Inpatient hypertension rates are high
MedWire News: Hypertension is common among patients in hospital, and the rate of appropriate diagnoses at discharge of these patients is poor, show the results of a systematic review.
"Multiple lines of evidence suggest that failure to appropriately manage hypertension observed in the inpatient setting can impact subsequent medication use and disease outcomes for high-risk patients," say R Neal Axon (The Medical University of South Carolina, Charleston, USA) and colleagues.
The group explains that approximately 30% of patients with hypertension are unaware of their condition, and a large proportion of known hypertension patients in the USA (overall control rates=44%) remain untreated.
Recognition, treatment, and control of hypertension could be improved by focusing on hospitalized patients, says the research team, who investigated rates of hypertension in the inpatient setting using randomized controlled trials, meta-analyses, and observational studies published since 1976.
In all, nine studies met inclusion criteria, either reporting estimates of the prevalence of hypertension or specifying hypertension diagnoses or treatment as a primary focus.
Overall, hypertension rates ranged between 50.5% and 72.0%, with estimates varying according to definition, diagnostic tools and measurement techniques, and patient populations.
In the two studies that used 24-hour blood pressure (BP) monitoring to estimate prevalence, hypertension rates ranged from 56.4% to 72.6%. A total of 28.0% to 38.0% of these hypertensive patients were undetected by routine methods, suggesting that "routine BP measurements may underestimate the prevalence of hypertension," write Axon et al in the Journal of Hospital Medicine.
The one study that recorded BP at hospital admission as well as discharge showed that just 23.2% of the cohort who had uncontrolled BP at admission (≥140/90 mmHg) left hospital with a controlled BP (<140/90 mmHg).
In four further studies, the proportion of patients with elevated BP and/or a history of hypertension who did not receive an appropriate diagnosis on discharge ranged between 8.8% and 44.0%. One of the studies showed that surgical patients were significantly more likely than medical patients to be discharged without an appropriate hypertension diagnosis.
From the three studies that reported patients receiving appropriate treatment, younger age, fewer drugs at admission, a lower comorbidity index, a diagnosis of congestive heart failure, a lengthy hospital stay, and increasing BP (diastolic and systolic) levels were associated with aggressive prescribing practices.
One study showed that patients with documented inpatient hypertension but no recorded diagnosis at admission were four times more likely to be untreated for their hypertension at 6-18 months postdischarge, compared with patients who left hospital with an appropriate diagnosis (and treatment).
Importantly, note Axon and colleagues, the data collected suggest that the medical literature is lacking, with only nine studies identified that comment on hypertension prevalence and care in adult inpatients.
"Clearer diagnostic and therapeutic guidelines for the detection and treatment of inpatient hypertension could contribute to further improvements in control rates of all hypertensive patients, especially if coupled with improved care transitions between the inpatient and outpatient setting," the team concludes.
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By Sarah Guy