Adherence To JNC Vii Guidelines For Hypertension PDF

To The Graduate School:
The members of the Committee approve the thesis o f Linda Edman Johnson
presented on April 30, 2004.
Mary Burman, Chairperson
r i^ 777.
Ann Marie Hart
Linda Martin
A PPK ÊD
y^ Pamela N. Clarke, Dean, Fay W. Whitney School o f Nursing
P.:a
Don Roth, Dean, The Graduate School
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Johnson, Linda Edman, Adherence to JNC VII Guidelines for Hypertension Management
at a Free Clinic. M.S., Fay W. Whitney School o f Nursing, May,
2004.
The overall objeetive o f this study is to improve the care o f hypertensive clients at
the Laramie Downtown Clinic in Laramie, Wyoming by evaluating how client eare
conforms to the guidelines for hypertensive care as set forth by the Joint National
Commission on Prevention, Detection, Evaluation, and Treatment o f High Blood
Pressure (JNC VII).
This study is a retrospeetive chart review o f 35 hypertensive clients at the
Laramie Downtown Clinic in Laramie, Wyoming. Participants were chose using a
convenience sample o f the hypertensive clients treated at the clinic. There were two
seleetion criteria: candidates must have been identified by a health care provider as being
hypertensive, and candidates must have been clients o f the Downtown Clinic for at least
6 months. The author translated the JNC YII guidelines into a checklist. This checklist
was used to evaluate conformity o f the Downtown Clinic staff to these guidelines.
The Downtown Clinie was able to achieve blood pressure control rates o f 54%,
significantly higher than the national average. Nonetheless, improved compliance to the
JNC VII guidelines as well as a patient education program could improve control rates
even further.
ADHERENCE TO JNC VII GUIDELINES FOR HYPERTENSION

MANAGEMENT AT A FREE CLINIC
by
Linda Edman Johnson
A thesis submitted to the Fay W. Whitney School o f Nursing

and The Graduate School o f The University o f Wyoming
in partial fulfillment o f the requirements
for the degree o f
MASTER OF SCIENCE
in
NURSING
Laramie, Wyoming
May, 2004
UMI Number: EP22834
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Acknowledgements
I would like to acknowledge my committee for their support and guidance.
Particularly, I thank my chair, Dr. Mary Burman, for her infinite patience, wisdom, and
endless editing. I thank Debbie Shoefelt for her work formatting and typing my thesis. I
thank my mother, Charlotte OMeara Edman, R.N., who was my first professional role
model. I thank my sister, Charlotte, for her encouragement. Finally, I thank the patients
at the Laramie Downtown Clinic for all they have taught me.
I dedicate this thesis to my husband, Paul, to my sons Paul, Joseph, Patrick, and
Zachary, and to my daughter-in-law, Amanda.
11
Table o f Contents
Chapter
Page
I.
INTRODUCTION..............................................................................................................1
II.
BACKGROUND AND SIGNIFICANCE OF RESEARCH.......................................5

Impact o f Chronic Illness....................................................................................5
Special Concerns o f the Un-insured.............................................
8
Evidence-based Health Care............................................................................ 10
Hypertension Control and Treatment............................................................. 13
Barriers to Hypertension Control.................................................................... 17
Access to Health Care....................................................................................... 18
Guideline Familiarity and Practice Patterns.................................................. 19
Summary o f Recent Research......................................................................... 23
III.
METHODS......................................................................................................................25
Description o f the Population and Sampling Procedure.............................. 25
Survey Instrument.............................................................................................26
RehabilityAâlidity o f Instrument...................................................................27
Effect o f Sample Size on Results....................................................................28
Description o f Data Analysis.......................................................................... 29
Ethical Considerations......................................................................................29
Limitations o f this Study................................................................................. 30
IV.
RESULTS........................................................................................................................ 31
V.
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS........................... 38

Patient-Centered Barriers................................................................................. 41
Provider-Centered Barriers..............................................................................42
Implications for Clinical Practice....................................................................44
Implications for Further Research...................................................................45
REFERENCES...............................................................................................................47
APPENDICES................................................................................................................ 52
111
List o f Tables
Page
Table 1.
Probability o f Missing an Inconsistency in the Protocol vs.

