Special article
Hypertension guidelines in elderly patients: is anybody listening?

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Abstract

Purpose

Previous guidelines for the management of uncomplicated hypertension in elderly patients have recommended diuretic agents and then beta-blockers. We examined trends in the initial treatment choice for elderly people with hypertension and the effects of a government-sponsored program to publish and disseminate a simplified version of the national guidelines for the treatment of hypertension to all physicians in Ontario, Canada.

Subjects and methods

Linked administrative databases containing information on the more than 1.2 million elderly residents in Ontario were used. Time series analysis was performed to determine prescribing trends from 1993 to 1998 for patients who began antihypertensive medication for the treatment of hypertension and to examine the effects of the simplified guidelines that were distributed in July of 1995.

Results

Diuretic agents were the most commonly prescribed medications, with annual rates from 35% to 38% (P = 0.59) throughout the study. Beta-blocker prescribing rose from 12% to 16% (P <0.01), whereas angiotensin-converting enzyme (ACE) inhibitor prescribing rose from 27% to 32% (P <0.01). Prescriptions for calcium channel blockers dropped significantly, from 23% to 14% (P <0.01). However, the publication and dissemination of the Ontario hypertension guidelines had no statistically significant effects on the proportion of patients who began treatment with a diuretic agent (P = 0.55), beta-blocker, (P = 0.32), ACE inhibitor (P = 0.09), or calcium channel blocker (P = 0.07).

Conclusion

The dissemination of simplified practice guidelines for hypertension did not have notable effects on prescribing patterns in Ontario.

Section snippets

Data sources

The Ontario Drug Benefit database was used to identify all elderly residents in Ontario who were newly placed on antihypertensive medication for the treatment of hypertension. All Ontario residents aged 65 years or older receive universal outpatient drug coverage from a minimally restrictive formulary. Potential contraindications and comorbid conditions in these patients were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes

Results

Of the more than 1.2 million elderly people aged 66 years or older in Ontario from January 1, 1993, to December 31, 1998, a total of 179,189 (>12%) were prescribed an antihypertensive medication for the first time for uncomplicated hypertension (approximately 30,000 patients per year).

Discussion

We had a unique opportunity to examine temporal trends in the initial prescribing patterns for elderly patients with hypertension in Ontario, Canada, before and after an extensive effort by the Ministry of Health to increase the use of low-cost diuretic agents and beta-blockers through province-wide dissemination of simplified, user-friendly guidelines. Although diuretic agents were the most commonly prescribed, we found very little change in the proportion of patients who received these

Acknowledgements

We would like to thank Dr. Andreas Laupacis, Dr. Dave Davis, and Dr. Finlay McAlister for their review of this manuscript, Jang Yun for data programming, and Dr. Malcolm Maclure and Dr. Colin Dormuth for providing us with data from British Columbia.

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    Supported by a grant from the Ontario Program for Optimal Therapeutics, Hamilton, Ontario, Canada. Jack V. Tu, MD, PhD, is supported by a Canada Research Chair in Health Services Research.

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