significantly greater patients had controlled BP in the < 140/90 mmHg group (61.3%) when compared to those with either diabetes or renal disease (38.6%), p<0.0001. The same number of patients, 194/378 (51.3%), achieved goal LDL-C values. Overall, 106/378 patients (28.0%) in the study cohort had both controlled blood LDL-C levels and controlled BP. When age was evaluated as a continuous variable, there was a significant relationship between age and overall (BP & LDL-C) goal attainment, p=0.032. Patients with diabetes, depression and a family history of premature CHD were less likely to have overall goal attainment.
CONCLUSION: There is suboptimal CHD risk reduction in this urban African American cohort. Aggressive management of both dyslipidemia and hypertension is warranted to lower CHD risk. Future research should develop inexpensive and efficient systems to improve BP and LDL-C goal attainment.
Coronary heart disease (CHD) continues to be the leading cause of morbidity and mortality in the United States (US) (CDC, 2002; Anderson, 2002; AHA, 2007). Several factors increase the risk of CHD, such as hypertension, age (> 45 years for men, >55 years for women), dyslipidemia, diabetes mellitus, estimated glomerular filtration rate < 60 mL/min, family history of premature cardiovascular disease (primary relative’s age < 55 years in men and < 65 years in women), microalbuminuria, obesity, physical inactivity, and smoking (ATP III, 2001; JNC VII, 2004). Cardiovascular risk factors often co-exist. More than 80% of patients with hypertension have one or more concomitant cardiovascular risk factors including glucose intolerance, obesity, and dyslipidemia (Kannel, 2000; Poulter et al, 1999). Two of the most prevalent and asymptomatic risk factors for CHD are hypertension and dyslipidemia and they commonly co-exist. The CHD risk in patients with co-morbid hypertension and dyslipidemia is greater than the sum of CHD risks for hypertension and dyslipidemia when they occur alone (Johnson et al, 2004, Kannel, 2000). The Third National Health and Nutrition Examination Survey (NHANES III) in the US provides an estimated prevalence of concomitant hypertension and dyslipidemia of about 15% adults, which equates to approximately 30 million adults in the US (Battleman et al, 2004).
The National Cholesterol Education Program (NCEP) Adult Treatment Panel 3 (ATP III) guideline recommends aggressive management of patients with concomitant hypertension and dyslipidemia (ATP III, 2001). Meta-analyses and clinical trials have found that antihypertensive and lipid-lowering medications significantly reduce the risk of cardiovascular disease and all-cause mortality in patients with CHD risk factors (LaRosa et al, 1999; Ross et al, 1999; Pignone et al, 2000; Law et al, 2003).
Medication therapy for the treatment of hypertension and dyslipidemia is becoming more complicated as over two-thirds of patients require 2 or more antihypertensive agents and at least 1 lipid lowering agent (JNC VII, 2004; ATP III, 2001, Kennedy et al, 2005).
The objectives of the current study are to describe the (1) demographic and clinical characteristics (2) blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) goal attainment and (3) use of antihypertensive and lipid-lowering therapy in patients with comorbid hypertension and dyslipidemia in a primary care setting.
Methods
Data Source and Patients
This retrospective study used administrative and clinical data from an urban mid-Atlantic primary care medical group. A computerized query identified patients with at least one International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code for hypertension (401.xx) and at least one ICD-CM code for hypercholesterolemia (272.xx) from January 1, 2005 to June 30, 2005. Patients were excluded if they were younger than 18 years on January 1, 2005.
Chart review was conducted during September and October of 2006 so that there would be at least a year of medical data to review following patient identification. The goal was to allow sufficient time for clinicians to achieve goal BP and LDL-C values in newly diagnosed patients. The following information was abstracted from the patients’ medical records: age (as of January 1, 2005), sex, ethnicity, risk factors for CHD (documentation of hypertension, dyslipidemia, diabetes mellitus, tobacco abuse and family history of premature CHD), renal disease, clinical diagnosis of any depression and/or prescription for anti-depressant medication, and BP and lipid profiles (including dates). Values on the most recent dates for non-acute medical visits were used for BP and lipid profiles. The current dosage and duration of any prescribed antihypertensive (Table 1) and lipid lowering medications (Table 2) were recorded. Initiation (i.e., prescribed date) of these agents (current drug and dose) was also obtained (including the first reported date for a patient presenting to the medical group already on therapy.) Patients were excluded if (1) there were no documentation of hypertension or dyslipidemia diagnosis and/or drug therapy for these disease states (Tables 1 and 2), (2) there were no lipid profiles or BP data from June 30, 2005 to present and (3) if there were any changes to their antihypertensive and/or lipid-lowering therapy within the 6 weeks prior to their recorded BP and lipid profile.
