|Year : 2015 | Volume
| Issue : 1 | Page : 60-65
A cross-sectional retrospective study to assess the pattern of prescribing for inpatient hypertensive cases in a tertiary hospital and to find out the possible avenues for betterment of hypertension management
Sandeep Kumar Gupta1, Roopa P Nayak1, R Rahavi1, Amit Kumar2
1 Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu, India
2 Department of Pharmacology, Narayan Medical College and Hospital, Jamuhar, Sasaram, Bihar, India
|Date of Web Publication||13-Apr-2015|
Dr. Sandeep Kumar Gupta
Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur - 621 212, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objective: The primary objective of this study was to characterize the prescribing pattern of antihypertensive agents in the tertiary care teaching hospital. The secondary objective of this study was to assess the appropriateness of the prescribing pattern of antihypertensive drugs as per the seventh report of the Joint National Committee (JNC-7) guidelines. Materials and Methods: A cross-sectional, retrospective study for the period of 7 months (June 2012 to January 2013) was conducted. Only inpatient hypertensive cases suffering from essential hypertension with or without other comorbid conditions were included in the study. Results: A total of 261 hypertensive patients on treatment, of which 57.9% were females and 42.1% males, were included. Hypertension alone was present in 26.8% of the patient whereas diabetes mellitus was the most common comorbid condition in 18.8% of the cases. Of the 261 patients studied, 47.1% were on monotherapy and 52.8% on combination therapy. The commonest monotherapy agents being prescribed were calcium channel blockers (CCBs) (26.8%), followed by diuretic (9.6%), angiotensin-converting enzyme inhibitor (ACEI) (5%), beta blockers (BBs) (3.8%) and angiotensin receptor blockers (ARBs) (1.9%). The commonest two drug therapy was with CCB and diuretic (15.7%), followed by CCB and BB (7.3%), CCB and ACEI (4.2%), ACEI and diuretic (3.4%), ARBs and diuretic (2.7%), BBs and diuretic (1.9%). The commonest three drug therapy was with CCBs, BBs, and diuretic (4.2%). Conclusion: The most favored class of antihypertensive drugs, either as monotherapy or combination therapy in hypertensive patients with or without comorbidities was CCBs. There was underutilization of thiazide diuretics, ACEIs and BBs in this study. Overall the general pattern of antihypertensive prescribing in this study is only partly in accordance with the guidelines of JNC-7.
Keywords: Angiotensin-converting enzyme inhibitors, calcium channel blockers, diabetes mellitus, hypertension, Seventh Report of the Joint National Committee guideline, prescribing pattern
|How to cite this article:|
Gupta SK, Nayak RP, Rahavi R, Kumar A. A cross-sectional retrospective study to assess the pattern of prescribing for inpatient hypertensive cases in a tertiary hospital and to find out the possible avenues for betterment of hypertension management. Arch Med Health Sci 2015;3:60-5
|How to cite this URL:|
Gupta SK, Nayak RP, Rahavi R, Kumar A. A cross-sectional retrospective study to assess the pattern of prescribing for inpatient hypertensive cases in a tertiary hospital and to find out the possible avenues for betterment of hypertension management. Arch Med Health Sci [serial online] 2015 [cited 2020 May 25];3:60-5. Available from: http://www.amhsjournal.org/text.asp?2015/3/1/60/154947
| Introduction|| |
One of the important public health issues in India and other developing countries is hypertension. , Fortunately, it is one of the most decisive modifiable risk elements for cardiovascular diseases.  Apart from the lifestyle modifications, the efficient management of hypertension with antihypertensive agents (AHAs) considerably decreases the possibility of stroke, heart failure, coronary heart disease, and end-stage renal disease. , To achieve the goal of normal blood pressure (BP), practice guidelines serve as useful tools for clinical decision making. ,, The most notable evidence-based practice guideline for the management of hypertension is the Seventh Report of the Joint National Committee (JNC-7) on the Detection, Evaluation and Treatment of High BP. JNC-7 provides guidelines and advisories delineated to improve treatment and control of hypertension. , Datta has pointed out that the Indian guidelines, recommended by the Cardiology Society of India, The Hypertension Society of India, and the Indian College of Physicians closely follow the JNC guidelines. 