Sample Size.......................................................................................... 29
Table 2.
Demographic Characteristics o f Patient Sample............................................31
Table 3.
Blood Pressure and Weight Characteristics o f Patient Sample.................... 32
Table 4.
Frequencies and Percentages o f Co-Morbidities (N = 3 5 )...........................33
Table 5.
Data Summary from Instrument: Lab Tests Documented (N = 35)............ 34
Table 6.
Prescribed Drug Therapy (N = 35).................................................................. 35
Table 7.
Appropriateness o f Drug Therapy................................................................... 36
Table 8.
Time Elapsed from Initial Visit for Follow-up Visits for Stage I and
Stage II Hypertensives........................................................................ 37
Table 9.
Control Rate o f Hypertensive Patients at DTC with Drug Therapy............ 37
IV
Chapter I
Introduction
In the United States, heart disease and stroke are the first and third leading causes
o f death (Benkert, Buchholz, & Poole, 2001). These conditions have a large social and
financial impact with $259 billion in direct and indirect annual costs (Benkert et a l,
2001). Hypertension is a chronic disease with large fiscal and personal cost. Although
substantial gains have been made over the last few decades in detecting, controlling, and
preventing high blood pressure, Americans continue to be at risk for hypertension. Fifty
milhon adults in the U.S. are hypertensive (Benkert et al., 2001). The authors o f the
Framingham Heart Study state that middle-aged patients face a 90% risk o f experiencing
hypertension in their hfetime. Epidemiological data suggest that by lowering the average
systolic pressure o f Americans by 5 mm o f mercury, the death rate from stroke would be
decreased by 14% and the death rate from heart disease by 9%, with an overall decrease
in mortality o f 7% (Joint National Committee on Prevention Detection, Evaluation, and
Treatment o f High Blood Pressure [JNC], 1997).
The National High Blood Pressure Education Program was established in 1972
with the mission o f detecting, controlling, and preventing high blood pressure. From
1976 to 1991, they were successful in their mission. During this time period, the
percentage o f hypertensives aware o f their diagnoses increased from 51% to 73%.
Treatment rates increased from 31% to 55% and death rates from stroke and coronary
2
heart decreased by 60% and 53% respectively. However, since 1993 these improvements
have slowed: stroke rates have risen, heart failure and end stage renal disease have
increased, and hypertension control rates have not continued to improve. The prevention
and treatment o f hypertension remains a major public health challenge (National
Institutes o f Health [NIH], 2003).
Failure o f the current health care system to deal with hypertension has led both
providers and patients to call for a more accountable system o f treatment. To this end, an
emphasis has been placed on evidence-based practice. Evidence-based practice consists
o f practice patterns that are research- based. In other words, they are patterns that have
been shown to contribute to a particular, positive outcome. A part o f evidence-based
practice is the clinical guideline (Shiffman et al., 2003). A guideline is a research-based
template for care o f a particular disease or condition. However, their format helps bridge
the gap between research and clinical practice. The goal o f guidelines is to reduce
inappropriate care and increase positive outcomes.
The Joint National Commission on Prevention, Detection, Evaluation, and
Treatment o f High Blood Pressure (JNC) has formulated guidelines for the treatment o f
hypertension. The efficacy o f guideline use in treating hypertension was demonstrated
by The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT) study. This study demonstrated that by using an evidence-based guideline
directive method, detection and treatment o f hypertension could be greatly improved
(Cushman et al., 2002). Yet, 41% o f American physicians have httle knowledge o f the
JNC guidelines for hypertension treatment (Hyman & Pavlik, 2000). This, and similar
3
studies, point to the need for increased familiarity and implementation o f the JNC
guidelines.
Diagnosis and treatment o f hypertension is difficult in the general population.
However when the barriers o f poverty, lack o f insurance, and lack o f healthcare access
are present, the challenge is even greater. Uninsured patients are more likely to receive
substandard care (McCarthy, 2003). They are also less likely to receive routine checkups
and screenings (Carasquillo, Himmelstein, Woolhandler, & Bor, 1999). Adjusted
mortality rates are higher for uninsured individuals (Ayanian, Zaslavsky, Weissman,
Schneider, & Ginsberg, 2003). In a recent study in Wyoming, the realities o f lack o f
insurance were studied (Burman, Mawhorter, & VandenHeede, 2003). In a state where
14% o f the population is uninsured, the problems encountered by both patient and
provider were explored. Providers reported feeling constrained by finances in the care
they could provide to the uninsured. Care o f the poor, uninsured client is made more
difficult for all o f these reasons.
The overall objective o f this study is to improve the care o f hypertensive clients at
the Laramie Downtown Clinic in Laramie, Wyoming. The specific purpose o f this
research is to assess the treatment o f hypertensive patients at the Downtown Clinic,
specifically measuring how well practitioners follow JNC VII guidelines. This clinic
provides free medical, psychological, and pharmacological treatment to the non-insured.
It is the desire o f the Downtown Clinic to provide the best possible care to each chent.
However, a hypothesis could be made that hypertension control rates would be lower
than average at the clinic due to the fact that the care is free and there are multiple
providers for each client. The Seventh Report o f the Joint National Committee on
4
Prevention, Detection, Evaluation, and Treatment o f High Blood Pressure describes the
protocol, which defines appropriate care o f hypertensive clients (NIH, 2003). (The
author refers to this document as the JNC VII.) This study identifies areas in which the
care o f the hypertensive chent can be improved, as weU as documents areas in which the
protocols are being followed. This research is being undertaken at the invitation o f the
Downtown Clinic.
Chapter II
Background and Significance o f Research
In this chapter, the researcher will place the current study within the context o f
recent, relevant hterature. First, the broad category o f chronic illness (which includes
hypertension) is discussed. The use o f guidelines as a framework for treatment o f
chronic illness is then presented. Fiually, a discussion o f the chronic illness hypertension
wUl be discussed. Effective treatment o f hypertension, using guidelines as a protocol for
care, is presented.
Impact o f Chronic Illness
Chronic illness causes a decreased quaUty o f hfe for many people. It is estimated
that one out o f every ten Americans has a chronic illness (Norris, Glasgow, Engelgau,
OConnor, & McCuUoch, 2003). The more prevalent chronic diseases include stroke,
mental illness, asthma, diabetes, and cardiovascular disease. Chronic disease accounts
for 70% o f the annual deaths in the U.S. and has an estimated annual cost o f 1 trillion
dollars, roughly 70% o f national health care expenditures (Norris et al., 2003). The cost
o f chronic Ulness can be divided into three categories: direct cost, indirect cost, and
intangible cost. Direct cost includes hospital stays, treatment costs, and provider visits.
Indirect cost is reflected in loss o f individual productivity, for both patient and caregiver.
The term intangible costs describes issues regarding quahty o f life, for both patient and
caregiver (Woo & Cockram, 2000).
6
Chronic illness is not only an American problem; the World Health Organization
states that at least 50% o f the deaths in developing countries and 80% o f deaths in
industrialized countries are caused by chronic illness (non-communicable disease).
Chronic disease accounts for half the global burden o f disease. This reflects a 10%
increase from 1990 (World Health Organization [WHO], 2003). In fact, chronic
conditions are predicted to become the main cause o f death by 2020 and will represent
two-thirds o f the worlds health care cost (Bengoa, Kawar, & Sabate, 2001). These costs
are a monumental burden, especially to developed coimtries.
Meeting the needs o f the chronically ill is a major challenge to any health care
system. This is particularly true as populations are generally increasing in mean age.
Added to the burden o f care is the fact that the complexity o f care o f the chronically ill is
increased by co-morbidities. For example, half o f the people with type II diabetes have
hypertension and one-third o f them also have coronary heart disease (Rothman &
Wagner, 2003). Although the elderly are more likely to have a chronic disease, they
account for only 25% o f the general population with chronic illness, while working-age
adults account for 60% o f the general population with chronic illness (Radzwill, 2002).
This has implications for the uninsured, middle-aged worker who is not yet eligible for
Medicare benefits.
Chronic illness creates a subculture from a diverse community. In addition to a
myriad o f tasks and responsibilities resulting from their illnesses, the chronically ill share
an entire system o f beliefs (FitzGerald, Pearson, & McCutcheon, 2000). Everyday tasks
which are taken for granted by the healthy are time-consuming and emotionally
exhausting for a person living with chronic illness. In addition to the requirements o f
7
caring for their disease and maintaining everyday life, the chronically ill are forced to
respond on an emotional level to the interpersonal and pubhc burdens placed on them by
their disease. Essentially, patients Uving with chronic illness respond by becoming their
own primary care provider (Bodenheimer, Wagner, & Grumbach, 2002).
It has been proposed that our health-care system is poorly suited to the care o f the
chronically ill (Norris et al., 2003). Traditional medical care has historieaUy been
oriented toward the treatment and cure o f acute disease (Lorig, 1993). Practitioners often
find it difficult to deal with chronic disease as it is not cured, but rather is controlled
(FitzGerald et al., 2000). Treating these patients is time-consuming. For these and other
reasons, patients with chronic disease often receive substandard care. Care can be
fragmented and redundant (Rothman & Wagner, 2003).
This fragmentation and redundancy can be blamed, iu part, on the failure o f
practitioners to employ proposed guidelines for various chronic illnesses (OConnor,
Sperl-Hillen, Pronk, & Murray, 2001). For example, in a survey o f primary care
providers, only 64-75% o f chronically ill patients were treated according to guidelines.
In another study, only 27% o f patients with heart failure were receiving recommended
therapy (Norris et al., 2003). Primary care, in particular, has been sbown to be weak in
evidence-based practice (Campbell, Braspenning, Hutchinson, & Marshall, 2003). This
is significant in that visits to primary providers accormt for 58% o f aU medical visits in
the U.S. (Rothman & Wagner, 2003).
Failure o f our current health care system to successfully deal with chronic illness
has led both provider and patient to call for a more accountable system o f treatment.
Although initially spearheaded by a demand for cost containment by reimbursers, the
8
focus has expanded to include treatment goals. It is generally acknowledged that putting a
focus purely on cost containment is short sighted and in the long run increases cost.
Evidence o f this change in direction is demonstrated by a recent proposal in the United
Kingdom. In response to public demands for accountability, beginning in April 2005,
general practitioners in Britain will be given ratings on how weU they handle chronic
illness. This point system will enable patients to choose a General Practitioner based on
this rating scale (Patients Pick G.P.s, 2003).
Our health care system must move away from episodic care o f chronic illness
(Bengoa et al., 2001). QuaUty care o f the chronically ill must include: optimal disease
control and prevention o f eo-morbidities, informed patients with the skills to manage
their condition, a mutually formulated plan o f care, and long-term follow-up (Rothman &
Wagner, 2003). To meet this goal, a system o f disease management has been proposed.
The Mayo Clinic coined the term disease management in the 1980s. It
originated with a focus on cost control. Over time, disease management has come to
mean a systematic approach to at-risk patients, using interventions based on evidencebased protocols (Norris, et a l, 2003). OUveria et al. (2002) propose a multi-step program
to best care for the chronically ill. It consists o f the development o f a program to identify
patients with chronic conditions for which cUnically based guidelines are avaUable,
identification o f measurable outcomes based on the goals o f these guidelines, and
measurement o f outcomes to monitor improvement.
Special Concerns o f the Un-insured
Lack o f insurance continues to be a significant barrier to health care in the United
States. After a slight decrease in the 1990s, the number o f uninsured in this country
9
continues to rise. Lack o f health insurance is no longer a problem that only affeets the
poor. In fact, lower and middle income families account for most o f the recent inerease
o f the uninsured (Carrasquillo, Himmelstein, Woolhandler, & Bor, 1999). While U.S.
health care spending increased in 2001, one in seven Amerieans went without health
coverage for the entire year (McCarthy, 2003). Closer to home, fourteen percent o f
Wyomings population remains uninsured (State o f Wyoming Health Care Commission,
2003).
Lack o f insurance has a direet impact on health. Uninsured patients are more
likely to receive substandard eare than their insured counterparts (McCarthy, 2003).
They are also less likely to reeeive routine checkups and screening and have high rates o f
preventable hospitalizations (Carrasquillo et al., 1999). This is o f particular import for
the chronically ill. Uninsured adults with hypertension were significantly less likely to be
aware o f their condition, and uninsured patients who developed hypertension were less
likely to receive care (MeCarthy, 2003).
The NHANES 1 study found that adjusted mortality was higher for uninsured
individuals (Ayanian et al., 2003). This may be due in part to laek o f a primary eare
provider. In a study to be presented to the Soeiety for Academic Emergency Medicine,
researchers from Temple University Hospital and School o f Medicine studied emergency
room visits in four hospitals over one week (Urgency Overwhelms Pieture, 2004). The
authors found that emergency room (ER) physicians focus on immediate problems, while
ignoring broader healthcare issues. This is significant to the uninsured, as they tend to
use emergency departments for their primary care. In this same study, it was shown that
1400 o f the patients studied had hypertensive blood pressure readings in the ER. Most o f
10
these patients were not referred for follow-up. By not addressing blood pressure, both the
patient and provider missed a window o f opportunity for care.
Lack o f health insurance presents dilemmas for both the patient and provider. In a
recent study in Wyoming, the realities o f lack o f insurance were studied. Providers felt
constrained in the care they could provide. For example, appropriate referrals and
laboratory tests could not always be done due to fiscal limitations. To further complicate
the situation, positive screening test results left the provider in a quandary as to where to
proceed without sufficient funds. For the uninsured patient, illness presents an added
dimension o f worrymoney (Burman et al., 2003).
The Downtown Clinic (DTC) in Laramie, Wyoming, is one communitys attempt
to provide care for the uninsured. This population provides special challenges to the
provider. Like uninsured patients in the previously described study o f E.R. visits, the
uninsured DTC patient is likely to be unaware o f their diagnoses. As uninsured clients,
they are also less hkely to have received care for their medical conditions and they
present with significant fmancial stressors (New York Times, 2004).
Evidence-based Health Care
The market economy and patient expectation for quality care have given rise to an
emphasis on evidence-based practice. This type o f practice includes the melding o f
theory, chnical decision-making, and evaluation o f research. In other words, it is an
approach to clinical care based on the best available evidence (Lee, 2003).
An essential part o f evidence-based medicine is the clinical guideline. Shiffman
et al. (2003) found that evidence-based guidelines reduce inappropriate care and
introduce research into clinical practice. Guidelines often translate complicated research
11
into easily understood recommendations. This is particularly important to the primary
care practitioner who has been shown to be less likely than the specialist to be current on
particular disease management (American Diabetes Association, 2003). Guidelines can
be used as a template o f care and a tool to focus the attention o f the provider on
appropriate interventions (OConnor et a l, 2001).
However, the quality o f guidelines is variable. Historically, development o f
guidelines followed a process referred to as GOBSAT; Good Old Boys Sitting at a Table.
This process entailed the leaders in a field sitting at a table giving their views on what
constituted good practice, with a selective eye to evidence (Keeley, 2003). In one study,
it was demonstrated that o f the 431 guidelines produced by medical specialty groups, 67
to 87% did not apply the proper criteria in formulating guidelines (Shiffman et al., 2003).
To remedy this deficiency, various conferences have been convened to promote guideline
standardization and to facilitate guideline implementation.
From these conferences, groups have been formed to oversee guideline
development. For example, in the United Kingdom, a central guideline service has been
formed. The British National Institute for Clinical Excellence (NICE) assesses all
guidelines funded by the National Health Service (NHS). Internationally, the Appraisal
o f Guideline Research and Evaluation (AGREE), made up o f a multi-national
membership, performs the same function (Keeley, 2003). Other groups have published
checkhsts to assure guideline quality. Shiffman and colleagues (2003) convened the
Conference on Guideline Standardization (COGS), which formulated such a checklist.
The implementation o f guidelines is an essential aspect o f evidence-based care.
Studies have been done to better understand the barriers to implementation o f guidelines.
12
In rural settings, Coon and Kulkowski (2002) found the following reasons that guidelines
were not followed: ageism o f the provider, provider inertia, lack o f auxiliary service (e.g.
nutritionist), and patient non-compliance. Lee (2003) noted that there is sometimes a fear
that implementing guidelines will jeopardize a providers relationship with the patient.
He also found that successful implementation can be dependent on the support o f peers
and administrators. Other researchers have determined lack o f provider awareness o f
guidelines as a major barrier to implementation (Cushman et al., 2002). Suggested
methods o f encouraging implementation by increasing guideline awareness include the
distribution o f hterature describing guidelines to both patients and providers and
publication o f guidelines in peer-reviewed journals and on pertinent World Wide Web
sites (Keeley, 2003). In order for guidelines to have maximum clinical efficacy, they
need to be revised as new research and provider/patient feedback dictate (Norris et al.,
2003). Recent revision o f the Guidelines o f the American Diabetes Association and the
JNC Guidelines for Hypertension Treatment (JNC VII) are examples o f guideline
revisions driven by these demands (American Diabetes Association, 2003). The Institute
o f Medicine (lOM) has also published a guideline for guidelines.
The Institutes recommendation for effective promulgation o f its guidelines
recognizes a number o f components essential for successful implementation. Desirable
characteristics o f guidelines are; validity, rehability, reproducibility, chnical applicability,
clinical flexibility, clarity o f demonstration, documentation, development by an
interdisciplmary process, and a rubric for review (Shiffman et al., 2003). Yet guidelines
can be problematic, and when inapplicable to a wide-range o f cultural, social, and
geographical circumstances, remain unused. Often guidelines are presented as absolute
13
directives to providers and patients; effective guidelines should be framed in the light o f
recommendations rather than requirements. Guidelines do not exist in a vacuum: they
must be flexible enough to respond to local context and specific patient circumstance
(Campbell et al., 2003). While guidelines are necessarily elastic to allow providers the
freedom to respond to special needs o f the patient, this does not mitigate the central focus
o f guidelines as an effective tool for the provider to achieve optimum patient benefit.
Helpful guidelines require that patients have a role in their development. Guideline-level
treatment is only attained when a motivated patient works with a provider who is
knowledgeable about current guidelines and is at ease implementing them in the specific
context and circumstance o f the patient (Keeley, 2003).
Hypertension Control and Treatment
Hypertension is a worldwide problem affecting developed as well as developing
countries. Among the indigenous people o f Africa, hypertension rates range from 16 to
22%. In Cuba, hypertension affects 35% o f males. Hypertension affects 15% percent o f
the populations o f India, Indonesia, and Thailand. Eastern Europe has increasing rates o f
hypertension. Given this trend, death rates from parasitic and infectious diseases in
Africa and the Mid-East wUl soon be equaled by hypertension in those regions (WHO,
1998).
In the United States, reducing the number o f poorly controlled hypertensive
patients to 50% was deelared a public health care priority by the Healthy People 2000
document (Berlowitz et al., 1998). This goal remains unehanged in the Healthy People
2010 document (Centers for Disease Control and Prevention [CDC], 2000). As
previously stated, hypertension continues to be a chronic condition with high tangible and
14
intangible costs. Once developed, it is costly to treat. However, even small changes in
blood pressure can reap benefit. It has been demonstrated that decreases o f as little as five
mm o f mercury in the systolic pressure can dramatically decrease mortahties and
morbidities such as stroke, heart disease and kidney disease (Joint National Commission
on Prevention, Detection, Evaluation, and Treatment o f High Blood Pressure [JNC VI],
1997). Aylett, Creighton, Jachuck, Newrick, and Evans (1996) found that the more that
blood pressure is lowered, the lower the cardiovascular risk. Today, in spite o f a growing
pharmaceutical armament and evidence-based practice guidelines, hypertension remains
poorly controlled.
Hypertension is one o f the most common responsibilities o f the primary provider
and is the leading cause o f office visits in the United States (Hyman & Pavlik, 2001).
Paradoxically, rates o f control have been reported as variable in a range o f studies. In
their study o f 16,095 adults over the age o f 25, Hyman and Pavlik (2001) found only 25%
o f hypertension to be adequately controlled. Another study o f 2500 physicians found
therapeutic control o f blood pressure to range from 6-25% (Ambrosioni et al., 2000).
The National Health and Nutrition Examination Survey III (NHANES III) demonstrated
that 27% or 9.7 million o f hypertensives are controlled (Hyman & Pavlik). Even more
problematic is the finding in that same study that 32% o f hypertensives (13 million
Americans) are unaware o f their hypertension. Seven million more hypertensive clients
are aware o f their diagnosis, but are not receiving treatment. Twelve million more
hypertensives are treated but are not controlled (Hyman & Pavlik).
Although the abovementioned studies report discouraging success rates, one large
study was able to demonstrate that better control was an achievable goal. The Anti-
15
Hypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)
examined current rates o f hypertension control (Cushman et al., 2002). This study,
sponsored by the National Heart and Lung Institute, was conducted at 623 centers in the
US, Canada, and the Caribbean. Community practice clinics were the majority o f sites
