Background: Over three quarters of a million Americans die every year from cardiovascular disease (CVD). Hypertension is a major risk factor for the development of CVD, especially stroke. African American patients have a disproportionate disease burden from stroke.

Objective: This retrospective cohort study utilizing the University Health System Consortium [UHC] Clinical Database seeks to measure the degree to which appropriate pharmacologic therapy is prescribed to hypertension patients while they are inpatients at a US Academic Medical Center.

Methods: 2,694,970 adult admissions to 106 academic medical centers were analyzed to evaluate hypertensive patients and an assessment was made to determine whether appropriate therapy for hypertension was prescribed. Mortality rates were measured and compared between and among the groups.

Results: Of the more than 1.2 million cases with hypertension reviewed, 63.9% were prescribed appropriate pharmacologic therapy for hypertension while inpatients at a US academic medical center. Patients prescribed appropriate pharmacologic hypertension therapy had a statistically significant improvement in their inpatient mortality rates.

Conclusions: This study concludes that most patients discharged from an academic medical center were prescribed appropriate hypertension pharmacologic therapy. Inpatient mortality rates are improved when hypertensive patients are prescribed appropriate therapy for hypertension during their hospital stay. The group studied was confined to their inpatient stay at an academic medical center. Blood pressure control was not a focus of this study. Outpatient adherence to therapy was not evaluated. More research is needed to elucidate the multifactorial issues that may be behind the increased incidence of stroke in African Americans. 

Barba V (2014) Pharmacologic Prescribing Practices for Inpatients with Hypertension at US Academic Medical Centers. J Family Med Community Health 1(1): 1003.

The cardiovascular disease burden on the US is immense. Major cardiovascular disease is the leading cause of death in the US [1]. Annually more than 770,000 Americans die from cardiovascular diseases, including heart disease and stroke, with costs of 312 billion dollars per year [1].

Heart disease alone costs Americans 195 billion dollars annually [1]. There are over 5 million cases of heart failure reported in the US today [1]. Myocardial infarction or fatal events from coronary heart disease affect 915,000 Americans per year [1]. Stroke is responsible for 1 in 19 deaths in the US and 130,000 Americans die of stroke every year. Approximately 795,000 Americans have a stroke per year for a cost of about $39 billion [2].

Hypertension is a major cause of cardiovascular morbidity and mortality. Hypertension is the leading risk factor in stroke development [2]. Overall, 67 million adult Americans are living with hypertension while less than half have their disease under control [1].

Blood pressure control has been increasing over the last 20 years yet African American patients seem to lag behind white Americans [1]. Approximately 40% of African Americans have their hypertension under control as compared to 50% of white Americans [1]. Income does not seem to influence control rates in the manner this problem is studied by the CDC [1].

African Americans have a higher prevalence of stroke than other groups, with the exception of Native Americans and Alaskan natives. While stroke incidence appears to be declining in white Americans, African Americans have not experienced a similar decline and the disparities continue [3]. The risk of an African American having a stroke is twice that of a white American. African American stroke patients are more likely to die from their stroke [2].

Is the etiology of the increased stroke morbidity and mortality in African Americans one of disparities in care? Are there modifiable risk factors and quality of care issues that can be addressed in order to reduce the stroke incidence and burden on this population? Perhaps pharmacologic management of hypertension is not racially equitable?

The most authoritative guideline to date is the “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure,” better known as JNC 7, which was published in 2003 by the US National Institutes of Health. The authors conclude that diuretic therapy ought to be the cornerstone of hypertension treatment. They write, “In trials comparing diuretics with other classes of antihypertensive agents, diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension” [4].

Recently JNC 8 was released. The recommendations regarding drug therapy are not substantively different from JNC 7. The JNC 7 authors state, “The prevalence, severity, and impact of hypertension are increased in African Americans, who also demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic” [5]. JNC 7 recommends the thiazides as primary therapy with the possible addition of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers or beta blockers [5].