Categorization by CHD risk status
Patients were categorized into 3 CHD risk categories (CHD/CHD Risk Equivalents, 2 or more CHD risk factors and 0-1 risk factor) and blood LDL-C values were classified as at goal based on NCEP ATP III (ATP III, 2001). BP was classified as at goal if BP was < 130/80 mmHg for patients with diabetes and/or renal dysfunction and < 140/90 mmHg for the remaining patients (JNC VII, 2004).
Goal attainment
Overall LDL-C and BP goal attainment was compared among patient demographics (e.g., age, ethnicity), clinical parameters [i.e., presence of comorbid CHD, DM and 3 or more additional CV risk factors without presence of CHD (e.g., smoking, HDL < 40 mg/dl, etc)] and use of antihypertensive and lipid-lowering therapy.
Statistics
To obtain 80% power to detect a 10% difference in goal attainment among study variables, a study sample of 350 was required. Statistical analysis included calculations of means and standard deviations for continuous variables. The χ2 statistic was used for univariate analyses of differences in characteristics between groups of at goal and not at goal. Binary logistic regression was used to examine the correlation between study variables and combined goal attainment for BP and LDL-C. Statistical significance was set at a p value of 0.05.
To ensure compliance with the Health Insurance Portability and Accountability Act, all data was de-identified after each patient was assigned a unique identifier. The University of Maryland institutional review board approved the study.
Results
Patient Demographics
The computerized query of medical claims found 389 patients (5.6% of the estimated patient population) with at least one ICD-9-CM code for hypertension (401.xx) and at least one ICD-CM code for hypercholesterolemia (272.xx) from January 1, 2005 to June 30, 2005. All patients identified were greater than 18 years. Medical charts were found for 386 patients. Of the 386 patients whose medical charts were reviewed, 8 were excluded from analysis, resulting in a final cohort of 378 evaluable patients. Reasons for excluding the 8 patients were: 3 patients did not have lipid profile values recorded from July 1, 2005 to present and 5 patients had changes to their antihypertensive and/or lipid-lowering therapy within 6 weeks prior to BP or lipid profile data.
The average age of patients in the cohort was 56.7 +/- 11.8 (range 25-82) years and 43.4% (n=164) were men. More than 75% of the patients were between the ages of 45 and 74 years. There were 8 (2.1%) patients between 18-34 years, 54 (14.3%) patients between 35-44 years, 104 (27.5%) patients between 45-54 years, 92 (24.3%) patients between 55-64 years, 98 (25.9%) patients between 65-74 years and 22 (5.8%) patients 75 years and older. The majority of patients in this urban clinical setting were African American and the largest demographic group was African American women, n=178 (47.1%).
Risk factors for cardiovascular disease were common (Table 3). Nearly all patients had 3 or more risk factors due to the fact that patients had 2 risk factors (i.e., hypertension and dyslipidemia) to be included in the cohort. The most common additional risk factors were age (81.7% of men were 45 years or older and 59.4% of women were 55 years and older) and diabetes (43.9%). All other risk factors had prevalence rates between 20-30% except for family history of premature CHD with a rate of 13.8%. Depression was also examined and was found to have a low prevalence of 6.9%.
