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Chronic Disease

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Factors such as disease status and sex affect adherence to drug prescribing guidelines for hypertension

Current guidelines recommend the use of diuretics or beta blockers—which are less expensive than other medications—as the first choice antihypertensive agents. Yet a new study found that fewer than 40 percent of patients received a diuretic or beta blocker, even though they had access to health care and prescription drug benefits. Certain clinical and nonclinical factors were associated with adherence to prescribing guidelines for hypertension among 5,789 patients with hypertension of a large New England managed care organization.

Women were 63 percent more likely than men to receive diuretics or beta blockers, which may be accounted for by several factors. Doctors may perceive that men are concerned about the sexual dysfunction that often occurs with these medications. Doctors also may preferentially treat men who have both hypertension and benign prostatic hypertrophy with alpha blockers to treat both conditions. A disproportionately larger number of men than women suffer from heart failure and, therefore, may be treated with angiotensin converting enzyme (ACE) inhibitors. Patient age was not a significant correlate of guideline adherence.

Patients with diabetes were 47 percent less likely than patients without diabetes to receive diuretics or beta blockers. To prevent the kidney complications of diabetes, most people with diabetes and hypertension are treated with an ACE inhibitor or angiotensin receptor blocker, which are now considered initial therapy for patients with both conditions. Compared with HMO coverage, Medicare coverage was associated with 38 percent greater guideline adherence. Fee-for-service coverage was associated with 34 percent less guideline adherence (perhaps because prescribers are less constrained by drug formularies). The study was supported in part by the Agency for Healthcare Research and Quality (HS10391 and HS12019).

See "Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization," by Philip C. Skelding, M.P.H., Sumit R. Majumdar, M.D., M.P.H., Ken Kleinman, Sc.D., and others, in the June 2006 Journal of Clinical Hypertension 8, pp. 414-419.

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