Effective Management of Hypertension: A Cross-Sectional Study of Five Health Facilities

doi:10.21203/rs.3.rs-4471168/v1

Background

Hypertension remains a significant global health concern due to its high incidence and association with cardiovascular diseases, stroke, and other complications. This research aimed to determine the dynamics of blood pressure control over the course of disease management, focusing on the systolic and diastolic readings at baseline and at the time of the study and on the number of years of patient management and sex.

Methods

A retrospective study with a multicenter approach was used. The information of a total of 373 patients was collected and analyzed using Python and SPSS.

Results

Overall, 72.9% of the patients were female, and 27.1% were male. The mean age was 62.57 ± 0.635 years. A regression model was used to evaluate the associations between the number of years of hypertension management, systolic anddiastolic BP at first diagnosis and current systolic and diastolic BP at R-square, (13.2% and 29.2%, respectively; p<0.01). There was a significant reduction in the systolic BP before (M = 157.01 ± 28.159) compared to after (M =138.07 ± 19.591), t (372) = 12.959, p <0.001. Similarly, the results showed a significant reduction in the diastolic BP of the patients before (M = 91.85 ± 15.934) compared to after (M =85.19 ± 12.955), t (372) = 9.062, p <0.001. There was a greater systolic BP at first diagnosis in males than in females.

Conclusions

The number of years of hypertension management and BP at first diagnosis may be associated with the outcome of management. Appropriate treatment combinations involving two classes of antihypertensive drugs may encourage patient adherence and yield positive outcomes.

Clinical Pharmacology

Hypertension

calcium-channel blockers

comorbidities

diabetes mellitus

arthritis

adherence

polypharmacy.

Hypertension, a chronic medical condition characterized by elevated blood pressure levels, remains a significant global health concern due to its high prevalence and association with cardiovascular diseases, stroke, and other complications [1, 2]. Effective management of hypertension is essential for mitigating the risk of adverse health outcomes and improving the overall quality of life of affected individuals [3].

In recent years, there has been increasing recognition of the complexity surrounding hypertension management, particularly concerning diverse prescribing patterns, varying durations of management, and the presence of comorbidities [4, 5]. Healthcare providers face the challenge of tailoring treatment strategies to meet the unique needs of each patient while navigating through an array of available antihypertensive medications and therapeutic approaches [5, 6].

The management of hypertension involves the prescription of various classes of antihypertensive medications, including diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and others [7, 8, 9]. Each class of medication has distinct mechanisms of action and efficacy profiles, necessitating careful consideration of individual patient characteristics and treatment goals when selecting the appropriate regimen [10, 11].

Understanding the different prescribing patterns adopted by healthcare providers is crucial for evaluating their impact on treatment outcomes, patient adherence, and healthcare resource utilization [12]. Variations in prescribing practices may stem from factors such as clinical guidelines, physician preferences, patient demographics, and drug availability, highlighting the need for comprehensive assessment and comparison of these approaches [3, 12, 13].

The duration of hypertension management encompasses both short-term interventions to achieve blood pressure control and long-term strategies aimed at preventing disease progression and reducing cardiovascular risk [2]. Effective management requires a sustained commitment to treatment adherence, lifestyle modifications, and periodic monitoring to ensure that therapeutic goals are met and maintained over time [14, 15].

Hypertension frequently coexists with various comorbidities, including diabetes mellitus, obesity, dyslipidemia, chronic kidney disease, and cardiovascular disorders, posing additional challenges to effective management [16]. The presence of comorbid conditions may influence treatment decisions, medication selection, and treatment goals, requiring a comprehensive and multidisciplinary approach to patient care.

Addressing the complex interplay between hypertension and comorbidities necessitates integrated management strategies that consider the unique clinical characteristics and treatment priorities of each patient [17].

In summary, effective management of hypertension requires a nuanced understanding of multiple factors, including diverse prescribing patterns, treatment durations, and comorbidities. By exploring these aspects through rigorous research and evidence-based practices, healthcare providers can enhance the quality of hypertension care and mitigate the burden of this prevalent chronic condition on individuals and healthcare systems worldwide.

The quest for managing hypertension is an ongoing challenge in the medical field. This research aimed to determine the dynamics of blood pressure control over the course of treatment, focusing on systolic and diastolic readings as primary indicators of cardiovascular health. The study was predicated on the hypothesis that current systolic and diastolic pressures should be lower than those recorded at the initial diagnosis, reflecting the efficacy of the interventions applied. The second hypothesis that is closely related to the first is that as the number of years of management increases, there should be a corresponding decrease in the blood pressure reading, thus making the current systolic and diastolic measurements lower than those at the first diagnosis.