In spite of the presence of practice guidelines and effective drugs, hypertension management in the society is far from satisfactory. Reported studies have shown that only 50% of physicians prescribe in accordance with guideline recommendations. , Hence, the primary objective of this study was to characterize the prescribing pattern of AHAs in the tertiary care teaching hospital in order to get insight of the patterns of care for inpatients hypertensive cases and to find possible avenues for betterment of hypertension management. The secondary objective of this study was to assess the appropriateness of the prescribing pattern of antihypertensive drugs as per the JNC-7 guidelines.
| Materials and Methods|| |
In-patient Department of General Medicine at Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Perambalur, Tamil Nadu, India.
The study was approved by institutional Ethics Committee of DSMCH, Perambalur. Permission was also obtained from Head of the institute to access case records.
As the study involved only retrospective analysis of records, it is not applicable.
It was a cross-sectional retrospective study. Initially, the case records of patients from the Medical Records Unit of the hospital were retrieved. Then, the relevant information from the case record was entered in the preformed performa. The requisite patients' information included: Registration number, age, gender, systolic, and diastolic BP readings (at the time of admission), the antihypertensive medications prescribed and comorbid conditions. The name of the patient was not included in the recording format to maintain the confidentiality. The hypertension was classified in the study based on JNC-7 guidelines. The prescribing pattern of antihypertensive drugs in the studied population was noted and whether patients were on monotherapy or polytherapy was also observed. The prescription of one antihypertensive drug with only one active ingredient was designated as monotherapy. Polytherapy was denoted when patients were prescribed more than one active ingredient, either in one combination or as two different, single pills. The pattern of monotherapy or polytherapy was also examined. 
Data were collected for the period of 7 months (June 2012 to January 2013).
Inclusion and exclusion criteria
Patients above 18 years of age and suffering from essential hypertension and on at least one antihypertensive drug with or without other comorbid conditions were included in the study. All the outpatient department cases were excluded and only inpatient cases of Department of General Medicine regardless of the span of hospitalization were included in the study.
Only 261 case reports met the inclusion criteria.
Data analysis was performed using the Statistical Program for the Social Sciences (SPSS) software, version 16.
| Results|| |
A total of 261 hypertensive patients on treatment were included, of which 57.9% were females and 42.1% males. Mean age was 57.87 years (SD ± 12.23). [Table 1] shows demographic details. The patients were classified according to the JNC-7 classification criteria for hypertension. Majority of the patients in this study were categorized as stage 2 hypertension. Others were classified as stage 1 and least number of patients in the prehypertensive category of JNC-7 [Table 2].
|Table 2: Classification of patients according to the JNC-7 criteria for staging of hypertension|
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Hypertension alone was present in 26.8% of the patient whereas diabetes mellitus was the most common comorbid condition in 18.8% of the cases. Other comorbid conditions were nephropathy (13.8%), ischemic heart disease (IHD) (8.4%), and cerebrovascular disease (5.0%). Many patients were also suffering from more than one comorbid condition at the same time [Table 3].
Mono or combination therapy
Of the 261 patients studied, 47.1% were on monotherapy and 52.8% on combination therapy. Of the patients on combination therapy, 40.2%, 10.7%, and 1.9% were on 2, 3, and 4 drugs, respectively [Table 4]. The most common monotherapy agents being prescribed were calcium channel blockers (CCBs) (26.8%), followed by diuretic (9.6%), angiotensin-converting enzyme inhibitors (ACEIs) (5%), beta blockers (BBs) (3.8%), and angiotensin receptor blockers (ARBs) (1.9%). The most common two drug therapy was with CCB and diuretic (15.7%), followed by CCB and BB (7.3%), CCB and ACEI (4.2%), ACEI and diuretic (3.4%), ARB and diuretic (2.7%), BBs and diuretic (1.9%). The most common three drug therapy was with CCBs, BBs, and diuretic (4.2%), followed by ARB + diuretic + CCB (1.5%) and ACEI + CCB + BB (1.1%) [Table 5].
|Table 5: Frequency (%) of prescription of one, two, three, and four antihypertensive drug|
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Antihypertensive drugs prescribed with different co-morbidities
The commonest monotherapy agents prescribed in hypertensive with diabetes mellitus were CCB (5.74%), followed by diuretic (1.91%), ACEI (1.53%), BBs and ARBs (0.76% each). The commonest monotherapy agents prescribed in hypertensive with nephropathy were CCB (3.44%), followed by diuretic (0.76%) and ACEI (0.38%). CCB (0.76%), diuretic (0.76%), BBs (0.76%) and ACEI (0.38%) were the different monotherapy agent prescribed in hypertensive with IHD.