Goal Attainment
Hypertension was controlled in 194/378 (51.3%) patients (Table 4). Patients without diabetes or renal disease (n=212) had a BP goal of < 140/90 mmHg. Significantly greater patients had controlled BP in the < 140/90 mmHg group (61.3%) when compared to those with either diabetes or renal disease (38.6%), p<0.0001 (chi-square). The same number of patients, 194/378 (51.3%), achieved goal LDL-C values (Table 5). Note that there were 2 patients with elevated triglyceride levels without measured LDL-C values recorded in the chart, and were therefore considered not at goal for LDL-C. When examining the cohort in terms of CHD risk, only 14.8% of patients were low-risk while the remaining patients (85.2%) were moderate to high risk. The largest number of patients fell into the highest risk category (n=222, 58.7%) with the most aggressive LDL-C goal of <100 mg/dl. The percentage of goal attainment was inversely related to CHD risk. Patients in the highest risk category (i.e., CHD/CHD risk equivalents) were significantly less likely to achieve goal LDL-C values when compared with the 2+ risk category (p=0.031) and the lowest 0-1 risk category p=0.01 (chi-square). Of the patients who did not have CHD, but had 3 or more risk factors 14/378 (3.7%), 10/14 (71.4%) achieved goal LDL-C.
Overall, 106/378 patients (28.0%) in the study cohort had both controlled blood LDL-C levels and controlled BP (Table 6). Patients at high risk for CHD had similar overall goal rates. Patients with CHD, DM and those with 3 or more risk factors without CHD had rates of 28.6%, 21.7% and 28.6% (4/14), respectively.
Table 1. Lipid Lowering Agents
Bile Acid Sequestrants |
Cholestyramine (Cholybar, Questran) Colestipol (Colestid) Colesevelam (Welchol) |
HMG CoA Reductase Inhibitors (Statins) |
Lovastatin (Mevacor) Pravastatin (Pravochol) Simvastatin (Zocor) Fluvastatin (Lescol) Atorvastatin (Lipitor) Rosuvastatin (Crestor) |
Fibric Acid Derivatives |
Gemfibrozil (Lopid) Clofibrate (Atromid-S) Fenofibrate (Tricor) |
Block Absorption of Cholesterol |
Ezetimibe (Zetia) |
Combination Therapy |
Amlodipine/Atorvastatin (Caduet) Ezetimibe/Simvastatin (Vytorin) |
Miscellaneous |
Nicotinic Acid (Niacin) |
Table 2. Oral Antihypertensive Agents
Diuretics |
Midamor (Amiloride Hydrochloride) Corzide (Bendroflumethiazide) Bumex (Bumetanide) Inspra (Eplerenone) Edecrin (Ethacrynic Acid) Lasix (Furosemide) Hydrodiuril (Hydrochlorothiazide) Lozol (Indapamide) Zaroxolyn (Metolazone) Aldactone (Spironolactone) Demadex (Torsemide) |
Calcium Channel Blocker |
Norvasc (Amlodipine) Cardizem or Tiazac (Diltiazem) Plendil (Felodipine) Dynacirc (Isradipine) Cardene (Nicardipine) Procardia or Adalat (Nifedipine) Sular (Nisoldipine) Calan or Covera or Isoptin (Verapamil) |
Angiotensin Converting Enzyme (ACE) Inhibitors |
Lotensin (Benazepril ) Zebeta (Bisoprolol) Capoten (Captopril) Vasotec (Enalapril) Monopril (Fosinopril) Prinivil or Zestril (Lisinopril) Univasc (Moexipril) Aceon (Perindopril) Accupril (Quinapril) Altace (Ramipril) Mavik (Trandolapril) |
Angiotensin II Receptor Antagonist |
Atacand (Candesartan) Teveten (Eprosartan) Avapro (Irbesartan) Mevacor (Losartan) Benicar (Olmesartan) Micardis (Telmisartan) Diovan (Valsartan) |
Alpha-1 Blockers |
Cardura (Doxazosin) Minipress (Prazosin) Hytrin (Terazosin) |
Beta Blockers |
Sectral (Acebutolol) Tenormin (Atenolol) Ziac (Bisoprolol) Coreg (Carvedilol) Trandate (Labetolol) Lopressor (Metoprolol) Corgard (Nadolol) Levatol (Penbutolol) Visken (Pindolol) Inderal (Propranolol) Betapace (Sotalol) |