A Cochrane systematic review published in 2007 recommended against beta blocker therapy for primary hypertension therapy [6]. The authors reviewed 13 randomized controlled beta blocker trials and concluded that there was no improvement in all-cause mortality when beta blockers were compared to placebo [6]. They also noted the lack of evidence that beta blockers prevented stroke or coronary heart disease [6]. Beta blocker therapy tended to portend worse outcomes when compared to treatment with diuretics, calcium channel blockers, and renin angiotensin system inhibition [6]. Based on the strength of this recommendation, this study does not include beta blockers as appropriate care for hypertension [6].

Controlling hypertension appears to be the best strategy to prevent cardiovascular disease, especially in African Americans with the known excess burden of stroke [1]. The evidence appears to recommend using a thiazide type diuretic, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, or a calcium channel blocker alone or in combination to achieve blood pressure control [4-6]. This study seeks to ascertain what percentage of hypertensive patients discharged from US academic medical centers was on recommended therapy for hypertension during their stay.

The University Health System Consortium’s Clinical Database/ Resource Manager v. 1.5.0.10 [UHC CDB/CRM] employing the 2012 University Health System Consortium [UHC] risk model was used to analyze information related to patients discharged in calendar year 2012 from 106 US academic medical centers that are part of the Clinical Resource Manager program. This database draws information from the hospitals’ Uniform Billing 04 form. UHC analyzes the data and assigns “Medicare severity diagnosisrelated groups (MS-DRGs), all patient refined DRG, severity of illness and risk of mortality, potentially avoidable complications and identification of Agency for Healthcare Research and Quality comorbidities, Patient Safety Indicators, Inpatient Quality Indicators, and Pediatric Quality Indicators” [7].

The database was queried for adult inpatients [18-100 years old] discharged in calendar year 2012 with any diagnosis of hypertension that was prescribed an appropriate pharmacologic therapy for the treatment of hypertension. Bad data as defined by UHC to mean records with key data elements missing or invalid was excluded [7]. Hospice patients were also excluded. Early deaths and length of stay outliers were included. Outcomes as contained in the database were reported as analyzed by the UHC database and probabilities were reported. The z ratio test was used to determine the statistical difference between ratios regarding medication usage and mortality rates among categories of cases. Probabilities were reported. Hypertension is defined in Table 1.

Table 1: Hypertension defined by International Classification of Diseases 9.

Cardiovascular disease for medical management is defined in Table 2.

Table 2: Cardiovascular disease for medical management defined by MS-DRG codes.

Appropriate hypertension pharmacologic therapy is defined in Table 3.

Table 3: Appropriate hypertension pharmacologic therapy (one or more of the following).

The cohorts analyzed included: all adult inpatients, adults with hypertension, adults with hypertension admitted for medical management of cardiovascular diseases, white adults, white adults with hypertension, black adults and black adults with hypertension.

The US Office for Human Research Protections does not regard this type of study as research involving human subjects. 45 CFR part 46 does not apply to this research since it does not contain individually identifiable information and does not involve intervention or interaction with individuals. [http://www.hhs. gov/ohrp/policy/checklists/decisioncharts.html#c2].

In calendar year 2012 2,694,970 adult admissions were reviewed from 106 academic medical centers. Table 4 shows the results of the several cohorts analyzed including all adults, adults with hypertension, adults with hypertension admitted for medical management of cardiovascular diseases, white adults, white adults with hypertension, black adults and black adults with hypertension.

Table 4: Cases Included in Study.

*Denotes statistically worse than the UHC expected value at p<0.01
**Denotes statistically better than the UHC expected value at p<0.01

1,325,972 of those adult admissions were for patients with any hypertension diagnosis. The inpatient mortality rate for this group was 2.84% which was 15% better than expected using the UHC expected inpatient mortality rate. These results were statistically significant at the p<0.01 level. These 1.325 million cases were admitted to the hospital for a variety of reasons as listed in Table 5.

Table 5: Most Common Admitting Diagnoses.

There were 1,251,605 cases available in the database for medication utilization analysis. Appropriate hypertension therapy was prescribed for 800,134 cases (63.9%). Table 6 demonstrates the results of the cases receiving appropriate hypertension pharmacologic therapy.

