|Ahead of print
|A study on physicians' adherence to joint national committee guidelines for hypertension
Nagavaishnavi Venkata Bhaskara1, Ravi Kiran Andra2, Medha Bhat1, KK Mithun Reddy1, Ravi Shankar1, Amogh Diwakar1, Pratibha D Nadig3
1 Intern, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
2 Post Graduate Student, Department of General Surgery, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
3 Professor and Head Pharmacology, Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research, Ramanagara, Karnataka, India
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|Date of Submission||02-Feb-2021|
|Date of Decision||09-Jun-2021|
|Date of Acceptance||20-Jul-2021|
|Date of Web Publication||02-Mar-2022|
Background: Increased blood pressure (BP) is the second leading risk factor for death and disability globally according to the Global Burden of Disease Study. Therefore, various guidelines have been issued. The American College of Cardiology/American Heart Association issued guidelines and Joint National Committee (JNC) 7 and JNC 8 guidelines, which were laid down by the JNC are a few guidelines for hypertension (HTN) management. Many countries have not implemented effective public policies to prevent and control HTN. Objective: The objective of this study was to assess the number of physicians' adherent to JNC 7, JNC 8, and AHA guidelines when prescribing medications to patients. In addition, the efficacy of the medications, trends in prescribing medications, and adverse drug reactions that a few patients presented with were assessed. Materials and Methods: A cross-sectional, questionnaire-based observational study was conducted on hospitalized hypertensive patients in a tertiary care hospital in South India. Data were collected on a detailed interview basis after receiving an informed consent based on a specific set of preformulated questions. The sample size was met, and the obtained data were analyzed appropriately using the SPSS software version 21. Results: Seventy two patients had diabetes and/or CKD along with hypertension out of 198 patients who participated in the study.Maximum number of prescriptions were adherant to JNC 8 and the least were observed with AHA guidelines.The blood pressure was more controlled in those patients where physicians were adherant to guidelines.The most commonly prescribed drugs were Calcium channel blockers followed by Angiotensin receptor blockers,beta blockers and ACEinhibitors. Adverse drug reactions were seen in only 5 patients Conclusion: The overall adherence to antihypertensive medications guidelines by physicians in India is only modest and much lesser when comorbidities are associated. There is a need to build awareness. Further the antihypertensive classes of medications currently recommended appear to be efficacious and safe.
Keywords: Antihypertensives, blood pressure, efficacy, Joint National Committee guidelines, physician adherence
|How to cite this URL:|
Bhaskara NV, Andra RK, Bhat M, Mithun Reddy K K, Shankar R, Diwakar A, Nadig PD. A study on physicians' adherence to joint national committee guidelines for hypertension. APIK J Int Med [Epub ahead of print] [cited 2022 Oct 6]. Available from: https://www.ajim.in/preprintarticle.asp?id=338896
| Introduction|| |
Hypertension (HTN) is a major public health problem due to its high prevalence all around the globe. Around 7.5 million deaths or 12.8% of the total of all annual deaths worldwide occur due to high blood pressure (BP). It is predicted to be increased to 1.56 billion adults with HTN in 2025.
Increased BP is the second leading risk factor for death and disability globally according to the Global Burden of Disease Study. Clinical interventions have not been systematically applied in both economically developed and developing countries. Many countries have not implemented effective public policies to prevent and control HTN. Some national HTN organizations do not have policy statements and do not advocate for policies aligned with those developed by the WHO for the effective prevention and control of HTN.
Hence, there is a need for uniform guidelines that can be applied to a wider patient population. The Joint National Committee (JNC) 7 guidelines were laid down by the JNC, where the seven categories of BP defined in JNC 6 were simplified and reduced to four categories: (a) Normal BP: systolic blood pressure (SBP) 120 mmHg and diastolic blood pressure (DBP) <80 mmHg (b) Prehypertension: These are patients on the cusp of developing HTN. It is defined as an SBP of 120–139 mmHg or a DBP of 80–89 mmHg (c) Stage I HTN: SBP 140–159 mmHg or DBP 90–99 mmHg and (d) Stage II HTN: SBP 160 mmHg or DBP 100 mmHg. When lifestyle modifications fail to prevent or correct HTN, pharmacologic therapy with 1 or more drugs is warranted. Thiazide diuretics were the first-line in the drugs of choice, followed by angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), aldosterone receptor blockers, beta-blockers (BB), calcium channel blockers (CCBs), alpha-blockers, and direct vasodilators unless other compelling indications exist.
The JNC 8 guidelines permit a higher goal of BP at 130/90 compared to JNC 7 which advocates 120/80 mmHg, and also lesser use of multiple antihypertensive medications. The new guidelines emphasize the control of SBP and DBP with age- and comorbidity-specific treatment cutoffs. The new guidelines also introduce new recommendations designed to promote the safer use of ACEIs and ARBs. The important changes were: (a) In patients 60 years or older who do not have diabetes or chronic kidney disease (CKD), the goal BP level is now <150/90 mmHg. (b) In patients 18–59 years of age without major comorbidities, and in patients 60 years or older who have diabetes, CKD, or both conditions, the new goal BP level is <140/90 mmHg. (d) First-line and later-line treatments should now be limited to 4 classes of medications: Thiazide-type diuretics, CCBs, ACEIs, and ARBs. These guidelines are also inclusive of the factor of race and recommend that when initiating therapy, patients of African descent without CKD should use CCBs and thiazides instead of ACEIs. (d) The use of ACEIs and ARBs is recommended in all patients with CKD regardless of ethnic background, either as first-line therapy or in addition to first-line therapy.