Combination Therapy |
Caduet (Amlodipine Besylate/Atorvastatin Calcium) Lotrel (Amlodipine/Benazepril) Lexxel (Enalapril/Felodipine) Tarka (Trandolapril/Verapamil) Lotensin HCT (Benazepril/Hydrochlorothiazide) Vaseretic (Enalapril/Hydrochlorothiazide) Monopril HCT (Fosinopril/Hydrochlorothiazide) Uniretic (Moexipril/Hydrochlorothiazide) Accuretic (Quinapril/Hydrochlorothiazide) Capozide (Captopril/Hydrochlorothiazide) Prinzide (Lisinopril/Hydrochlorothiazide) Atacand HCT Candesartan /Hydrochlorothiazide Teveten HCT (Eprosartan/Hydrochlorothiazide) Avalide (Irbesartan/Hydrochlorothiazide) Hyzaar (Losartan /Hydrochlorothiazide) Benicar HCT (Olmesartan /Hydrochlorothiazide) Micardis HCT (Telmisartan/Hydrochlorothiazide) Diovan HCT (Valsartan/Hydrochlorothiazide) Tenoretic (Atenolol/Chlorthalidone) Ziac (Bisoprolol /Hydrochlorothiazide) Lopressor HCT (Metoprolol/Hydrochlorothiazide) Inderide (Propranolol/Hydrochlorothiazide) Timolide (Timolol/Hydrochlorothiazide) Moduretic (Amiloride Hcl/Hydrochlorothiazide) Dyazide or Maxzide (Hydrochlorothiazide/Triamterene) Aldactazide (Spironolactone/Hydrochlorothiazide) Aldoril (Methyldopa/Hydrochlorothiazide) |
Carbonic anhydrase Inhibitor |
Diamox (Acetazolamide) |
Central alpha-2 agonists and other centrally acting agents |
Catapress (Clonidine) Aldomet (Methyldopa) |
Direct Vasodilators |
Apresazide (Hydralazine) Loniten (Minoxidil) |
Table 3. Study Cohort Demographics and Cardiovascular Risk Factors*
Variable |
Cohort (n = 378) |
Age, y |
56.7 ± 11.7 |
Sex Men, n (%) Women, n (%) Unknown, n (%) |
164 (43.4) 212 (56.1) 2 (0.5) |
Ethnicity African American, n (%) Caucasian, n (%) Other/Unknown, n (%) |
314 (83.1) 56 (14.8) 8 (2.1) |
Age > 45 y for men, n (%) Age > 55 y for women, n (%) |
134/164 (81.7) 126/212 (59.4) |
Coronary heart disease, n (%) |
112 (29.6) |
Cigarette smoking, n (%) |
104 (27.5) |
Diabetes, n (%) |
166 (43.9) |
Depression, n (%) |
26 (6.9) |
Family history of premature heart disease, n (%) |
52 (13.8) |
HDL < 40mg/dL |
78 (20.6) |
Negative Risk Factor: HDL > 60mg/dL |
76 (20.1) |
* Values presented with a plus/minus sign are means ± SD.
Table 4. Blood pressure goal attainment
BP goal |
Total (n=378) |
At goal (n=194) |
Not at goal (n=184) |
< 130/80 mmHg (diabetes and renal disease) |
166 (43.9%) |
64 (38.6%) |
102 (61.4%) |
< 140/90 mmHg |
212 (24.5%) |
130 (61.3%) |
82 (38.7%) |
Table 5. LDL-C Goal Attainment
Risk Category |
Total (n=378) |
LDL-C at goal (n=194) |
LDL-C not at goal (n=184) |
CHD/CHD Risk Equivalents* |
222 (58.7%) |
100 (45.0%) |
122 (55.0%) |
2+ Risk Factors |
100 (26.5%) |
58 (58.0%) |
42 (42.0%) |
<1 Risk Factor |
56 (14.8%) |
36 (64.3%) |
20 (35.7%) |
*This category includes patients with coronary heart disease (CHD) and CHD risk equivalents of diabetes, abdominal aortic aneurysm, peripheral arterial disease, symptomatic carotid disease and 10-year CHD risk > 20%
Table 6. Goal attainment by study variables
Variable |
BP & LDL-C at Goal (n = 106) |
LDL-C at Goal (n = 194) |
BP at Goal (n = 194) |
Sex Male, n (%)
Female n (%) |
52/164 (31.7%)
54/212 (25.5%) |
96/164 (58.5%) p=0.041 98/212 (46.2%) |
76/164 (46.3%)
118/212 (55.7%) |
Ethnicity African American, n (%) Caucasian, n (%) Other, n (%) |
88/314 (28.0%) 16/56 (28.6%) 2/8 (25.0%) |
158/314 (50.3%) 30/56 (53.6%) 6/8 (75%) |
160/314 (51.0%) 30/56 (53.6%) 4/8 (50%) |
Age > 45 y for men, n (%)
