Initial medication selection for treatment of hypertension in an open-panel HMO

During the past 25 years recommendations for treating hypertension have evolved from a stepped-care approach to monotherapy or sequential monotherapy as experience has been gained and new antihypertensive agents have been introduced. In an effort to develop a disease management strategy for hypertension, we investigated the prescribing patterns of initial medication therapy for newly treated hypertensive patients.

We examined paid claims data of an open-panel HMO located in the midwest. Charts from 377 patients with newly treated hypertension from a group of 12,242 hypertensive patients in a health insurance population of 85,066 persons were studied. The type of medication regimen received by patients newly treated for hypertension during an 18-month period was categorized into monotherapy, sequential monotherapy, stepped care, and initial treatment with multiple agents. With monotherapy, the class of medication was also reported. Associations between use of angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, or beta-blockers and presence of comorbid conditions were reported.

Fifty-five percent of patients received monotherapy, 22 percent received stepped care, and 18 percent received sequential monotherapy. Of those 208 patients receiving monotherapy, 30 percent were prescribed a calcium channel blocker, 22 percent an ACE inhibitor, and 14 percent a beta-blocker. No customization of treatment for comorbid conditions was noted.

Physicians attempt to treat patients' hypertension with monotherapy. In the majority of cases, they have used either a calcium channel blocker or ACE inhibitor as initial monotherapy. Costs for treating hypertension could be reduced and care improved if thiazide diuretics, a combination of potassium-sparing and thiazide diuretics, or beta-blockers were used more frequently as initial monotherapy.