Table 6: Cases Receiving Appropriate care.

The inpatient mortality rate was 2.01% which was 31% better than expected. This was statistically significant at p<0.01. Of these patients with hypertension, 220,845 were admitted to the hospital specifically for medical management of a cardiovascular disease. The inpatient mortality rate was 3.43%, 15% better than expected. This result was statistically significant at the p<0.01 level.

There were 206,892 of these cardiovascular admissions with hypertension were available for analysis with reference to medication utilization. Table 6 lists 151,089 (73%) that were treated with appropriate hypertension therapy. The inpatient mortality rate was 2.17% which was 35% better than expected which was statistically significant at p<0.01.

White patients as identified in the UHC CDB/CRM totaled 1,746,639 admissions. The inpatient mortality rate was 2.38% which was 13% better than expected which was statistically significant at the p<0.01 level.

There were 853,222 white adult admissions with any diagnosis of hypertension in CY 2012. Their inpatient mortality rate was 2.94% which was 14% better than expected. This difference was statistically significant at p<0.01. 819,987 cases of white patients with hypertension were available for medication utilization review in the UHC CDB/CRM. In Table 6, 506,808 cases (61.8%) were found to have been prescribed appropriate hypertension therapy. The inpatient mortality rate was 2.13% which was 30% better than expected. This was statistically significant at the p<0.01 level. Table 7 reveals the results of further analysis of the white patients on appropriate hypertension pharmacologic therapy by drug class.

There were 524,476 discharged inpatients in the database that were identified demographically as black for the defined calendar year. The term “black” is understood to mean African American. These patients had a 2% inpatient mortality rate, which was statistically better than expected at the p<0.01 level compared to the UHC expected mortality rate. 300,851 hypertension cases were identified as black in the database. The inpatient mortality rate for this group was 2.36% which was 20% better than expected and statistically significant at the p<0.01 level.

Out of the black hypertensive population there were 273,449 cases for which medication utilization data was available for analysis. Table 6 demonstrates that appropriate hypertension therapy was recorded for 191,436 cases (70%). The inpatient mortality rate was 1.56% which was 38% better than expected. This was significant at the p<0.01 level. Table 7

Table 7: Class of Medication Prescribed.

reveals the results of further analysis of the black patients on appropriate hypertension pharmacologic therapy by drug class. Table 6 reveals the results of comparisons that were made relative to the mortality rates of the groups. The mortality rate of the category of cases was compared to the mortality rate of the patients on appropriate therapy. All groups demonstrated a statistically significant improvement in mortality when prescribed appropriate therapy. Table 7 reveals the results of comparisons made regarding the medications prescribed to the white versus black patients. The black patients received medication more frequently than the white patients for all types of medication. This difference was statistically significant in all cases.

This retrospective cohort study concludes that 63.9% of inpatients with hypertension received appropriate hypertension pharmacologic care while inpatients at a US academic medical center included in the UHC database. Furthermore, the hypertensive cases admitted to the hospital had a 16% improvement in observed to expected inpatient mortality if they were on appropriate hypertension therapy which was statistically significant across all groups. The hypertension patients admitted to the hospital for medical management of cardiovascular disease had a 20% improvement in observed to expected inpatient mortality if they were on appropriate pharmacologic hypertension therapy.

Previously published studies have found that African Americans lag behind whites in BP control [1]. The outcome of this failure to control hypertension is that stroke prevalence has not decreased over time in the African American population as it has in the white population [3]. This study published here demonstrates that African American inpatients are receiving appropriate pharmacologic hypertension care in 70% of the cases analyzed compared with 61.8% of the white inpatients.

In this study white inpatients’ observed to expected inpatient mortality rates were 16% better if they were prescribed appropriate hypertension therapy while black inpatients’ observed to expected mortality rates were 18% better on appropriate hypertension therapy.