Age > 55 y for women, n (%) |
48/134 (35.8%) p=0.017 34/126 (27.0%) |
84/134 (62.7%) P=0.023 64/126 (50.8%) |
62/134 (46.3%)
66/126 (52.4%) |
Coronary heart disease, n (%) |
32/112 (28.6%) |
56/112 (50.0%) |
70/112 (62.5%) p=0.005 |
Cigarette smoking, n (%) |
24/104 (23.1%) |
44/104 (42.3%) p=0.031 |
58/104 (55.8%) |
Diabetes, n (%) |
36/166 (21.7%) p=0.015 |
80/166 (48.2%) |
64/166 (38.6%) p=0.0001 |
Depression, n (%) |
2/26 (7.7%) p=0.0001 |
4/26 (15.4%) p=0.0001 |
4/26 (15.4%) p=0.0001 |
Family history of premature heart disease, n (%) |
4/52 (7.7%) p=0.0001 |
10/52 (19.2%) p=0.0001 |
11/52 (21.2%) p=0.0001 |
HDL < 40mg/dL |
26/78 (33.3%) |
52/78 (66.7%) p=0.002 |
38/78 (48.7%) |
Negative Risk Factor: HDL > 60mg/dL |
18/76 (23.7%) |
40/76 (52.6%) |
38/76 (50.0%) |
The relationship between goal attainment and study variables was examined (Table 4). When age was evaluated as a continuous variable, there was a significant relationship between age and overall (BP & LDL-C) goal attainment, p=0.032 (binary logistic regression analysis). Using chi-square analysis, men who were 45 years and older were more likely to have BP at goal compared with their younger counterparts. Patients with diabetes, depression and a family history of premature CHD were less likely to have overall goal attainment.
Patients with CHD were significantly more likely to have their BP at goal. In contrast, patients with diabetes, depression or a family history of premature CHD were significantly less likely to have their BP at goal.
There were a significantly greater number of men with LDL-C at goal compared with women. Men who were 45 years and older were more likely to have achieved goal LDL-C compared with men younger than 45 years. In addition, patients with a low HDL-C were significantly more likely to have controlled LDL-C. Similar to the relationship between study variables and BP at goal, patients with a family history of premature CHD or those who had depression were less likely to have LDL-C controlled. In addition, patients who smoke were less likely to have LDL-C controlled.
There were only 6.3% (n=24) of patients without any prescribed antihypertensive therapy compared with 20.6% (n=78) of patients without prescribed lipid-lowering therapy. The average number of antihypertensives and lipid-lowering agents per patient was 1.7 +/- 1.0 and 0.8 +/- 0.5, respectively. There was no association between antihypertensive and lipid-lowering drug therapy and control of BP and LDL-C, respectively.
Discussion
Our study evaluates an urban African American population with a high CHD risk. There is overall poor goal attainment for BP and LDL-C in this cohort. About 50% of patients achieved goal BP or goal LDL-C, but only 28% achieved both goal BP and LDL-C. The BP results from our study mimic two other retrospective cohort studies which had rates of 49.8% and 59.0% goal BP attainment (Singer et al, 2002; Ornstein et al, 2004). The higher goal attainment of 59% was found in an academic hypertension specialist office (men 49.4%, average age 64 years and 20% co-morbid diabetes) (Singer et al, 2002). The other study with a 49.8% BP goal attainment rate had a population more similar to ours as it was a retrospective chart review of patients with hypertension found in 20 primary practices in 14 states. The average age was 61.9 years with 43% men and 32.6% having co-morbid conditions such as CHD, DM, heart failure and chronic renal insufficiency (Ornstein et al, 2004).