The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High BP in adults reduced the SBP and DBP thresholds for HTN to 130 and 80 mmHg, respectively. This represents a reduction of 10 mmHg in both SBP and DBP levels used to define HTN compared with previous guidelines, such as the Seventh Report of the JNC on Prevention, Detection, Evaluation, and Treatment of High BP (JNC 7).
The ACC/AHA HTN guidelines were released in 2017 at the AHA annual meeting in Anaheim, CA, USA, with simultaneous publication in the journals HTN and the Journal of the ACC. This guideline is the first official guideline announced after JNC 7 that was published 14 years ago. The JNC 8 were not made official, except for publication by sub group of authors. These guidelines became controversial as there was poor quality of evidence. Most of them were on expert opinions the authors themselves mention that “Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.”
It was probably because of this reason that during our preliminary interaction with the physicians in India, we observed that physicians differed in the preference of guidelines followed for antihypertensive management (unpublished data). Physicians who followed JNC 7 and AHA 2017 did so as these were officially declared, however, there were some who followed JNC 8 guidelines although they were yet to be officially announced and followed. Therefore, the present study was designed to explore the extent of physician adherence and bridge the gap in the Indian context with regard to all three guidelines.
Further, although these guidelines are developed each with a rationale, there is a deviation in the Indian and global scenario as far as adherence is concerned. In a study conducted by Ardery G et al., it was found that adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration. Varkantham V et al., conducted a study to assess the antihypertensive medication use among South Indian adults with HTN in compliance with the HTN treatment guidelines, namely JNC 7 or JNC 8. It was found that JNC 8 guidelines were followed more closely by the clinicians. Combination therapy regimens must be adopted as per the JNC guidelines, versus monotherapy, for effective achievement of BP goals. However, these kinds of retrospective studies on patient data from medical records and prescriptions come with the drawback of missing out on first-hand information from patients themselves. There is greater reliability when information regarding chronology and practice of drug use is derived from patients themselves, since they are the biggest stakeholders of their health. This is the gap we have tried to bridge through this study.
Therefore, the present study was designed to explore the extent of physician adherence and bridge the gap in the Indian context with regard to all three guidelines. Through this study, the trend of physician adherence to each of the above guidelines was evaluated along with, the effectiveness of medications used and adverse drug reactions to the medications if any.
| Materials and Methods|| |
A cross-sectional, questionnaire-based observational study was conducted at a tertiary care hospital in South India. This was done among hospitalized hypertensive patients in all the clinical departments of the hospital from July 2019 to February 2020.
The aim of this study was to assess the number of physicians adherent to JNC 7, JNC 8, and AHA guidelines when prescribing medications to patients. In addition, the efficacy of the medications was also assessed, along with adverse drug reactions that a few patients presented with. Adherence to the BP guidelines was evaluated based on the choice of drugs and how medication was changed in association with various comorbidities. Efficacy of medications was noted by recording a fall in BP after initiation of therapy. The last recorded BP measurement was also considered. The patients were asked to recollect adverse drug reactions that appeared after therapy was commenced and the same was recorded in the data collection forms. A sample size of 195 was estimated at a 95% level of confidence, assuming prevalence to be 53.5% and standard error as 5%. Individuals aged between 18 and 70 years, hypertensive patients on antihypertensive medication, and patients willing to provide informed consent were included.
Data were collected on a detailed interview basis after receiving an informed consent based on a specific set of preformulated questions which had been uploaded on a mobile application called “epicollect 5,” after seeking ethical clearance from the institutional ethics committee. The patients were asked about their history of diagnosis with HTN, the medication they were on for the same, along with any changes in the medication, their compliance to the same along with any adverse reactions based on the class of drug prescribed. The sample size was met and the obtained data were analyzed appropriately by using SPSS software version 21 (IBM, India).
The proportion of physicians' adherence to the JNC and AHA/ACC guidelines was analyzed using the descriptive statistics. The percentage of patients in whom adequate control of BP was achieved with and without adherence to the guidelines was calculated. Finally, adverse drug reactions following therapy were evaluated. All results have been analyzed through the descriptive statistics.
| Results|| |
A total of 198 participants were approached for the study during the study period. All of them consented to participate and hence were included in the study. Took part in this study, and all of them were enrolled in the study with voluntary informed consent. The mean age was 52.57 ± 12.74 years.
As shown in [Table 1], there was male preponderance in participation than female. Patients with HTN were obtained from different wards, namely cardiothoracic and vascular surgery, nephrology, oncology, general surgery, general medicine, gynecology, orthopedics, ophthalmology, and ear nose throat of the tertiary care hospital where the patients were admitted.