studied. ALLHAT was a randomized, double-blind, active-controlled clinical trial, with
a mean follow-up o f 4.9 years. The study included 33,357 hypertensive participants,
aged 55 years and above, who had at least one other coronary risk factor. The study
iocluded many o f the groups which are difficult to control: blacks (35%), the elderly, and
diabetics (36%). Forty-seven percent o f the participants were women. At the beginning
o f this study, 27% o f the participants had their hypertension controlled. Patients were
randomly assigned to receive chlorthalidone 12.5-25 mg/d, amlodipine 2.5-10 mg/d, or
lisinopril 10-40 mg/d. Doses were increased and other drugs added to achieve blood
pressure control. A control rate o f 66% and a mean BP o f 135/75 were achieved after 5
years o f participant follow-up. The ALLHAT results are in direct contrast to the control
rate in the US o f 27 to 29%. This study demonstrates the ability to control hypertension
using evidence-based, guideline-directed methods for the detection and treatment o f
hypertension. The ALLHAT findings are easily generalizable due to the demographics
o f the study, which included difficult to control groups and the fact that the bulk o f sites
studied were primary care site.
ALLHAT aside, few other studies have been able to demonstrate that
hypertension is well controlled. As demonstrated by the Healthy People 2010 goals, it
remains a public health mandate (CDC, 2002). Toward the goal o f controlling blood
pressure, several international groups have formulated guidelines for the prevention.
16
diagnosis, and treatment o f hypertension. Among these groups are the World Health
Organization (2002), the British Hypertension Society (Ramsay et al, 1999), and the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment o f
Hypertension (JNC).
On May 14, 2003, the JNC, under the auspices o f the National Heart, Lung, and
Blood Institute (NHLBI), released its seventh report on hypertension (NIH, 2003). The
NHLBI is composed o f 46 professional, voluntary, and federal organizations. Their
previous report on hypertension guidelines was issued four years earlier, in November o f
1997. Since then, thirty worldwide studies demonstrated the need to revise the
guidelines. The committee saw a need for clearer, more concise, guidelines, along with a
need to simplify blood pressure classification. There was also recognition that the
previous JNC report was not being implemented (NIH, 2003). Thirty-three national
hypertensive experts reviewed the new guidelines, and several key modifications were
made. These included 1) the establishment o f a new pre-hypertension level (BP >
130/80); 2) the lowering o f the diagnostic blood pressure threshold (BP > 140/90); 3) and
the merging o f stage 2 and 3 risk stratifications; 4) the recommendation o f thiazide-type
diuretics as the drug o f choice for most patients (although another drug will need to be
used in combination to control most patients); 5) recognition that a systoHc blood
pressure o f 140 mm Hg or more in patients over 50 is a larger risk factor than an elevated
diastohc blood pressure; and 6) recognition that CVD doubles with each rise o f 20/10
mm Hg above readings o f 115/75. These new guidelines were distributed to the public,
physicians, and patients. They were published on the worldwide web, and also were
17
included in the May 21, 2003 issue o f The Journal o f the American Medical Association
(JAMA) (Chobanian et al., 2003).
Barriers to Hypertension Control
The folio wing paragraphs will summarize the major barriers to hypertension
control as discussed in current literature, with emphasis on patient-related barriers, access
to care, physician familiarity with guidelines, and physician use o f guidelines. The
barriers to control o f hypertension are numerous and have been the subject o f a number
o f studies.
In a study analyzing physician-perceived barriers to control o f hypertension,
Oliveria et al. (2002) noted several obstacles to hypertension control: patient noncompliance to pharmaceutical/ lifestyle change programs, patient lack o f understanding
regarding hypertension as a chronic disease, cost o f care, and drug side effects.
Ambrosioni et al. (2000) suggest that the drugs available, physician behaviors, and
patient response to treatment dictate hypertension care. Another proposed reason for lack
o f hypertension control is non-comphance due to secondary medication effects. Other
authors have foxmd that obstacles to blood pressure control include: lack o f awareness o f
hypertension condition, poor medical management, patient noncompliance, and access to
care (Maue, Rivo, Weiss, Farrelly, & Brower-Stenger, 2002).
In studying patient non-compliance in particular, secondary effects o f
pharmaceuticals and their effect on compliance has been examined. It was found that
provider appreciation o f secondary effects differs from that o f patients. Ambrosioni et al.
(2000) executed a dual-survey study in which they asked both physicians and their
patients whether or not drug side effects were significant. Twenty percent o f physicians
18
reported significant side effects while 69% o f their patients reported significant side
effects. Physicians tended to only take note o f major side effects while patients noted all
side effects. This dual perception can lead to increased non-compliance as providers may
not see the need to switch drugs based on their subjective perception.
The abovementioned patient-related barriers are amplified in the homeless.
Constituting between 14- 25% o f the homeless, hypertension is second only to alcohol
abuse as the most common chronic problem o f the homeless (Kinchen & Wright, 1991).
The homeless are a special population who present with significant patient- related
harriers. These harriers include non- compliance to laboratory referral and to treatment
plans. If a laboratory test is not done on-site, it is usually not performed. The homeless
patient finds it difficult to travel to an off-site lab for testing. Treatment plans present
another barrier to the homeless. Dietary control is difficult for those with limited food or
who may he eating in soup kitchens. Smoking reduction and relaxation techniques are a
moot point for those trying to meet basic survival needs. The co-morhidities o f alcohol
abuse and mental illness further complicate treatment plans. Alcohol abuse, in itself,
contributes to hypertension and multiple drug therapies are often impractical for this
population (Kinchen & Wright, 1991).
Access to Health Care
Access to care has been suggested as a cause for poor rates o f blood pressure
control. However, several studies refute this claim. In his study o f compliance to
hypertension guidelines in Italy, Cuspidi et al. (2002) demonstrated that undiagnosed and
treated but uncontrolled hypertension often occurred in people who visited a physician
frequently. They demonstrated that lack o f control was not confined to the poor or
19
uninsured. In fact, surprisingly, rates o f control are greater in the U.S. than in countries
with socialized medicine. This suggests that access to care is not the main determinant o f
hypertension control. Similar results were found by Hyman and Pavlik (2001), who
studied characteristics o f hypertensive patients. They found that 92% o f uncontrolled
hypertensives had health insurance and made an average o f 4.28 visits per year to a
provider. However, Romaine, Patel, Heaberlin, and Zarowitz (2003) contradict this
conclusion. These authors and Maue et al. (2002) found that access to care was one o f
the major contributors to hypertension control. In their study o f patients in a health
maintenance organization, 74% o f the hypertensive patients were controlled. The authors
hypothesize that this rate o f control was achieved for several reasons. The patients in this
study had full health coverage including drugs and they visited a physician two or more
times a year. They consider this above average control rate to also be due to the fact that
more women were included, and that most o f the hypertensives had established
hypertension. It has been reported that women tend to be generally more compliant to
therapies and that newly diagnosed hypertensives demonstrate lower control rates
(Hyman & Pavlik, 2001).
Guideline Familiarity and Practice Patterns
Lack o f familiarity with guidelines has been proposed by Hyman and Pavlik
(2000) as a major barrier to hypertension control. Their study was based on a 26-item
mail questionnaire sent to 1200 primary care physicians randomly chosen from the AMA
master file. The goal o f this study was to determine how physicians diagnose and treat
hypertension. Hyman and Pavlik note that one o f the major limitations to this study is
that the respondent tended to report desirable clinical behaviors that cannot always be
20
documented by the medical record. The authors found that 60% o f physicians usually
followed the guidelines while only 14% always did. This data indicates the need for
provider behavior change, increased familiarity, and implementation o f practice
guidelines along with familiarity with evidence-based medicine.
A gap has been noted between physician perception and actual rates o f blood
pressure control. In one study, physicians perceived that blood pressure was controlled in
50-60% o f patients (Oliveria et a l, 2002). In this study the authors used a descriptive
survey to identify physician barriers to treatment o f uncontrolled hypertension. They
sampled patient visits to the Henry Ford Medical Group (Detroit) physicians during a
specific 3-week period. Physicians treating uncontrolled hypertensives during that period
were queried as to why they were having trouble controlling hypertension in each
specific case. Physicians were asked to complete a questionnaire. Twenty-one
physicians responded to questionnaires on 270 patient visits. The authors found that 40%
o f physicians in their study had httle familiarity with the JNC guidelines (at the time o f
JNC V). The same researchers demonstrated that physicians who were aware o f the
guidelines consistently reported lower blood pressure treatment thresholds. The
generalizability o f study is limited in that it was a one-site study in a large metropolitan
area. The median client age was 69, and the population was 42% minority, and all o f the
clients were insured.
Even when the practitioners are familiar with the guidelines, they dont always
follow them. In the above-mentioned study, it was noted that prescribed first-line agents
were generally inconsistent with the guidelines, regardless o f how familiar the
practitioner was with the guidelines. Cuspidi et al. (2002) found that one-third o f the
21
providers they studied were hesitant to begin treatment at levels suggested by the
guideline. This study also demonstrated that a large fraction o f patients treated with
hypertensive drugs were prescribed without a rninimum workup. The goal o f this
research was to determine how weU the WHO 1999 hypertensive guidelines were used to
diagnose and treat hypertension in eight Itahan hypertension centers. The first forty
patients to visit each center who had been diagnosed with hypertension within the last
two years were chosen to participate in this study. The population was about half men
and half women, with a mean age o f 51. The results are not easily generalizable to the
DTC study presented here because it took place in a country with socialized medicine and
about two-thirds o f subjects included were women.
Oliveria et al. (2002) also studied guideline use. The researchers found that
physicians who were familiar with the guidelines didnt always implement them. In
particular, they found that physicians are willing to accept elevated blood pressures in
patients. In fact, 150 mm is the lowest systohc blood pressure at which physicians chose
to initiate treatment in this study. This is particularly true in the elderly. Treatment is
three times greater in isolated diastohc pressure than in isolated systolic hypertension,
which most often affects the elderly. Fagard and Van den Enden (2003) foimd that only
25% o f systolic hypertension was treated as opposed to 75% o f diastohc hypertension.
The authors surveyed 253 Belgian physicians, asking them to report on the first 15 men,
55 or older, visiting their clinic for examination. O f the 3,761 patients sampled, 75%
were hypertensive. At that time, this study demonstrated lack o f adherence to the 1999
WHO-ISH guidelines (World Health Organization, 2002). The relevance o f this study to
the Downtown Clinic study is limited because it deals only with older, Belgian, males.
22
Similarly, Silverberg, Rosenfeld, Agmon, Regev, and Aviva (1979) found that 85% o f
diastolic hypertension received medication compared with 51% o f systolic hypertensives.
They found that 26% o f the patients with recorded blood pressures were hypertensive. In
this study the authors reviewed the charts o f patients 20 years old and older o f 17 general
practitioners and six family elinics in Tel Aviv. The total sample size was 7,192.
Although the client population was evenly distributed between men and women, the
demographics were not well-described and Israel practices socialized medicine. This
limits the generalizability o f the study.
Ubel, Jepson, and Aseh (2003) also demonstrated that physieians do not always
follow guidelines. The authors studied the question o f how prescribing practices and
attitudes changed after the release o f the JNC guidelines in 1997 and again in 2000. The
study consisted o f a mail survey sent to 1700 randomly chosen family practitioners and
internists. Six hundred and forty seven o f the surveys were returned and found consistent
with the sample criteria. The physicians were asked to rank the effectiveness and
tolerabihty o f ACE inhibitors, beta-blockers, ealeium channel blockers and diuretics in a
stage I hypertensive patient. Use o f sample medieations was also assessed. The authors
found that attitudes toward hypertension remained unehanged over the three year period.
Even after the release o f the JNC guidelines, physicians persisted in viewing diuretics as
less effeetive and viewed beta-blockers as being poorly tolerated. The relationship
between sample availability and prescribing patterns was also studied. The authors
demonstrated that availability o f sample medications increased the rate o f new drug
adoption. Physicians who use diuretics and beta-blockers as first line agents are less
likely to provide samples. This research raises an interesting question in regard to the
23
Laramie Downtown Clinic. How does the limited formulary at DTC influence
prescribing patterns?
Summary o f Recent Research
Hypertension remains a major healthcare challenge. In spite o f advances in drug
therapy and the existence evidence-based guidelines, the average control rate for
hypertension in the United States is approximately 27%. Other countries are even less
successful in diagnosing and treating hypertension (NIH, 2003). This lack o f control
wages a heavy toll on societyboth in tangible and intangible cost. It is estimated that
the annual cost o f hypertension in the U.S. is 259 billion dollars. By increasing
hypertension control, we could realize a significant reduction in the co-morbidities o f the
condition. It has been demonstrated that even a small reduction in blood pressure (5 mm
mercury) can reap substantial health benefit.
With hypertension control as a goal, studies have been done to determine how
control rates can be increased. The provider-patient dyad is the focus o f these studies.
Although patient- centered causes have been hypothesized, research has also
demonstrated a need for changes in practitioner behaviors. The researchers study
focuses on a particular practitioner clinical behavior. This study will evaluate provider
adherence to the JNC VII guidelines at the Laramie Downtown Clinic.
Practitioner familiarity and adherence to guidelines has been studied. It has been
shown that 40% o f providers are not familiar with the JNC Guidelines. Furthermore,
practitioners familiar with the guidelines do not always follow them (Oliveria et al.,
2002). Studies demonstrate that when guidelines are followed, hypertension control rates
are increased (Cushman et al., 2002).
24
Patient compliance and access to care have been proposed as client-centered
causes o f lack o f hypertension control. All data dealing with patient compliance is
subjective. In gathering this data, one has to rely on the accuracy o f patient reporting.
Several studies have been done evaluating the role o f access to care in hypertension
control. These studies have demonstrated that lack o f blood pressure control is not
confined to the poor or un-insured. Control rates were low even in those clients who had
access to, and availed themselves of, care. The legitimacy o f this conclusion can be
called into question as people without access to care are not seeking care and are
therefore not part o f these studies. For this reason, I challenge the generalizability o f
these findings, in particular to the population in the DTC study. The DTC population is
poor and uninsured and has not been duplicated in the foregoing studies. Nevertheless,
these studies do demonstrate that, on average, 73% o f patients currently followed by
providers, do not attain optimal control rates.
Theoretically, the optimum control rate would be 100% o f hypertensives with
blood pressures at or below guideline-mandated levels. A more practical goal might be
the 66% demonstrated in the ALLHAT. This study is generalizable in that it included a
wide demographic which included several hard-to-eontrol groups. Most o f the care was
provided in a family practice setting. ALLHAT demonstrates that optimum control rates
can be greatly increased.
Chapter III
Methods
This study is a retrospective chart review o f 35 hypertensive clients at the
Laramie Downtown Clinic in Laramie, Wyoming. Participants were chosen using a
convenience sample o f the hypertensive clients treated at the clinic. Clients were not
chosen with respect to age or gender.
The results o f the study are presented in terms o f percentage compliance for each
checklist topic. The results will be used to make recommendations to the primary care
staff o f the Downtown Clinic regarding improvements in care o f the hypertensive patient.
The purpose o f this survey research is not to generalize from this small sample to a larger
population, but rather to demonstrate how closely practitioners follow the JNC VII
Guidelines.
Description o f the Population and Sampling Procedure
The Laramie Downtown Clinic was established in 1999 to serve the medical,
psychological, and dental needs o f the uninsured in the community. Over the past five
years, more than 1,400 chents have received care at the clinic. The clinic is open for four
hours every Wednesday and an average o f 34 clients is seen each week. The elients are
the working poor. Over half o f the patients are employed. However, aU clients meet the
financial limit o f 185% o f poverty or less. In fact, sixty three percent o f people are at less
than 100% o f poverty levels.
25
26
Chronic diseases constitute the bulk o f the caseload at the DTC. Asthma,
diabetes and hypertension are the most common diagnoses. The adult clinic population is
made up o f 63.5% women and 36.5% men (L. Johnson, personal communication, April
12, 2004). Children eligible for the DTC services are usually found eligible for KidCare,
Wyomings state childrens health care program These children are referred to this
program and are then able to receive care from a local provider. However, acute
conditions in a pediatric patient are cared for upon presentation at the clinic.
The population o f this study consists o f hypertensive clients o f the Laramie
Downtown Clinic (DTC) who had been clients o f the clinic for at least 6 months.
Sampling was done using a convenience sample. There were two selection criteria:
candidates must have been identified by a health care provider as being hypertensive, and
candidates must have been clients o f the DTC for at least 6 months. One hundred clients
charts identified as hypertensive by the DTC Pharmacy computer were reviewed. These
clients were either self-diagnosed on intake or were identified by hypertensive
medication usage. All 100 charts were then reviewed in order to confirm diagnoses o f
hypertension using JNC VII criteria. As a result, 35 clients were identified who met the
sampling criteria. Sixty-five clients were rejected because they: 1) were self-identified
hypertensives with no such provider identified diagnosis, 2) had only one clinic visit, or
3) were patients for less than 6 months at the Downtown Clinic.
Survey Instrument
The author translated the JNC VII guidelines into a checklist (see Appendix A).
All items were a translation o f the guidelines with the exception o f sulfonamide allergy,
chronic cough, and angioedema/hives, which were added at the request o f my thesis
27
committee to better evaluate rationale for chosen drug therapy. Even though the patients
were chosen during the time that the JNC VI protocol was in effect, this research is
concerned with how well chent care at DTC is responsive to the more current JNC VII
guidelines, as released in May 2003. My thesis committee, a pharmacist and two family
nurse practitioners (FNP), served as reviewers for the checklist. Consistency with the
JNC VII protocol was evaluated. The checklist was found to be consistent with the
protocol.
Reliability/Validity o f Instrument
The method o f this study has inherent flaws with regard to reliability and vahdity.
There have been several studies regarding the limitations o f studies based on chart
reviews and health records. Mahabir and Gulliford (1999) state that in using this method
to collect data, one studies the care that was recorded, not the care that was delivered.
Ideally, these should be the same. In reahty, there is sometimes omission in the written
record, particularly o f informal instruction or education. There is also the possibihty o f
omission o f health care that was received at a different elinic or facility. As Aaronson
and Burman (1994) point out, there is possibility for error at several points; data
collection, data documentation, data extraction, and interpretation. They found physical
assessment, medical diagnoses, specific tests, and abnormal lab findings had reasonable
validity and reliability. However, patient histories are less reliable and valid when
obtained from health records.
The implications to my study are that the empirical data regarding weight, lab
measurements, documentation o f physical assessment, etc., can be considered more
reUable and valid than the data drawn from patient history, such as patient recorded
28
health history. In spite o f the aforementioned inherent rehability and validity problems,
the researcher attempted to control for these in several ways. The validity o f the
instrument can be demonstrated by the fact that it is based on the JNC VII Guidelines.
The face validity was addressed by having two family nurse practitioners and one
pharmacist review the instrument. To demonstrate rehability o f the study, the same
questions were used for each chart and the same researcher used the same criteria in
reviewing each chart. In addition, rehability o f the instrument was checked by a second
reviewer independently assessing the checklist for a single chent. The results were
eomparable, with the exception o f age. This researcher used age at first visit, whereas the
reviewer appeared to use age at time o f review. This rehability error can be addressed by
having one reviewer perform ah o f the chart reviews. The researcher approached each
chart consistently. However, recoding o f several charts and reassessment using the
ehecklist to check for researcher consistency was not done. Such a technique would have
further inereased the studys rehability.
Effect o f Sample Size on Results
Sample size is determined by the likelihood that the study will determine that a
protocol is consistently used, when in fact it is not in play some small percentage o f the
time. My goal was to measure as inconsistent each time a protocol was missed 5% (or
more) o f the time, and to do so with a probabihty approaching 90%. Probabilities vs.
sample size are listed in Table 1. (The table is derived fi'om the formula P = 0.95^, where
P is the probability o f missing an ineonsistency that oecurs 5% o f the time and N is the
sample size (Bevington & Robinson, 2002)). Based on Table 1 ,1 have determined a
sample size goal o f 40. Due to eonstraints in choosing appropriate chents from the DTC,
29
the achieved sample size was 35, corresponding to a probability o f missing an
inconsistency o f 0.17.
Table 1
Probability o f Missing an Inconsistency in the Protocol vs. Sample Size
Sample Size
Probability o f Missing an Inconsistency
10
0.60
15
0.46
35
0.17
40
0.13
45
0.10
60
0.05
Description o f Data Analysis

