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First-line first? Trends in thiazide prescribing for hypertensive seniors
Steve Morgan1, Kenneth L Bassett, James M Wright
1Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada. morgan@chspr.ubc.ca
Insights
First-line hypertension treatment for seniors often deviates from evidence-based guidelines. Thiazide diuretics, recommended for effectiveness and cost, were underutilized, especially in patients with comorbidities, indicating significant health and financial costs.
Area of Science:
- Cardiology
- Pharmacology
- Geriatrics
Background:
- Thiazide diuretics are recommended as first-line treatment for hypertension due to proven cardiovascular benefits and cost-effectiveness.
- Hypertension management in seniors requires careful consideration of comorbidities and evidence-based prescribing.
Purpose of the Study:
- To assess the proportion of senior patients receiving thiazide diuretics as first-line hypertension therapy.
- To investigate whether cardiovascular and other comorbidities influence the choice of initial hypertension treatment.
Main Methods:
- Utilized British Columbia PharmaCare data (1993-2000) to identify seniors initiating hypertension drug therapy.
- Linked prescription data with health claims to analyze first-line treatment choices in relation to patient demographics and comorbidities.
Main Results:
- 82,824 seniors were included; first-line thiazide use varied significantly (38% without comorbidity to 9% with prior myocardial infarction).
- First-line thiazide prescribing increased over the study period, with higher rates in women and older patients.
- Comorbidities, particularly acute myocardial infarction, were associated with lower thiazide prescribing rates.
Conclusions:
- First-line hypertension prescribing practices in seniors are not fully aligned with evidence from clinical trials.
- Suboptimal selection of effective and cost-efficient therapies incurs substantial health and financial burdens.
Background:
Evidence of reduced cardiovascular morbidity and mortality as well as cost support thiazide diuretics as the first-line choice for treatment of hypertension. The purpose of this study was to determine the proportion of senior hypertensives that received thiazide diuretics as first-line treatment, and to determine if cardiovascular and other potentially relevant comorbidities predict the choice of first-line therapy.
Methods And Findings:
British Columbia PharmaCare data were used to determine the cohort of seniors (residents aged 65 or older) who received their first reimbursed hypertension drug during the period 1993 to 2000. These individual records were linked to medical and hospital claims data using the British Columbia Linked Health Database to find the subset that had diagnoses indicating the presence of hypertension as well as cardiovascular and other relevant comorbidities. Rates of first-line thiazide prescribing as proportion of all first-line treatment were analysed, accounting for patient age, sex, overall clinical complexity, and potentially relevant comorbidities. For the period 1993 to 2000, 82,824 seniors who had diagnoses of hypertension were identified as new users of hypertension drugs. The overall rate at which thiazides were used as first-line treatment varied from 38% among senior hypertensives without any potentially relevant comorbidity to 9% among hypertensives with previous acute myocardial infarction. The rate of first-line thiazide diuretic prescribing for patients with and without potentially relevant comorbidities increased over the study period. Women were more likely than men, and older patients were more likely than younger, to receive first-line thiazide therapy.
Conclusions:
Findings indicate that first-line prescribing practices for hypertension are not consistent with the evidence from randomized control trials measuring morbidity and mortality. The health and financial cost of not selecting the most effective and least costly therapeutic options are significant.
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