A majority of the participants had only HTN; however, few of them had other comorbidities such as heart disease, asthma/chronic obstructive pulmonary disease, and thyroid disorders as well, as shown in [Table 1]. [Figure 1] shows participants who had associated diabetes mellitus (DM) and CKD.
Physician adherence to blood pressure guidelines
As shown in [Table 2], maximum overall physician adherence was noted for JNC 8 guidelines and the least for AHA guidelines. A low level of adherence was seen in those with DM and CKD along with HTN. Obtaining data on the history of medication prescribed by physicians of the participants for HTN from the time of diagnosis to the present, the following was found. JNC7 guidelines were followed while prescribing the antihypertensive medication in 101 (51.01%) participants, of whom 92 participants had only HTN, and 9 had HTN and DM. When the adherence to JNC8 guidelines was assessed similarly, it was found that guidelines were adhered in 117 (59.09%) participants of whom, 100 had only HTN, 15 had HTN and DM, and 2 had HTN, DM, and CKD. These prescribed medications were in accordance with 2017 ACC/AHA guidelines in only 62 (31.31%) of the participants, where 53 participants had only HTN and 9 had HTN and DM.
Trends in drug use
On analyzing the various classes of antihypertensive drugs that were being prescribed by physicians to the participants, the following trends in drug use were found. Overall, CCBs were most commonly prescribed, followed by ARBs, then BBs, ACEIs, and thiazides. CCBs were prescribed irrespective of the complication and associated comorbidities. The least prescribed were alpha-blockers [Figure 2].
Efficacy of the anti-hypertensive medication as per the Joint National Committee 7, Joint National Committee 8, and 2017 American College of Cardiology/American Heart Association guidelines
The efficacy of the medications recommended under the three guidelines was assessed based on the control of BP wherever the prescription adhered to the guidelines. Further, the same was also evaluated according to the subcategories such as isolated HTN, or association with DM and CKD. As shown in [Table 3], in all the participants in whom the prescribed medication was in accordance with the JNC7 guidelines, BP was found to be under control, whereas, 25 participants out of 97 attained control of BP where the guidelines were not followed. Similarly, all the participants in whom JNC 8 guidelines were adhered to showed control of HTN, but 37 participants with nonadherent prescription of medication showed control. Finally, all participants in whom ACC/AHA 2017 guidelines were followed also showed control of BP. However, only 53 with nonadherent prescriptions showed control of BP.
Adverse drug reactions
Of the 195 participants in the study, five participants reported the occurrence of adverse drug reactions. Four out of five patients had adverse drug reactions to ARBs (3 to Telmisartan, 1 to Losartan), and 1 to CCB's (Amlodipine). Diarrhea, trouble in breathing, and palpitations were the adverse reactions to ARBs. Lightheadedness, swelling of feet, ankle, and legs, burning of feet, and disturbed sleep due to pain in the legs were the adverse reactions to CCBs.
| Discussion|| |
Despite the existence of various BP guidelines and their updates, the percentage of patients being adequately controlled is still only around 50%, as per the previous reports. However, the present study revealed that there was an adequate control of BP that in all the participants where prescriptions were adhered to. One reason for the uncontrolled and untreated rates is that JNC guidelines are algorithms designed on the basis of response observed in the large populations of patients presenting with similar characteristics. We cannot predict with certainty if a given antihypertensive is the correct choice for a specific patient. However, CCB's and ARB's seem to be the most commonly prescribed drugs by the physicians in our study.
In the present study, adverse drug reactions were observed in a total of five patients. Four out of these five patients had adverse drug reactions to ARBs and 1 to CCB's. In the study conducted in Norway by Harald Oslen et al., out of 1636 hypertensive patients, majority of the patients showed adverse drug reactions to BB (n = 356) followed by calcium antagonists (n = 434), and ACEIs (n = 382), alpha-blockers (n = 117), and diuretics (n = 144). Fatigue, cold hands/feet, dryness of mouth, dizziness upon standing up, and reduced sexual urge were the most common drug reactions.
In the present study, 51.01% were adherent to JNC 7, 59.09% were adherent to JNC 8, and 72.22% were adherent to 2017 ACC/AHA guidelines. One of the possible causes of lack of adherence is the lack of accessibility, time, guideline instruction, and critical appraisal ability. Lugtenberg et al. reported a lack of agreement with the recommendations as the most observed barrier, followed by environmental factors and lack of knowledge regarding the guidelines recommendations.
| Conclusions|| |
It can be concluded from the present study that the adherence to global guidelines is only modest among the Indian physicians. There is a need to explore the actual reasons for the same. We also need to appraise the physicians and hospital policy-makers on the need for adherence to the recommendations as there may be limited knowledge of the same.
Limitations of the study
The study was conducted as an observational cross-sectional study. The recall bias may be a possibility as far as the assessment of efficacy and adverse reactions of medications were. In addition, the reasons for the physicians preferring a particular guideline could not be addressed in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Pratibha D Nadig,
Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research, Ramanagara, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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