The current analysis is used to report the consistency o f use o f the JNC VII
protocol for hypertensive patients. It is expected that in a clinic where the JNC VII is
used consistently and charting is complete and accurate, each checklist item would
achieve a score o f 100%. Sample size is only a limitation in uncovering infrequent
inconsistencies in protocol usage. If, for example, one uses a sample size o f 10 clients, it
would be conceivable that one would not measure deviations in one protocol that only
occurred 5% o f the time.
Ethical Considerations
Client privacy was assured by translating patient names into numbers at the
begiiming o f the study. Only one master list o f patient names and corresponding number
30
existed. This was kept under lock and key by the author and only the author had access.
The master list was destroyed at the end o f this study. The JNC VII protocol was
translated to a checklist by the researcher. Notes were taken from the charts o f each o f
the 35 selected clients without retaining any personal identification to describe adherence
or deviation from each o f the items on the JNC YU checklist. Actual patient care at the
Downtown Clinic is compared to the checklist for each client to assess JNC VII
compliance. The University o f Wyoming Institutional Review Board gave approval for
this study (see Appendix B).
Because this study was a chart review, the ethical risks were few. Clients were
not direct participants in this study nor were they at risk for physical or emotional harm.
Although there is no direct benefit to the individual participant, the potential benefit to
the community is significant and outweighs the risk to the participant (close to zero).
Limitations o f this Study
Because o f the well-defined population, this study would not be valid in reaching
general conclusions with regard to the use o f the JNC VII protocol elsewhere. The study
is limited in its accuracy to the historical accuracy o f the charts. Due to the sample size,
the chance o f error is increased.
Chapter IV
Results
A total o f 35 charts were audited in this study. Each client had a diagnosis o f
hypertension and had been a patient o f the DTC for at least six months. O f the 35
patients included in this study, 13 were men and 22 were women (see Table 2). Twentythree subjects were white, three Hispanic, one Native American, and two o f unreported
race. All males were white. The mean age was 51 9 years.
Table 2
Demographic Characteristics o f Patient Sample
Demographic Characteristics
Patient Sample
Number o f Patients
35
Mean age in years (SD)
51(9)
Gender (male/female)
13/22
Percentage o f patients undergoing drug therapy
97
Percentage Caucasian
83
Percentage Hispanic
Percentage Native American
Clinic blood pressure at the initial visit was 159 27 (systolic) 99 14