To explore this phenomenon, we identified current systolic and diastolic blood pressure as dependent variables, which are influenced by various factors throughout the management period. The number of years of treatment or management was considered an independent variable, providing insight into the longitudinal impact of sustained medical intervention on blood pressure levels.

Furthermore, the research investigated potential disparities in systolic and diastolic blood pressure based on the sex of the patient to determine the demographic factors influencing treatment outcomes. Additionally, we examined the correlations between current systolic and diastolic blood pressure measurements and their respective values at the first diagnosis to assess the long-term trends in blood pressure changes. Through this study, we aim to contribute valuable data to the body of knowledge on hypertension management, potentially informing future treatment protocols and improving patient care outcomes.

Study Design

A retrospective study with a multicenter approach was used to capture diverse patient populations and healthcare settings. Quantitative data collection methods were used for comprehensive analysis.

Inclusion criteria

Adults aged 18 years and above were diagnosed with hypertension.

Patients receiving treatment for hypertension in the selected health facilities.

Exclusion criteria

Patient information retrieval software or folders lacked the required information.

Sampling Strategy and Site

Convenience sampling was performed at five health facilities (Bomso Clinic, Rev. Walker Specialist Hospital, AAMUSTED Clinic, Anwiam District Hospital and Pramso Hospital in Ashanti Region-Ghana).

Data collection and sample size

The quantitative data included baseline demographic information, blood pressure measurements at baseline and at the time of data collection, management regimens, and changes in therapy. A total of 200 patient data points were collected from each health facility. However, after careful cleaning of the data gathered, we obtained a total of 373 participants.

Outcome Measures

Primary Outcomes: Blood pressure control rates defined by guideline-recommended targets based on the current systolic and diastolic blood pressure.

Incidence of cardiovascular events (e.g., myocardial infarction, stroke) and other hypertension-related complications.

Data analysis

Descriptive analysis of baseline characteristics and treatment patterns. Multivariate regression modeling was used to identify independent predictors of hypertension management outcomes, adjusting for potential confounders.

Ethics approval and consent to participate

Ethics approval and consent to participate were obtained from the institutional review board of the Institute of Research, Innovation and Development (IRID). Approval was also obtained from the health facilities since the research relied solely on patient information (secondary data). Patient confidentiality and privacy were maintained throughout the research process.

3.1 Demographics

There was a greater percentage of female hypertensive patients than male patients (72.9% and 27.1%, respectively). Additionally, the mean age was 62.57 ± 0.635 years. It was observed that, in some patients, the systolic and diastolic BP increased rather than decreased, leading to negative values for the difference in systolic and diastolic BP. (Table 1)

3.2 Association between the number of years of hypertension management and outcome (current systolic and diastolic)

When regression models were estimated using Python, several regression equations were generated.

Null Hypothesis: There is no association between the number of years of hypertension management and current systolic/diastolic BP.

Alternate Hypothesis: There is an association between the number of years of hypertension management and current systolic/diastolic BP.

Regression model 1

Y = -0.47X₁ + 0.264X₂ + 100.071

where Y = current systolic BP, X₁= number of years of management, and X₂= systolic BP at first diagnosis.

The R-square was 13.2%, and the F-statistic was significant at p<0.001. All the coefficients are statistically significant at p<0.01.

This means that we can reject the null hypothesis that there is no association between the number of years of hypertension management and management outcome, specifically, the current systolic level.

Regression model 2

Y = 0.204X₁ + 0.421X₂ + 45.066

where Y = current diastolic BP, X₁ = number of years of management, and X₂= diastolic BP at first diagnosis.

The R-square was 29.2%, and the F-statistic was significant at p<0.01. However, the coefficient of the number of years of hypertension management was not statistically significant.

This means that diastolic BP may not be strongly affected by the number of years of management.

3.3 Positive management outcomes (reduced current systolic and diastolic) with conventional drug therapy for hypertension

A paired sample t test was performed to evaluate the impact of pharmacological management on the BP readings. The results showed a significant reduction in the systolic BP of the patients before (M = 157.01 ± 28.159) compared to after (M =138.07 ± 19.591), t (372) = 12.959, p <0.001 (two-tailed). The mean decrease in systolic BP was 18.979, Std. Error was 1.465, with a 95% confidence interval ranging from 16.099-21.858. The eta-squared value of 0.311 indicated a medium effect size. (Table 2)

Similarly, the results showed a significant reduction in the diastolic BP of the patients before (M = 91.85 ± 15.934) compared to after (M =85.19 ± 12.955), t (372) = 9.062, p <0.001 (two-tailed). The mean decrease in diastolic BP was 6.66, Std. Error was 0.735, with a 95% confidence interval ranging from 5.215-8.105. The eta-squared value of 0.181 indicated a small effect size. (Table 2)

It can also be inferred from the data analysis that conventional drug therapy yields a positive outcome. Additionally, there were few records (2 out of 373, 0.54%) of cardiovascular accidents (CVA), strokes (none reported) or hypertensive crises (none reported).

