Prior research has shown poor adherence to hypertension guidelines in the outpatient setting. Our study is the first to show low rates of adherence to JNC VII guidelines among nursing home patients. Adherence, defined as the use of a thiazide diuretic, was poor in all hypertensive patients, hypertensive patients without a compelling indication for another class of medications, and in a subset of the latter group even after excluding patients with other factors that might make a diuretic relatively contraindicated, such as incontinence and hospice care.
This study examined adherence to the thiazide recommendation among all nursing home residents with hypertension. As expected, the population was elderly and mostly female, with a slightly higher percent of blacks than the general population. There was no difference in age between those on a thiazide and those not treated with a thiazide. However, a greater percentage of patients on a thiazide were female and black. The increased percentage of blacks on a thiazide may be explained by the known benefits of thiazides in blacks.1,3
The increased percentage of females on thiazides is puzzling given the higher risk of hyponatremia among women on thiazides.1
Thiazide use was associated with an increasing number of overall medications, an association likely related to trends in polypharmacy. That is, patients on more medications are more likely to be on a thiazide. Finally, patients at for-profit nursing homes were more likely to receive thiazides, perhaps due to more aggressive cost reduction efforts at these facilities.
Our study has a number of strengths. First, the data come from a large nationally representative survey of nursing home patients. Therefore, the results are robust and likely to represent actual care received by nursing home patients in the US. Second, we accounted for patient comorbidities, which may affect recommended antihypertensive regimens.15,16
Finally, we clearly defined adherence as use of a thiazide diuretic.
There are a few limitations that must be recognized prior to interpreting our findings. First, blood pressures were not available, making it impossible to assess the percent of patients achieving guideline-recommended blood pressures. Second, our definition of adherence was based on medication use and comorbidities and did not account for other aspects of hypertension guideline adherence such as the initial diagnostic workup, follow-up care, and laboratory monitoring (e.g., lipid panel, creatinine, electrolytes).15
Another limitation is the cross-sectional nature of the data—the data lack information on prescription history and response to current treatment. Finally, we did not have access to information regarding allergies and adverse reactions to recommended medications.
It should also be noted that many of the nursing home patients in the survey had likely been treated for hypertension for many years. Therefore, the medications they were taking at the time of the survey may reflect continuation of medications prescribed under previous JNC recommendations, which included diuretics and beta blockers as first-line therapy.17
However, data collection for the 2004 NNHS occurred more than 1 year after publication of the JNC VII guidelines. Finally, while we observed adherence to guidelines within the nursing home population, the low rate of adherence might be reflective of adherence in elderly patients with hypertension who are not in a nursing home.
Despite guidelines being well published and easily available, adherence to guidelines is poor, with clinicians often overestimating their own adherence.18,19
Poor adherence to hypertension guidelines is likely multifactorial, including patient, system, and physician factors. Patient factors that contribute to poor adherence may include contraindications or allergies to recommended medications, prior non-response, and preferences for alternative approaches to treatment. Systems issues could include lack of availability or increased costs associated with recommended medications, albeit unlikely in the case of thiazide diuretics. Among nursing home patients, poor adherence could be related to the transition of care from the primary care physician to the nursing home physician and the resultant lack of continuity.
Physician factors leading to poor adherence may include simple lack of awareness of guidelines, disagreement with guidelines, and clinical inertia.20
Physicians caring for the elderly may disagree with JNC VII recommendations and may be hesitant to treat hypertension because most are based on trials in younger populations. However, recent guidelines specific to the vulnerable elderly recommend treatment of hypertension, albeit without suggestion of a first-line agent in patients without comorbidities.21
Also, recent evidence suggests that treatment with a thiazide-like diuretic in subjects over 80 years of age reduces all-cause mortality.14
Improving adherence to hypertension guidelines may decrease morbidity and mortality, and reduce costs. A recent study in patients over 80 years of age showed a reduction in all-cause mortality with a thiazide-like diuretic as compared to placebo.14
With regard to cost, while the majority of patients with hypertension live in the community, more than 15 percent of patients with hypertension older than 85 years reside in nursing homes.22
Thiazides cost less than 20 cents per day, while more expensive ACE-I, beta blockers, and calcium channel blockers often cost well over 1 dollar per day. Given the clinical benefits of thiazides and the prevalence of hypertension, this difference represents a significant potential cost savings.
Methods to improve adherence to guidelines have been evaluated. Simon et al. performed a cluster-randomized controlled trial of a method borrowed from the pharmaceutical industry—academic detailing.23
At 1 year, practices randomized to group detailing increased rates of recommended antihypertensive medications by 13.2% compared to a 12.5% increase in practices randomized to individual detailing with only a 6.2% increase observed in the usual care practices.23
Other methods shown to improve guideline adherence range from national guideline development and dissemination programs to patient-specific advisories to physicians.24–26
Hypertension is a leading cause of morbidity and mortality, especially among the elderly. Guidelines have been developed for the diagnosis and treatment of hypertension. Despite the availability of these guidelines, numerous studies have shown that patients receive suboptimal care in the outpatient setting. We are the first to report poor adherence among nursing home patients, a group of patients that, despite their advanced age, is likely to benefit from appropriate treatment of hypertension.14
The poor adherence to JNC VII guidelines within this cohort may reflect the use of more expensive antihypertensive medications in non-nursing home patients of similar demographics.