The most common two drug therapy in hypertensive with diabetes mellitus was with CCB and BB (1.91%), CCB and diuretic (1.53%), CCB and ACEI (1.53%), ARB and diuretic (0.76%) and BBs and ACEI (0.76%). The most common two drug therapy in hypertensive with nephropathy was with CCB and diuretic (4.21%), CCB and BB (1.15%), BBs and diuretic (0.38%), CCB and ARB (0.38%). The most common two drug therapy in hypertensive with IHD was CCB and diuretic (1.15%), CCB and BB (0.76%), ARB and diuretic (0.76%), CCB and ACEI (0.38%), ACEI and diuretic (0.38%), BB, and ACEI (0.38%). The most common three drug therapy in hypertensive with IHD was BB + ACEI + diuretic (0.76%).
| Discussion|| |
In this cross-sectional retrospective study done on inpatients of the department of medicine in a tertiary care teaching hospital, there was a higher prevalence of hypertension in elderly patients. The maximum number of patients was found to be in the age group of 50-64 years followed by age group of ≥65 years. In fact, it is well established fact that increase in BP happens gradually with the increasing age, and that majority of the elderly can be denoted as hypertensive with stage 2 hypertension. , The present study observed that hypertension was more prevalent in female than in males. This finding corroborates with the result of the study conducted in Chandigarh which also reported that the incidence of hypertension was high among women.  Moreover, hypertension is one of the main causes of mortality due to cardiovascular disease in women. ,
Calcium channel blockers were more commonly prescribed drugs both as a single drug therapy and in overall utilization. The other antihypertensive drugs were prescribed alone or in combination in following order diuretic, BBs, ACEI, and ARBs [Table 6]. Amlodipine was the most commonly prescribed individual drug [Table 7]. The large proportion of prescription of CCB's may be because of the type of patients referred to this tertiary care center with complications related to the cardiovascular, renal and other systems or refractory hypertension.  Moreover, because in this study majority of the subjects were above 50 years of age, the extensive use of CCB was noted because drug of choice for the elderly patient is CCB or diuretic. , It was however noted that though the use of diuretics was present but in less proportion. Surprisingly, the prescription of furosemide was relatively more in this inpatient study compared to the thiazide diuretics [Table 7].
|Table 6: Antihypertensive drugs prescribed as monotherapy and in overall utilization in hypertensive patients|
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|Table 7: Antihypertensive drugs prescribed individually in overall prescriptions|
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Seventh Report of the Joint National Committee guidelines recommend that thiazide diuretics should be prescribed as initial treatment for most patients with uncomplicated hypertension either alone or in combination with drugs from other classes. ,, In spite of these recommendations, diuretics particularly thiazide diuretics were found to be prescribed less often to patients as single drug treatment in our study. The restricted prescribing of diuretics by doctors has been earlier reported due to the misconception about the safety and efficacy of diuretics. ,, For example, doctors hesitate to prescribe diuretics due to apprehension about an adverse electrolyte imbalance, like hyponatremia, which particularly in the elderly patients could have harmful effects. 
