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BP overtreatment common as older adults transition from hospital to home
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Physicians may be overtreating BP in older adults admitted to the hospital for non-CV conditions by intensifying antihypertensive medication at discharge, even if the patients had previously well-controlled outpatient BP, according to a study published in The BMJ.
“Our results show evidence that doctors are treating inpatient blood pressures aggressively, despite there being no evidence to suggest this is beneficial,” Timothy S. Anderson, MD, primary care research fellow in the division of general internal medicine at the University of California, San Francisco, said in a press release. “As there are no guidelines for physicians on how to manage inpatient blood pressures, it appears physicians are applying outpatient blood pressure targets to the inpatient setting. Because hospitalized older adults are particularly vulnerable to medication harms, this may be quite risky.”
To investigate the frequency in which older adults admitted to the hospital for conditions unrelated to CV issues have their antihypertensive treatment intensified, researchers conducted a retrospective cohort study of 14,915 patients aged at least 65 years who had a diagnosis of hypertension and were admitted to a Veterans Affairs hospital between 2011 and 2013 for pneumonia (n = 7,726), urinary tract infection (n = 5,639) or venous thromboembolism (n = 1,550). These conditions were chosen because they are common reasons for hospital admission and aggressive BP management is typically not required to treat them, according to the researchers.
Patients were prescribed a median of one antihypertensive drug on admission.
The primary outcome was whether a patient was prescribed one or more intensified outpatient antihypertensive agents at discharge.
Aggressive regimens
After calculating the median of the three most recent BP readings recorded at outpatient visits before the week directly preceding admission, researchers found that 65% of patients had well-controlled outpatient BP, 32% had high outpatient BP and 2% had very high outpatient BP.
Throughout hospital stay, 19% of patients had moderately elevated inpatient BP, 5% had severely elevated inpatient BP, and although elevated inpatient BP occurred more frequently in patients who had chronically elevated outpatient BP before admission, 47% of those with elevated inpatient BP had normal BP before admission.
At discharge, 14% of patients had their antihypertensive treatment intensified, although approximately half of these patients had well-controlled BP before admission, according to the researchers.
Furthermore, after adjustment for potential confounders, researchers found that 8% (95% CI, 7-9) of patients without elevated inpatient BP, 24% (95% CI, 21-26) of patients with moderately elevated inpatient BP and 40% (95% CI, 34-46) of patients with severely elevated inpatient BP where discharged with intensified hypertensive treatment. Inpatient BP readings served as a greater predictor for intensification than outpatient BP readings.
There were no significant differences in rates of intensification at discharge by life expectancy, diagnosis of dementia or metastatic malignancy. Patients with a history of congestive HF were 2% (95% CI, 0.4-4) more likely to have antihypertensive intensification than those without (P = .01), but there were no differences in the probability of intensification for patients with a history of MI (P = .53), cerebrovascular disease (P = .37) or renal disease (P = .73).
“While the VA patient population is unique, this research is more about physician-prescribing patterns, which are likely to be similar between VA physicians and physicians at other hospitals, as the VA is a major training site for most U.S. medical schools and many residency programs,” Anderson said in the release. “The practices trainees learn at the VA may influence care down the road, regardless of where they end up practicing medicine.”
Matters of concern
In a related editorial, Nathan M. Stall, MD, of the division of geriatric medicine at the University of Toronto, and Chaim M. Bell, MD, PhD, of the division of general internal medicine at Sinai Health System in Toronto, wrote: “Whether or not intensified antihypertensive treatment at hospital discharge results in measurable harm, the study findings highlight two pressing matters of concern to front-line clinicians and researchers: the need for a more judicious approach to the in-hospital management of chronic diseases, especially for older adults; and the need to move beyond more traditional means of medication reconciliation at hospital discharge. ... In the case of intensified antihypertensive treatment during hospital admission, the discharge reconciliation process should include measuring blood pressure before discharge to reassess the need for the intensification, communicating changes in antihypertensive treatment to all outpatient entities responsible for the patient, and ensuring prompt outpatient follow-up with the patient’s primary care provider.” – by Melissa J. Webb
Disclosures: The authors report receiving grant support from the U.S. National Institute of Aging and U.S. Health Resources and Services Administration. Bell and Stall report no relevant financial disclosures.
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