Our LDL-C goal attainment results can be compared to studies with similar endpoints. A recently published study evaluated LDL-C goal attainment in high prescribing physicians of lipid-lowering therapy who agreed to participate in the study. The physicians selected patients and a random sample revealed a 68% goal attainment rate was reported for LDL-C. This study found higher goal attainment compared with our 51.3%, but may have been confounded by patient self-selection from the physician (Stacey et al, 2006). Another retrospective cohort study of 290 patients with CHD reported a 46.2% LDL-C goal attainment rate and also found a similar sex bias in favor of men (Cooke et al, 2006).
This cohort fared better than data from NHANES which estimated that fewer than 10% of patients with comorbid hypertension and dyslipidemia were at both goal BP and LDL-C (Battleman et al, 2004). One of the differences is that our patients were considered to be receiving active care which may have been unlike the population in NHANES. Another study within the VA system evaluated about 10,000 patients with co-morbid hypertension and dyslipidemia. Control of BP and LDL-C among symptomatic and asymptomatic patients with and without diabetes ranged from 13.4% to 24.4% (Johnson et al, 2006).
The patients at highest risk were least likely to achieve goal lipid parameters and BP parameters, except for patients with CHD who were more likely to have BP at goal. This is disappointing as the greatest benefit from management occurs in patients at the greatest CHD risk.
There was at least a year between the claims data and chart review to allow sufficient time to achieve goal parameters in patients diagnosed with hypertension and dyslipidemia. Almost all of the patients were on drug therapy, but it was insufficient. We are unaware of the reason for poor goal attainment, but realize that it may lie with the clinician, the patient or likely, a combination of the two. While the clinician may have prescribed drug therapy, the dose may be too low or therapy may not be aggressive enough. Patients with hypertension often require at least 2 antihypertensives to achieve goal. Our patient cohort averaged 1.7 antihypertensive medications which fall short of the recommended 2 or more drugs to achieve goal BP (JNC-VI, 2004). This may explain why patients with diabetes who have a more aggressive BP goal were less likely to achieve goal BP and thus, overall goal attainment.
Patient adherence may also be of concern. We used documentation in the medical record for prescription use and have no data on prescription claims or adherence. Using the AHA statistics, we can estimate that three out of every four Americans are non-adherent (AHA Medication, 2004). This figure is a result of the fact that 12% never fill their initial prescription, another 12% never take any of the purchased prescription, another 22% take less than what was prescribed and another 29% stop taking the medicine early. A retrospective cohort study of 10,526 members of a US managed care plan found that only 34% of patients were adherent to concomitant antihypertensive and lipid-lowering therapy at 6 months (Chapman et al, 2004). Another 27% to 32% of patients were adherent to either their antihypertensive or lipid-lowering therapy, but not both. In this study, patients were more likely to be adherent to concomitant therapy if they initiated these therapies together and had a low medication burden.
We found patients with depression to be less likely to achieve goal BP and goal LDL-C. Patients with depression have been found to be less adherent to other medications besides their depression treatment. Two studies in patients with diabetes found that those with major depression had lower adherence to oral hypoglycemics, antihypertensives, and lipid-lowering medications (Ciechanowski et al, 2000; Lin et al, 2004).
Limitations
The results of this study should be interpreted with some caution due to limitations. Limitations inherent to retrospective chart review include a dependency on previously recorded data in the chart, whose quality may be limited by systematic or recorder bias and incomplete data. We used mention of antihypertensive and lipid-lowering therapy in the medical record to proxy for utilization and have no data on adherence. Patients may have filled their medication, but we have no data on actual use of the medication.
Conclusion
There is suboptimal CHD risk reduction in this urban African American cohort. Aggressive management of both dyslipidemia and hypertension is warranted to lower CHD risk. Future research should develop inexpensive and efficient systems to improve BP and LDL-C goal attainment.
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Catherine E. Cooke is President, PosiHealth and Clinical Assistant Professor, University of Maryland School of Pharmacy, Baltimore, MD. Teisha A. Robertson is Clinical Program Manager, Express Scripts. (At the time of the research, she was Managed Care Resident at the University of Maryland School of Pharmacy, Baltimore.)
Corresponding author: Catherine E. Cooke, PharmD, BCPS, PAHM, 5106 Bonnie Branch Road, Ellicott City, MD 21043,
Copyright Priory Lodge Education Limited 2007
First Published September 2007
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