Seventh Report of the Joint National Committee guidelines advocate ACEIs as the favored drug for hypertension associated with chronic kidney disease, diabetes, or congestive heart failure. ACEIs or diuretics are also recommended for preventing recurrent stroke. , Because there were a high number of hypertensive patients suffering from diabetes and kidney disease in our study, hence the decreased usage of ACEIs is not in conformance with JNC-7 guidelines which advocate its use for renoprotection in this patient group. JNC-7 reports endorse that except for the contraindications, patients with diabetic and non-diabetic renal disease should be prescribed an ACEI to halt the disease progression. ,
Furthermore, prescription of BBs in our study was not in accordance with recommendations of JNC-7. JNC-7 guideline recommends that BBs, particularly cardioselective BBs, are useful to diabetics as part of multidrug therapy, even though there is less clarity about their utility as monotherapy. It further states that a BB should be prescribed in diabetic patients with IHD even though they are inferior in preventing stroke. , Under prescription of BBs in our study might be due to the reason that most of our patients were simultaneously suffering from diabetes mellitus, and conventionally the use of these drugs are discouraged in diabetes. 
In our study, majority of the patients were on combination therapy and diuretic was part of most of the combination regimen [Table 5]. This finding is as per the JNC-7 guideline which also asserts that most patients require two or more drugs to achieve BP control and diuretics should form a part of the combination if two drugs are being used to treat hypertension. , As diuretics are known to complement the antihypertensive efficacy of multidrug regimen, they can be valuable in accomplishing BP control and moreover they are cheaper than other AHAs. The addition of diuretics in multidrug regimens has been reported to be useful for BP control due to their competence to reduce blood volume and vascular resistance. Above all, the JNC-7 guideline reports that volume overload due to inadequate diuretic therapy is one of the commonest reason for resistance to hypertension treatments. ,,
Strengths and limitations of the study
It is a well-known fact that the prescribing pattern surveys are one of the effective techniques that provide an unbiased picture of prescribing habits. Prescription surveys permit the identification of suboptimal prescribing patterns for further evaluation.  This study was done on inpatients, and inpatient based prescription survey has benefit of reducing the subjects who drop out due to various reasons.
There were a number of limitations of the study which includes its cross-sectional nature. Another limitation is the retrospective nature of this study. This was a single center study, and, therefore, the findings cannot be generalized to reflect the entire tertiary care setting in India. It is recommended that larger prescribing pattern surveys involving more tertiary care hospitals be conducted to assess the overall situation. Moreover, this study has been conducted in a tertiary care hospital and patients who receive health care in primary or secondary centers may have a different pattern of antihypertensive therapy.
| Conclusion|| |
It was noted that the most favored class of antihypertensive drugs, either as monotherapy or combination therapy in hypertensive patients with or without comorbidities was CCBs. There was underutilization of thiazide diuretics, ACEIs and BBs in this study, in spite of reasonable evidences backing their prescription. Overall, the general pattern of antihypertensive prescribing in this study is only partly in accordance with the guidelines of JNC-7. These findings reemphasize the fact that prescribing is a composite practice which is concurrently influenced by various factors and different practicing guidelines is only one of those factors.  Few other factors influencing prescribing might be viewpoint and understanding of both patients and doctors and cost of the medicine. The marketing influence of the pharmaceutical industry cannot be ruled out. The other factor influencing the therapeutic decisions of doctors regardless of guidelines might be accessibility of a particular drug in the hospital pharmacy. ,
The prescribing of thiazide diuretics should be boosted because they have got good safety profile and are cheaper, and various reported studies reinforce the role of thiazide diuretics in the treatment of hypertension to reduce cardiovascular complications and stroke.  The information about the efficacy and safety of thiazide diuretics should be forwarded to the prescribing physicians.  The use of ACEI should also be encouraged because in diabetic patients they have cardio- and renoprotective actions.  In addition, the use of BBs should be boosted because according to JNC-7 guideline, even though BBs can cause adverse metabolic effects in diabetics such as deterioration of insulin sensitivity and the masking of hypoglycemic symptoms, these issues can be easily managed, and these factors cannot out rightly restrict the use of BBs in diabetic patients with hypertension. 
