Beth Wallace, BSN, RN-BC, FNP-S Fairfield University Summer 2010 Hypertension Management Southwest Community Health Center - MARINA VILLAGE Bridgeport, CT Beth Wallace, BSN, RN-BC, FNP-S Fairfield University Summer 2010

Background Southwest Community Health Center Bridgeport, CT

Background Hypertension 31.3% of U.S. adults, about 75 million, has high blood pressure About 25% of U.S. adults has prehypertension Hypertension is a major risk factor for heart disease, stroke, heart failure, and kidney disease Heart disease and stroke are the first and third leading cause of death in U.S.

Background Hypertension Highest incidence among African Americans, occurs at earlier age, average BP much higher Among African Americans, highest rates middle aged or older, less educated, overweight, physically inactive, with diabetes 2006 death rates per 100,000 pop from hypertension: 15.6 white males, 51.1 black males, 14.3 white females, 37.7 black females

Background Hypertension Estimated to cost U.S. $76.6 billion in health care services, medications and missed days of work in 2010 The most common primary diagnosis in the United States 44 million office visits 9 million hospitalizations (primary or secondary diagnosis)

Background Hypertension 78.7% aware of diagnosis 69.1% under current treatment 45.4% controlled, 54.6% uncontrolled Most will require two or more medications to achieve BP goal

Background Hypertension Healthy People 2010 Disease prevention and health promotion Overarching goals to increase quality and years of healthy life and eliminate health disparities Hypertension goals Reduce proportion of adults with hypertension Increase proportion whose blood pressure is in control to 50%

Background Hypertension Guidelines

Background Hypertension Guidelines Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), December 2003 JNC 8 due Fall 2011

Background Hypertension Guidelines JNC 7 created by coalition of 39 major professional, public, voluntary organizations and seven federal agencies U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute National High Blood Pressure Education Program

Background Hypertension Guidelines JNC 7 classification BP Systolic BP mmHG Diastolic BP Normal < 120 and < 80 Prehypertension 120-139 or 80-89 Stage 1 Hypertension 140-159 or 90-99 Stage 2 >160 or > 100

Background Hypertension Guidelines JNC 7 management recommendations BP Classification Lifestyle Modification Initial Drug Therapy Without Compelling Indication Normal < 120/80 Encourage No antihypertensive drug indicated Prehypertension 120/80 – 139/89 Yes Stage 1 Hypertension 140/90 – 159/99 Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination Stage 2 > 160/100 Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

Background Hypertension Guidelines JNC 7 management recommendations BP Classification Lifestyle Modification Initial Drug Therapy With Compelling Indication Normal < 120/80 Encourage Prehypertension 120/80 – 139/89 Yes Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 Stage 1 Hypertension 140/90 – 159/99 Stage 2 > 160/100

Background Hypertension Guidelines JNC 7 management recommendations Compelling Indication Initial Drug Therapy Heart failure Diuretic, BB, ACEI, ARB, Aldo Ant Postmyocardial infarction BB, ACEI, Aldo Ant High coronary disease risk Diuretic, BB, ACEI, CCB Diabetes Diuretic, BB, ACEI, ARB, CCB Chronic kidney disease ACEI, ARB Recurrent stroke prevention Diuretic, ACEI

Objectives To measure the proportion of SWCHC patients that meet best practice hypertension guidelines Compare Marina Village homeless with non-homeless Compare diabetic with non-diabetic Create action plan based on findings

Method Chart review Special populations included Other characteristics Random selection of patients with hypertension 18 years or older Seen within last 12 months 3rd or more visit since hypertension diagnosis Special populations included Diabetic Homeless Other characteristics Sex, BMI, antihypertensive medications

Method 39 charts reviewed Female 22 56% Male 17 44% Homeless 21 54% Diabetic 17 44%

Findings Compliance with hypertension guidelines Total Marina Patients (39) 100% Homeless Patients (21) 100% Non-Homeless (18) 100% At BP goal (25) 64% (13) 62% (12) 67% Above BP goal (14) 36% (8) 38% (6) 33%

Findings Compliance with hypertension guidelines Total Marina Patients (39) 100% Diabetic Patients (17) 100% Non-Diabetic (22) 100% At BP goal (25) 64% (11) 65% (14) 64% Above BP goal (14) 36% (6) 35% (8) 36%

Findings Compliance with hypertension guidelines Total Marina Patients (39) 100% Homeless Patients (21) 100% Diabetic Non-DM (10) 100% (11) 100% Non-Homeless (18) 100% Diabetic Non-DM (7) 100% (11) 100% At BP goal (25) 64% (6) 60% (7) 64% (5) 71% Above BP goal (14) 36% (4) 40% (4) 36% (2) 29%

Findings Compliance with hypertension guidelines Medications Total Marina Patients (39) 100% At goal Above (25) (14) 100% 100% Homeless Patients (21) 100% At goal Above (13) (8) Non-Homeless (18) 100% At Goal Above (12) (6) 100% 100% One med (9) 36% (2) 14% (7) 54% (2) 25% (2) 17% - Two meds (12) 48% (3) 21% (4) 31% (3) 37.5% (8) 66% > Three meds (4) 16% (9) 65% (2) 15% (6) 100%

Findings Compliance with hypertension guidelines 64% of all Marina patients at BP goal Compliance among special populations 62% of Homeless patients at BP goal (67% of non-homeless) 65% of Diabetic patients at BP goal 60% of Homeless Diabetics at BP goal (71% of non homeless diabetics)

Findings Antihypertensive medications needed to reach BP goal 84% of patients at goal take one or two medications 65% of patients above goal are uncontrolled on 3 or more medications

Conclusions SWCHC Marina meeting hypertension guidelines Overall, 64% at BP goal Above Healthy People 2010 goal of 50% at goal Special populations also at goal including Homeless and Diabetic Utilizing combination medication therapy Future emphasis on lifestyle modification, particularly among those uncontrolled on three or more medications

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