(diastolic). Blood pressure at the last visit was 132 19 (systolic) 84 13 (diastolic).
31
32
Ninety-seven percent o f the patients were prescribed or using anti-hypertensive drugs.
For these 35 hypertensives, 17.1% (6 clients) were diagnosed at the DTC, while 85.7%
(30) were diagnosed by a previous provider (see Table 3).
Consistency o f documentation was an issue. Weight was not consistently
recorded: 22 people had unrecorded weights on the first visit and 12 were unrecorded on
the follow-up. Of these, there were two noted refusals to have weights taken. In
addition, no height data were recorded for any client. Consistent recording o f data was a
problem in other areas as well. Race was left blank in 10% o f the charts, age in 6%, and
sex in 6%. Blood pressure on initial visit was not noted in 6% o f the chents and on 9%
o f the last visits.
Table 3
Blood Pressure and Weight Characteristics o f Patient Sample
Characteristics
Patient Sample
SEP initial (mm Hg) (SD)
159 (27)
DBF initial (mm Hg) (SD)
99 (14)
SEP last measured (mm Hg) (SD)
132(19)
DBF last measured (mm Hg) (SD)
84 (13)
Weight initial, males (pounds) (SD)
213 (45)
Weight initial, females (pounds) (SD)
196 (45)
Weight last measured, males (pounds) (SD)
208(65)
Weight last measured, females (pounds) (SD)
215 (59)
33
Client co-morbidity data is summarized in Table 4. Fourteen o f the hypertensive
clients had co-existing risk factors: 26% were smokers, 17.1% were diabetic, and 11%
had dyslipidemia. In addition, 6% had a history o f COPD, 9% had asthma, 3% had a
neuropathy, 9% a retinopathy, 6% CHD, 3% were identified as menopausal female, and
6% had a family history o f CVD (in female relative less than 65, or a male relative less
than 55). No one in the study had a history o f stroke, was pregnant, was a male over the
age o f 60, or had a sulfonamide allergy, chronic cough, or angioedema/hives.
Table 4
Frequencies and Percentages o f Co-Morbidities (N = 35)
Number o f Clients
% o f Chents
Asthma
8.6
COPD
5.7
Smoking
25.7
Dyslipidemia
11.4
Diabetes
17.1
Neuropathy
2.9
Peripheral vascular disease
2.9
Retinopathy
8.6
CHD
5.7
Female: menopausal
2.9
Family history o f cardio-vascular event
5.7
Survey Data Recorded
34
Table 5 summarizes laboratory tests done on more than 50% o f the patients:
blood glucose, potassium, serum creatinine, serum calcium, and fasting Upid profile.
However, urinalysis (UA), 12-lead electrocardiogram (EKG), and
hematocrit/hemoglobin were performed on less than half o f the patients on their initial
visit.
Table 5
Data Summary from Instrument: Lab Tests Documented (N = 35)
Test Documented
Initial or Follow-up Visit
# o f Clients
% o f Clients
Urinalysis
Initial
follow-up
4
2
11.4
5.7
12 lead electrocardiogram
Initial
follow-up
1
0
2.9
0.0
Blood Glucose
Initial
follow-up
19
12
54.3
34.3
Hematocrit/Hemoglobin
Initial
follow-up
13
7
37.1
20.0
Serum potassium
Initial
follow-up
21
17
60.0
48.6
Serum creatinine
Initial
follow-up
21
17
60.0
48.6
Serum calcium
Initial
follow-up
21
17
60.0
48.6
Fasting Lipid profile
Initial
follow-up
18
19
51.4
54.3
Table 6 summarizes the number o f clients on specific drug treatments, for both
their initial visit and their follow-up (last) visit. Diuretics were prescribed for 46% o f the
(35) clients on their iirst visit and for 65% on their follow-up visit. An ACE was
35
prescribed for 43% on their first visit and for 57% on the follow-up. An Angiotensin II
blocker, calcium antagonist, or alpha blockers were prescribed 6% or less o f the time on
the initial visit and 11% or less on the second visit. No drugs were prescribed for 3% o f
the chents.
Table 6
Prescribed Drug Therapy (N = 35)
Drug Therapy Instituted
Initial or Follow-up Visit
# o f Chents
% o f Chents
Diuretic
Initial
follow-up
16
22
45.7
62.9
Beta-blocker
Initial
follow-up
4
5
11.4
14.3
ACE
Initial
follow-up
15
20
42.9
57.1
Angiotensin II blocker
Initial
follow-up
2
1
5.7
2.9
Calcium antagonist
Initial
follow-up
2
4
5.7
11.4
Alpha-blocker
Initial
follow-up
0.0
2.9
Initial
follow-up
7
2
20.0
5.7
2.9
Other
No drug therapy
Table 7 shows the drug therapy implemented for hypertensives requiring