Relationship between the BP at the first diagnosis and the current BP

There was a positive correlation between the systolic level at first diagnosis and the current level, as did the diastolic level (Figure 1 & Table 3). This result was significant at p < 0.001. (Table 4). This means that patients who had higher systolic or diastolic BP readings at first diagnosis had greater current systolic or diastolic BP readings than did those who had lower values.

Disparities between hypertension characteristics and management outcomes according to patient sex

Independent sample t tests were performed to compare hypertension characteristics between males and females. There were significant differences (t (371) = 3.37, p < 0.01) in the systolic blood pressure at first diagnosis, with the mean BP for males (M = 165 ± 33.2) being greater than that for females (M = 154.09 ± 25.5). The magnitude of the differences in means (mean difference = 10.91 ± 3.2, 95% CI: 4.54 to 17.27) was significant. However, there were no statistically significant differences between males and females for either the current systolic BP or both the diastolic BP at first diagnosis and the current diastolic BP. This finding implies that although there was a greater percentage of females with hypertension in this dataset, males had a relatively higher systolic BP at first diagnosis than females did. (Table 4).

Common first-line therapy drugs

Nifedipine and amlodipine are the most common calcium channel blocker drugs (CCBs) used for initial management. (Figure 2). Angiotensin II receptor blockers (ARBs) also seem to be prescribed more than angiotensin converting enzyme inhibitors (ACEIs). The term “polypharmacy”, which connotes the pattern of multiple prescriptions for hypertension management, did not seem to be evident, as the mean number of drugs per patient was 1.49 ± 0.031. (Table 1).

Prevalent comorbidities

Type 2 diabetes mellitus was the most prevalent comorbidity and was reported by many the respondents. (Figure 3). Notable comorbidities reported by patients were arthritis; peripheral neuropathy; and musculoskeletal conditions such as myalgia, lumbago, spondylosis, musculoskeletal pains, and mastalgia, among others. The group called “Others” included individuals with erectile dysfunction, chronic kidney disease, cellulitis, and cardiovascular accidents, among others.

Hypertension has been reported in other studies to be prevalent among people aged 65years and above [18]; in this study, the mean age (approx. 63years) of hypertensive patients was similar. The high incidence of hypertension in females in this study may be due to weight gain associated with pregnancy [19] and contraceptive use [20]. Weight gain has been linked to an increased chance of developing preeclampsia, a condition characterized by elevated blood pressure [19]. Some of these conditions can persist after childbirth [21]. Additionally, female sex is more strongly correlated with early-onset hypertension and hypertension in general with sex-specific genetic risk factors than male sex is according to a study performed in the Finnish population [22].

The regression model generated postulates a negative albeit possible association between the number of years of hypertension management and the systolic BP reading, which is acceptable. Generally, a positive management outcome, which is evidenced by a decrease in BP from the baseline of diagnosis, is expected after years of management, provided there is adherence to therapy and other modifications [23]. Patients who accept pharmacological treatment usually achieve positive outcomes within some years [24,25,26]. This was further confirmed in the present study, as reductions in both systolic and diastolic BP were observed. Notably, two classes of antihypertensives are used for management [18]. Both calcium channel blockers (CCBs) and angiotensin receptor blockers (ARBs) are predominant [12,18]. The combination of CCBs and ARBs is cost-saving [11]. Additionally, single-pill, fixed-dose combination treatment improved adherence and prevented or reduced the occurrence of resistant hypertension [27]. According to one study, CCBs are superior for the prevention of stroke [2]. This could be an informative factor for its preferred use. Ashdad reported that prescribing patterns may not occur according to guidelines in low- and middle-income countries (LMICs) [12], and this could be true, as a few discrepancies were observed in the dataset; however, because the average number of antihypertensive drugs per patient was approximately two (2), it can be said that prescribing patterns are good to some extent.

In this study, males were observed to have a greater systolic BP than females because males are more likely to defer hospital attendance and therapy. Some studies report that women have better reporting patterns of health conditions than men [28,29,30]. In view of this, the delay in seeking medical care could be the contributing factor to higher systolic BP readings at first diagnosis.

Among the 1000 patients with hypertensive crisis, 63 (6.3%) were included in one African study, and these patients were predominantly female [31]; however, in our study, none were reported. This is likely due to the small sample size.

Diabetes is undoubtedly a well-known comorbidity of hypertension, so proper control of one of these conditions is believed to lead to improvement in the other. It is not surprising that this was the highest reported comorbidity in this study. One other comorbid condition is arthritis [16].