The fact remains, however, that more than 36% of all cases analyzed in this report did not receive what is commonly thought to be appropriate pharmacologic therapy for hypertension while in the inpatient setting. Failure to deliver recommended care is not a new problem. In a 2003 study, researchers reported that patients received recommended care only 55% of the time [8]. They found that hypertension was undertreated, concluding that pharmacological therapy for uncontrolled mild hypertension was underused and therapy was not adapted for uncontrolled patients [8].

Another group of researchers demonstrated in 2006 that, in general, appropriate medications were used in only approximately 63% of cases reviewed [9]. These same researchers found that inappropriate medications were used in approximately 16% of cases reviewed [9].

Only 16.5% of white patients and 21.4% of black patients in this study were treated with a thiazide type diuretic. This is surprising since thiazides are highly recommended by JNC 7 [4]. There is a preponderance of evidence for their use as concluded by the authors of a Cochrane Review published in 2009. The authors reported that low dose thiazides reduced all morbidity and mortality outcomes related to hypertension while the evidence for angiotensin converting enzyme inhibitors and calcium channel blockers was “less robust.” They recommended that low dose thiazide diuretics should be the first choice for hypertensive therapy [10]. Receiving appropriate care while hospitalized is only one part of the equation aimed at controlling complications due to hypertension. A recent report based on NHANES data from 2003-2010 revealed that African American patients with hypertension were less likely to have their disease under control and were more likely to have advanced disease. Only 62% of the treated African American patients evaluated in NHANES had their disease under control while 75% of treated white patients achieved control. Interestingly, awareness and treatment is highest among African Americans studied in NHANES compared with other racial and ethnic groups [11].

In this study a statistically significant higher proportion of African American patients were found to be prescribed all classes of appropriate therapy when compared to white hypertensives.

While blood pressure control was not the focus of this study, appropriate medication use was found to be more prevalent in the black hypertensive’s than in the white inpatients studied. The solution to the dilemma of stroke disparity may have to do with other factors in addition to appropriate inpatient hypertension therapy in African Americans. Such issues as targeted blood pressure control, sodium intake, diabetes mellitus diagnosis and appropriate goal directed therapy, smoking cessation and hyperlipidemia diagnosis and therapy are major issues that must be studied. Outpatient adherence to pharmacologic and non-pharmacologic therapy plans is of major importance and must be studied for hypertension patients.

The limitations of a study such as this revolve around the use of an inpatient database culled from uniform billing data that is then risk adjusted. There are confounding issues that may preclude the use of these appropriate hypertension medications that have to do with the patient’s clinical presentation and disease state. For example a patient may present with electrolyte disorders that may preclude the continuation of diuretics while hospitalized. Those medications may be restarted when the patient is discharged and that information would not be captured in this report. Or perhaps the patient is allergic to a certain class of medications or has had an adverse reaction in the past. Studies such as this allow us to review large volumes of data to look for trends that may help us in planning future controlled trials to help unravel the problems we confront clinically.

Arguments can be made for and against the use of ACE inhibitors, ARBs, diuretics or calcium channel blockers, or any specific therapy for that matter, in the treatment of a particular patient. That being said, however, a drug class such as the thiazides, which has been highly recommended for many years, would be expected to be used in the majority of hypertension patients as a crucial building block for hypertension therapy. This was not found to be true in this study. More research is needed to uncover the barriers to appropriate care practices in hypertension. Appropriate hypertension care practices in the outpatient arena are also in need of study.

Inpatient mortality rates are improved when hypertensive patients are prescribed appropriate therapy for hypertension during their hospital stay. Only about 64% of inpatients at academic medical centers were prescribed appropriate pharmacologic hypertension therapy in calendar year 2012.

Hypertension therapy should include evidence based appropriate care and targeted pharmacologic therapy when needed to control blood pressure appropriately in order to prevent stroke and other major cardiovascular disease.

More research is needed to discover the barriers to appropriate hypertension care and further elucidate the multifactorial issues that may be behind the increased incidence of stroke in African Americans.

The author wishes to thank Dr. Mary Ann Sakmyster for her invaluable advice in reviewing this manuscript.

Note: The information contained in this article was based in part on the Clinical Database/Resource Manager (CDB/RM) maintained by the University HealthSystem Consortium (UHC).

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