specialized drug treatments, including diabetics, white males, and post-MI chents in
compliance with JNC VII guidelines. Although the JNC guidelines recommend specific
therapy for stroke victims and blacks, none were in this patient sample. O f the six
diabetics, ah were being treated with an ACE or an ARB. Sixty-one percent o f white
36
males were being treated with ACE. Both o f the two post-MI patients were treated with
both a diuretic and an ACE.
Table 7
Appropriateness o f Drug Therapy
Condition Requiring
Specialize Drug Therapy
[recommended drug(s)]
Diabetes (ACE or ARB)
White Males (ACE)
Post-MI (Diuretic with betablocker or ACE)
#of
Clients
# on
Recommended
Drugs
13
8*
% on
Recommended
Drugs
100
61.5
100
* There was one post-MI patient on beta-blocker and one white male patient with no drug
therapy noted.
Clinic follow-up is described in Table 8. Clinic follow-up is divided into three

categories. Fifty-five percent o f patients with Stage I hypertension had follow-up visits
in 1 to 3 weeks. However, 45% o f Stage I clients experienced no follow-up. Seventyfour percent o f Stage II had follow-up visits within 1 to 3 weeks. Twenty-six percent of
Stage II clients had follow-up at points beyond 3 weeks.
Table 9 is a presentation o f the overall performance o f the DTC with respect to
the control o f hypertension. The DTC experienced an overall control rate o f 54% with
for hypertensives.
37
Table 8
Time Elapsedfrom Initial Visitfo r Follow-up Visits fo r Stage I and Stage II
Hypertensives
Follow-up
Number
Stage I Clients*
1-3 Weeks
1 Month
2 Months
Not Noted
5
0
0
4
55
0
0
45
Stage II Chents**
1-3 Weeks
1 Month
2 Months
Not Noted
17
4
2
0
74
17
9
0
Not able to determine stage from charting
% o f Stage
* Stage I = SBP 140-159 or DBF = 90-99 mm Hg.