Limitations and Challenges

There was difficulty in controlling for confounding variables and external factors influencing treatment outcomes, one of which was the lack of knowledge on the concomitant use of herbal medicines and conventional antihypertensive agents.

Additionally, there are generalizability limitations due to variations in healthcare systems, patient populations, and treatment practices across different settings.

Recommendations

Collaboration with healthcare stakeholders and policy makers to encourage prescribers to continue to desist from polypharmacy, as this collaboration will improve concordance between health practitioners and patients.

It was concluded that the number of years of hypertension management is associated with the outcome of hypertension management, as is the number of blood pressure readings at first diagnosis. Appropriate treatment combinations involving two classes of antihypertensive drugs may encourage patient adherence and yield positive outcomes.

ACEIs – angiotensin-converting enzyme inhibitors

ARBs – Angiotensin receptor blockers

BP – Blood pressure

CCBs – Calcium channel blockers

RTI – Respiratory tract infections

Ethics Approval and Consent to participate - Ethics approval was obtained from the Institute of Research, Innovation and Development (IRID) at Kumasi Technical University. Reference number: IRID/EC2024/HS0003

Consent for publication – Not applicable.

Availability of data and materials – Data are available from the author upon request.

Competing interests – None declared.

Funding - No external funding

Author contributions – SAA was responsible for the research idea and supervision of the data collection and was a major contributor to the writing of the manuscript. JAA was responsible for shaping the research idea, formulating the research questions, and writing the manuscript. CKB was responsible for the analysis of the data. All the authors read and approved the final manuscript.

Acknowledgments – We would like to thank all the data collectors, namely, Theophilus Hodalor, Evans Akonnor, Samuel Opoku, Abigail Torsah, Nana Kwame Owusu-Ansah and Anita Opoku, for their hard work. Additionally, the Dean of Health Sciences, Prof. Samuel Osei-Djarbeng and Prof. Emmanuel Omari-Siaw (Head of Department, Pharmaceutical Sciences) deserve special mention for their support and experienced contributions during manuscript preparation.

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Table 1 Descriptive statistics of the scale variables

Descriptive Statistics
		Minimum	Maximum	Mean
Age		34	94	62.57 ± 0.635
Number of years of High BP Management		1	31	7.23 ± 0.279
Systolic BP on First Diagnosis		93	322	157.05 ± 1.458
Current systolic BP		84	218	138.07 ± 1.014
Difference in Systolics		-51	191	18.98 ± 1.465
Diastolic BP on First Diagnosis		10	150	91.85 ± 0.825
Current diastolic BP		50	151	85.19 ± 0.671
Difference in Diastolics		-76	50	6.66 ± 0.735
Number of BP drugs per patient		1	4	1.49 ± 0.031
Total Number	373

Table 2 Differences in the mean BP readings at first diagnosis and at the time of diagnosis.

*Paired Sample T test*
Paired Samples Statistics
		Mean	N	SD	Std. Error Mean
Pair 1	Systolic BP on first diagnosis	157.05	373	28.159	1.458
Pair 1	Current systolic BP	138.07	373	19.591	1.014
Pair 2	Diastolic BP on first diagnosis	91.85	373	15.934	0.825
Pair 2	Current diastolic	85.19	373	12.955	0.671

Paired Differences
		Mean	SD	Std. Error Mean	95% Confidence Interval of the Difference
					Lower	Upper	t	df	Sig.
Pair 1	Systolic BP on first diagnosis - Current systolic BP	18.979	28.285	1.465	16.099	21.858	12.959	372	0.000
Pair 2	Diastolic BP on first diagnosis - Current diastolic	6.66	14.193	0.735	5.215	8.105	9.062	372	0.000

Table 3 Correlations among different variables in the dataset.

*Correlations*
	Number of years of Management	Systolic on first diagnosis	Current systolic	Diastolic on first diagnosis	Current diastolic	Age
Number of years of Management		0.29	-0.02	0.19	0.18	0.21
Systolic on first diagnosis			0.34	0.39	0.34	0.07
Current systolic				0.24	0.54	-0.04
Diastolic on first diagnosis					0.53	-0.15
Current diastolic						-0.1

Table 4 Differences in the mean systolic BP at first diagnosis according to sex.

Independent Sample T test
	Sex	N	Mean
Systolic on first diagnosis	Male	101	165 ± 33.201
	Female	272	154.09 ± 25.483
F (equal variances assumed)	4.259
p value	0.04
t	3.37
df	371
sig.	0.001

Mean difference	10.908 ± 3.236
95% Confidence interval of difference	4.544-17.272

The authors declare no competing interests.

Effective Management of Hypertension: A Cross-Sectional Study of Five Health Facilities

Status:

Version 1

Abstract

Figures

1. BACKGROUND

2. METHODS

3. RESULTS

4. DISCUSSION

5. CONCLUSIONS

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1