Anand has earlier reported that the difficulty in the Indian context is that the knowledge about practicing guidelines is not passed on for implementation to the physicians. He further states that besides issues of cost and compliance, considerable effort and resources is needed to regularly update the knowledge of the physicians. He points toward the fact that JNC-7 also emphasizes that despite enhanced knowledge about hypertension, the healthcare systems across the world have not been able to translate knowledge about hypertension into practice. Hence, it is recommended that regular training should be provided to prescribers on practicing guidelines and rational use of drugs in hypertension. 
| Acknowledgment|| |
I gratefully acknowledge the help of Head of the Institute of the Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur - 621 212, Tamil Nadu, India.
| References|| |
Mohan S, Campbell N, Chockalingam A. Time to effectively address hypertension in India. Indian J Med Res 2013;137:627-31.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension : a0 nalysis of worldwide data. Lancet 2005;365:217-23.
Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ, Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.
Wang JG, Li Y. Primary and secondary prevention of stroke by antihypertensive drug treatment. Expert Rev Neurother 2004;4:1023-31.
Bøg-Hansen E, Lindblad U, Ranstam J, Melander A, Råstam L. Antihypertensive drug treatment in a Swedish community : S0 karaborg Hypertension and Diabetes Project. Pharmacoepidemiol Drug Saf 2002;11:45-54.
Wagner EH. Chronic disease management : w0 hat will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2-4.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness : t0 he chronic care model, Part 2. JAMA 2002;288:1909-14.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al.
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
U.S. Department of Health and Human Services. National Institutes of Health. National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 04-5230, August 2004. Available from: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
. [Last accessed on 2013 Jul 09].
Datta S. Use of antihypertensives in patients having associated renal parenchymal disorders : C0 ross sectional prescription pattern study in a tertiary care hospital. Int J Pharm Sci Drug Res 2011;3:256-9.
Ramli AS, Miskan M, Ng KK, Ambigga D, Nafiza MN, Mazapuspavina MY, et al
. Prescribing of antihypertensive agents in public primary care clinics - Is it in accordance with current evidence? Malays Fam Physician 2010;5:36-40.
Holmes JS, Shevrin M, Goldman B, Share D. Translating research into practice : a0 re physicians following evidence-based guidelines in the treatment of hypertension? Med Care Res Rev 2004;61:453-73.
Abdulameer SA, Sahib MN, Aziz NA, Hassan Y, Alrazzaq HA, Ismail O. Physician adherence to hypertension treatment guidelines and drug acquisition costs of antihypertensive drugs at the cardiac clinic : a0 pilot study. Patient Prefer Adherence 2012;6:101-8.
Virdis A, Bruno RM, Neves MF, Bernini G, Taddei S, Ghiadoni L. Hypertension in the elderly : a0 n evidence-based review. Curr Pharm Des 2011;17:3020-31.
Tiwari H, Kumar A, Kulkarni SK. Prescription monitoring of anti-hypertensive drug utilisation at the Panjab University Health Centre in India. Singapore Med J 2004;45:117-20.
Geraci TS, Geraci SA. Considerations in women with hypertension. South Med J 2013;106:434-8.
Pimenta E. Hypertension in women. Hypertens Res 2012;35:148-52.
Denis X, Noby M, Johnson P, Prem P. Pattern of drug use in hypertension in a tertiary hospital: A cross sectional study in the in-patient wards. Indian J Pharmacol 2001;33:456-7.
Steffen HM. Use of calcium channel antagonists for the treatment of hypertension in the elderly. Drugs Aging 2004;21:565-81.
Grossman E, Verdecchia P, Shamiss A, Angeli F, Reboldi G. Diuretic treatment of hypertension. Diabetes Care 2011;34 Suppl 2:S313-9.
Singh H, Johnson ML. Prescribing patterns of diuretics in multi-drug antihypertensive regimens. J Clin Hypertens (Greenwich) 2005;7:81-7.
Rochefort CM, Morlec J, Tamblyn RM. What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study. BMC Fam Pract 2012;13:9.
Maghrabi IA. Evaluation of antihypertensive prescribing patterns in the western region of Saudi Arabia and its compliance with national guidelines. Saudi J Health Sci 2013;2:118-26.
Konzem SL, Devore VS, Bauer DW. Controlling hypertension in patients with diabetes. Am Fam Physician 2002;66:1209-14.
Montgomery BD, Mansfield PR, Spurling GK, Ward AM. Do advertisements for antihypertensive drugs in Australia promote quality prescribing? A cross-sectional study. BMC Public Health 2008;8:167.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]