** Stage II = SBP > 160 or DBF > 100 mm Hg.
Table 9
Control Rate o f Hypertensive Patients at DTC with Drug Therapy
Patients
Percentage
Patients with controlled hypertension *
54
Patients with uncontrolled hypertension
37
Patients with insufficient documentation
* < 140/90 mm Hg
< 130/80 mm Hg for patients with diabetes or chronic kidney disease
Chapter V
Summary, Conclusions, and Recommendations
This study was designed to assess how closely the Laramie Downtown Clinic
adhered to the JNC VII Guidelines for the detection and treatment o f hypertension. A
chart review was done using a checklist designed by the researcher, which was based on
the JNC VII Guideline. The Downtown Clinic was able to achieve blood pressure
control rates o f 54% (see Table 8). This rate exceeds the rate o f 50% dictated by the
Healthy People 2000 document (Beriowitz et al., 1998). It also exceeds the control rate
o f 25% reported by Hyman and Plavik (2001) and the 27% control rate reported by
N H A N ESm .
Although the rate o f control demonstrated by the DTC is well above the rates
demonstrated in the aforementioned studies, it is below the rate attained in the ALLHAT
study (Cushman et al., 2002). The rate that was demonstrated in the ALLHAT study was
66%. Theoretically, the ALLHAT control rate could be generalized to the clinic
population, as it included a diversity o f ages, ethnicities, and co-morbidities. Romaine et
al. (2003) also speaks to the possibility o f increased control rates. Their study
demonstrates control rates o f 74%. This population was receiving care and drugs in a
managed care setting. Downtown Clinic patients also receive these services at no cost.
The DTC dispenses generic drugs from each o f the main categories. Optimum
(guideline) drug therapy is generally available.
38
39
At the DTC, 33% o f hypertensive patients with diabetes have their hypertension
controlled. This is in contrast to the study o f Maue et al. (2002) in which 14% o f
diabetic hypertensives were controlled before and 24% controlled after a physicianfocused education program. The researcher hypothesizes that the co-morbidity o f
diabetes alerts the practitioner to be more aggressive in treatment and to follow the
patient more closely. Other co-morbidities, such as target organ damage, are more
difficult to screen for and assess. Diabetics at the clinic are often referred to
complementary providers such as nutritionists. In total, these considerations lead to a
patient that is, iu general, probably more closely followed by providers and allowed a
lower tolerance for elevated blood pressures.
It has been documented that practitioners familiar with the JNC guidelines
comply with them more closely and achieve more control. This variable cannot be
analyzed, as the researcher did not survey practitioners at the clinic regarding their
familiarity with the guidelines. Familiarity can be inferred by how closely actual care
mimicked the guidelines.
In the population studied, 100% o f the diabetics were on an ACE or an ARB.
However, only 33% had blood pressures documenting control. Of the rest, 33% were not
controlled and 33% had no blood pressxire reported at their last visit. One himdred
percent o f post-MI patients were being treated per guideline recommendation o f a
diuretic combined with a beta-blocker or an ACE.
According to JNC VII guidelines patients should return at monthly intervals until
hypertension is controlled. Stabilized, at-goal patients should return at 3-6 months.
Stage II clients or those with co-morbid conditions should have more frequent follow-up
40
visits. Fifty-five percent o f Stage I elients and 91% o f Stage II clients were told to return
in one month or less. Forty-five percent o f Stage I patients had no proposed follow-up
plan recorded. There are several possible explanations for this. The clinician might have
forgotten to record the foUow-up plan or regarded the elevated Stage I blood pressure as
being clinically insignificant. The latter has been documented in several studies
including Oliveria et al. (2002).
Lab work proposed by JNC VII at the time o f diagnoses includes UA, 12 lead
EKG, blood glucose, hematocrit/hemoglobin, serum potassium, serum creatinine, serum
calcium, and a fasting lipid profile. As noted in Chapter 4, these tests are not performed
according to guidelines. At best, at the initial visit they are performed 50-60% o f the
time. This is one area that improvement is mandated. With the exception o f EKG, these
are not particularly expensive tests.
Race influences appropriate drug choice. However, it was not recorded in
11.47% o f the charts. Age and sex were omitted in 5.7% o f the charts. This is
demonstrative o f a need to increase consistency o f documentation.
It is suggested that thiazide type diuretics should be used as initial drug therapy m
hypertension. These agents can be used alone or in combination with other classes o f
drugs (Cushman et al., 2002; NIH, 2003). At the initial visit, 45.7% o f DTC chents were
prescribed diuretics. By the last visit 62.9% were using them. This demonstrates an
increased adherence by practitioners to JNC VII guidelines. However, according to the
guidelines this rate should be close to 100%.
Lifestyle modification can help manage hypertension. JNC VII suggests
maintenance o f a BMI between 18.5-24.7 kg/m^, the DASH diet rich in fruits and
41
vegetables but low in fat, sodium intake less than 2.4 g per day, 30 minutes o f daily
aerobic exercise, and moderation o f alcohol intake. Although not part o f the formal
checklist, it was noted by the researcher that hfestyle counseling was infrequently
recorded in the charts. Determination o f BMI would be difficult, as no client had his or
her height recorded.
The DTC achieved a blood pressure control rate o f 54.3%. Studies show that
rates can be increased by use o f aggressive therapy (Ambrosioni et al., 2000; Aylett et
al., 1996; Berlowitz et al., 1998). Use o f more than one agent or increased dosing can
bring uncontrolled patients under control. Fifty percent o f patients with mild to moderate
hypertension require two or more medications (Aylett et al., 1996). Yet physicians
demonstrate rates o f monotherapy in these patients ranging from 17.9-61% (Ambrosioni
et al., 2000, Aylett et al., 1996). This researcher found that 64% o f imcontroUed patients
at DTC were on two hypertension drugs, 28.5% were on monotherapy, and 7% were on
three drugs. The researcher did not record drug dosages.
This study calls into question how the DTC is able to attain hypertension control
rates higher than the national average and very close to the ALLHAT study. In studying
this question, one can use identified barriers to hypertensive control as a framework for
analysis o f this question. The researcher will evaluate both patient and provider centered
barriers to control as they pertain to the Downtown Clinic chent and provider.
Patient-Centered Barriers
Ohveria et al. (2002) identified cost o f care, patient non-compliance to drug and
lifestyle regimens, drug side effects, and lack o f knowledge regarding hypertension as
barriers to control. Maue et al. (2002) cite patient non-comphance, lack awareness o f
42
diagnosis, and access to care as barriers. Ambrosioni et al (2000) found medication noncompliance due to drug side effects. Kinchen and Wright (1991) found non-compUance
to multiple drug therapies, lifestyle changes, and the co-morbidities o f substance abuse
and mental illness to be barriers in the homeless population. Female hypertensives reach
higher rates o f control while minorities attain less control (Hyman & Pavlik, 2001).
Clients at the Downtown Clinic do not have several o f the barriers to control
listed above. Access to care is available and free to them. However, access is limited to
a four-hour period on Wednesdays. The DTC chents are aware o f their hypertension
diagnoses. Non-eomphance issues are difficult to assess, as they are dependent on
patient report alone. Non-compliance due to secondary drug effects was not well
documented. Demographics o f the sample made it inherently easier to control
hypertension. Two thirds o f the sample population was women and almost the entire
sample was Caucasian.
Barriers to eontrol that the chents at the Downtown Clinic may experience are:
co-morbidities such as mental illness, substance abuse, diabetes, asthma, COPD,
smoking, dyslipidemia, PVD, CHD. In fact, there were 32 incidences o f these co
morbidities in the sample. Substance abuse and mental health issues were noted in this
sample also. Although not officially tahied by the researcher, she noted several notations
regarding these problems. Lifestyle counseling was rarely documented.
Provider-Centered Barriers
Studies have shown that provider adherence to guidelines increases hypertension
control. Yet several researchers have demonstrated a lack o f famiharity with and lack o f
adherence to the JNC VII Guidelines (Cuspidi et al., 2002; Hyman & Pavlik, 2000;
43
Oliveria et al., 2002). Of particular note, was provider tolerance o f higher than
recommended levels, in particular with systohc versus diastohc hypertension (Fagard &
Van den Enden, 2003; Hyman & Pavlik, 2000; Ohveria et a l, 2002; Silverberg et al.,
1979). The lack o f laboratory tests and provider unwillingness to begin drug therapy
have also been identified as barriers to control (Kinchen & Wright, 1991).
This researcher did not evaluate provider famiharity with the JNC Guidelines.
However, some knowledge can be extrapolated due to the similarity between the
guidelines and practice patterns o f the DTC providers. One provider-centered barrier
noted by the researcher was tolerance o f higher than recommended blood pressures by
DTC providers. This was particularly true o f Stage I hypertension. This researcher
found that chents could visit the clinic several times with elevated pressures prior to any
notation o f the elevation being noted. Recommended laboratory tests were done on
between 11-54% o f the sample. A UA, EKG, and foUow-up HgB were done less than
20% o f the time. This could be explained by lack o f funds, lack o f on-site lab, or chent
non-comphance. In this sample, the researcher noted that these tests were often not
ordered at initial visit. However, they were sometimes ordered on subsequent visits.
There was httle hesitation to prescribe hypertensives to appropriate chents. Ninety seven
percent o f the sample was prescribed medication.
Although hypertension control rates at the Laramie Downtown Clinic exceed
national averages, it is below the rate demonstrated in the ALLHAT study. This studys
control rate is appropriate as a goal for the hypertension control rate at the DTC as the
study population was diverse and included difficult to control groups. Poverty
(regardless o f access to care) itself makes blood pressure difficult to control as diet
44
choices are not available and lifestyle changes are not easily made. Consideration o f
other provider-centered barriers include lack o f provider continuity and time pressures.
Implications fo r Clinical Practice
Need for improvement at the Laramie Downtown Clinic in following JNC VII
guidelines has been documented by this study. It is proposed by this researcher that the
use o f an operational flowchart based on JNC VII would improve the quahty o f care for
hypertensive patients at the DTC. Aylett et al. (1996) suggest the use o f flowcharts to
increase quality o f care. The use o f a flowchart for hypertensive patients would serve
two purposes. It would provide a framework for guideline adherence and it would
centralize pertinent patient data. This flowchart would be helpful in assuring consistent
care in the areas o f weakness identified by this study-consistent documentation.
The DTC uses multiple volunteer providers. The returning patient is imlikely to
see the same provider in two successive visits. Use o f a flow sheet would decrease time
wasted looking for information in the chart. This researcher found she had to read the
whole chart to assure information wasnt missed. Charts contained several examples o f
incorrectly filed information. Again, a checklist would centralize the information o f
these hypertensive chents.
It is the hope o f this researcher that implementation o f this studys checklist will
lead to implementation o f the JNC VII guidelines and thus improve the quahty o f care
for hypertensive patients at the Downtown Clinic. Also, Fischer and Avom (2004) have
demonstrated that use o f JNC VII guideline drugs results in significant savings.
However, as Campbell et al. (2003) states, guidelines are not mandates. In this vein, it
must be understood that the DTC deals with a restricted budget. Suggested diagnostic
45
tests are often expensive and beyond the economics o f the clinic and a patient. The
clinicians also deal with a restrictive formulary. However, many o f the guidelines
suggestions are not expensive and could be better implemented. Some examples are:
UA, height, weight, and consistent blood pressure measurements.
Although difficult to assess in a chart review, patient education is an important
part o f hypertension control. Several studies note the use o f education as a major factor
in blood pressure control. Ambrosioni et al. (2000) notes the need for parallel patient
education programs. Aylett et al. (1996) state that a praetice protocol should optimize
the use o f nursing skills. Silverberg et al. (1979) demonstrated that patient compliance
could be improved by supervision o f a physician/nurse team. Cuspidi et al. (2002)
demonstrated that a single educational meeting on hypertension significantly improved a
patients knowledge regardhig hypertension. There is no formal education program for
hypertensive clients at the Downtown Clinic. It is the researchers recommendation that
an education program be implemented for the hypertension patients. This program could
be taught by R.N.S or by student nurses.
Implications fo r Further Research
The control rate o f hypertensives at the Laramie Downtown Clinic was well
above the national average. As the researcher did not assess provider awareness o f
guidelines prior to the study, no conclusion can be drawn regarding familiarity with or
use o f guideline. Future research could be done regarding this if, in fact, the proposed
JNC VII checklist was adopted. Personally, this researcher was intrigued by the high
control rate in the absence o f a formalized guideline-based practitioner protoeol. A
future study to determine how this rate o f control was attained would be valuable. Future
46
studies could also examine provider type (MD/FNP) and how it influences control rates.
Ubel et al. (2003) and Ambrsioni et al. (2000) demonstrated that avaUahility o f drugs
could influence prescribing practices. This study proposes the question as to how the
limited formulary at the Downtown Clinic might increase guideline adherence. The
formulary at the clinic is limited and the drugs available are, in general, consistent with
the JNC guidelines. Perhaps the practitioners more often adhere to the guidelines due to
the lack o f prescrihmg options. A fixture study could be done to examine how
prescriptive patterns change if an unlimited formulary was available.
A natural implication o f this study to future research is a follow-up study. After
(if) the proposed checklist is adopted, a new chart review could he done to ascertain if
control rates increased. Evaluation o f control rates after educational intervention could
also be studied. As stated, this studys result is not generalizable beyond the Laramie
Dovmtown Clinic.
I have appreciated the opportunity to study a research question at the Laramie
Downtown Clinic. The special challenges that its patients and providers face provide for
a stimulating place both to volunteer and to do research. It is the sincere hope o f this
researcher that this study will prove valuable in caring for the chents o f the Downtown
Clinic.
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Appendix A
Study Checklist
Checklist
Participant ID
Hypertensive diagnosis made
At clinic
By previous provider
Documented Co-morbidity/mcreased risk stratification

Asthma
Pregnancy
COPD
Smoking
Dyslipidemia
Diabetes
Stroke
Neuropathy
Peripheral vascular disease
Retinopathy
CHD
Sex
Female; menopausal
Male: 60+
Family history o f cardio-vascular event in female relative less

male relative less than 55
Sulfonamide Allergy
Chronic cough
Angioedema/ hives
If yes, associated with ACE/ARB?
Yes
No
52
53
Appendix A, continued
Lab Work
UA
in ial
foUow-up
12 lead EKG
in ial
follow-up
Blood Glucose
in ial
follow-up
Hematocrit/Hgb
in ial
follow-up
Serum potassium
in ial
follow-up
Serum creatinine
in ial
follow-up
Serum calcium
in ial
follow-up
in ial
follow-up
Fasting Lipid profile including:

HDL
LDL
triglycerides
Height_______
Weight_______
initial
follow-up
Social History
Race
Age
Sex
Blood Pressure Readings
male
first visit
female
last visit
Drug Therapy Instituted

Type/dose
> Diuretic
in ial
last
> Beta-blocker
in ial
last
> ACE
in ial
last
> Angiotensin II blocker
in ial
last
> Calcium antagonist
in ial
last
> Alpha-blocker
in ial
last
> Other
in ial
last
Follow-up
One to three weeks
One to two months
Three months
Appendix B
Internal Review Board Approval
'L J N T I'V t-E S .S IT 'Y o f
V ice P re sid e n t for R esearch
OWYOMING
Laramie, W ycm m gK O ^l-V S S

(307) 766o353 ^ (307) 766-5320
FAX (307) 766-2608
TO:
Linda E. Johnson
519 South Fifth Street
Laramie, W Y 82070
FROM:
Roger Wilmot, Chairman, Institutional Review Board , 7 /

Associate Vice President for Research
^ 4 - ~ y
DATE:_
A p rill4 ,2 0 0 4
Re;
IRB Proposal, "Care o f the Uninsured, Hypertensive Patient, a

Retrospective Study
We have reviewed tlie proposal reference above. The proposal involves

_
_
a survey procedure
an interview procedure
public observation
research on the effectiveness o f instructional techniques
other: research involving the collection or study o f existing data [records]
recorded so that subjects cannot be identified.
and as such is exempt from review by the Institutional Review Board for projects involving
human subjects. The proposed procedures qualify as exempt only if the participants are at least
IS years o f age. If the participants w ill be under 18 years o f age, please let us know' immediately;
the age o f the participants could place your proposal in a different category.
W e appreciate your keeping the Board apprised o f your activities. You m ay proceed with the
proposed project. Please feel free to contact me i f you have any questions.
cc:
M. Burman
54

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To The Graduate School:

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y^ Pamela N. Clarke, Dean, Fay W. Whitney School o f Nursing

Don Roth, Dean, The Graduate School

ADHERENCE TO JNC VII GUIDELINES FOR HYPERTENSION

A thesis submitted to the Fay W. Whitney School o f Nursing

UMI Number: EP22834

ProQuest Information and Learning Company

BACKGROUND AND SIGNIFICANCE OF RESEARCH.......................................5

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS........................... 38

Probability o f Missing an Inconsistency in the Protocol vs.

Demographic Characteristics o f Patient Sample............................................31

Blood Pressure and Weight Characteristics o f Patient Sample.................... 32

Frequencies and Percentages o f Co-Morbidities (N = 3 5 )...........................33

Data Summary from Instrument: Lab Tests Documented (N = 35)............ 34

Prescribed Drug Therapy (N = 35).................................................................. 35

Appropriateness o f Drug Therapy................................................................... 36

Control Rate o f Hypertensive Patients at DTC with Drug Therapy............ 37

Probability o f Missing an Inconsistency

Description o f Data Analysis

Mean age in years (SD)

Percentage o f patients undergoing drug therapy

Percentage Native American

Clinic blood pressure at the initial visit was 159 27 (systolic) 99 14

SEP initial (mm Hg) (SD)

DBF initial (mm Hg) (SD)

SEP last measured (mm Hg) (SD)

DBF last measured (mm Hg) (SD)

Weight initial, males (pounds) (SD)

Weight initial, females (pounds) (SD)

Weight last measured, males (pounds) (SD)

Weight last measured, females (pounds) (SD)

Peripheral vascular disease

Family history o f cardio-vascular event

Survey Data Recorded

Initial or Follow-up Visit

Fasting Lipid profile

Initial or Follow-up Visit

Table 7 shows the drug therapy implemented for hypertensives requiring

Clinic follow-up is described in Table 8. Clinic follow-up is divided into three

Not able to determine stage from charting

* Stage I = SBP 140-159 or DBF = 90-99 mm Hg.

Patients with controlled hypertension *

Patients with uncontrolled hypertension

Patients with insufficient documentation

Documented Co-morbidity/mcreased risk stratification

Peripheral vascular disease

Family history o f cardio-vascular event in female relative less

If yes, associated with ACE/ARB?

Fasting Lipid profile including:

Blood Pressure Readings

Drug Therapy Instituted

> Angiotensin II blocker

> Calcium antagonist

One to three weeks

One to two months

'L J N T I'V t-E S .S IT 'Y o f

V ice P re sid e n t for R esearch

Laramie, W ycm m gK O ^l-V S S

Roger Wilmot, Chairman, Institutional Review Board , 7 /

IRB Proposal, "Care o f the Uninsured, Hypertensive Patient, a

We have reviewed tlie proposal reference above. The proposal involves

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