Berlowitz D R, Ash A S, Hickey E C, Friedman R H, Glickman M, Kader B, Moskowitz M A
Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Affairs Hospital, MA 01730, USA.
N Engl J Med. 1998 Dec 31;339(27):1957-63. doi: 10.1056/NEJM199812313392701.
Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care.
We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure.
Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment.
In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.
许多高血压患者的血压控制不佳。改善高血压治疗需要了解医生管理这种疾病的方式以及评估这种治疗效果的方法。
我们在两年时间里对新英格兰地区五个退伍军人事务部医疗点的800名高血压男性患者的治疗情况进行了研究。他们的平均（±标准差）年龄为65.5±9.1岁，高血压平均病程为12.6±5.3年。我们使用递归划分法，通过几个变量来评估在特定门诊就诊时增加抗高血压治疗的概率。然后我们利用这些预测结果来确定研究期间每位患者的治疗强度，并研究治疗强度与血压控制程度之间的关联。
尽管平均每年有超过六次与高血压相关的就诊，但仍有大约40%的患者血压≥160/90 mmHg。在6.7%的就诊中出现了治疗增加的情况。与增加抗高血压治疗相关的特征包括此次就诊时收缩压和舒张压水平升高（而非之前的就诊）、之前治疗方案的改变、冠状动脉疾病的存在以及预约就诊。接受更强化治疗的患者血压控制明显更好（P<0.01）。在两年期间，接受最强化治疗的患者收缩压下降了6.3 mmHg，而接受最不强化治疗的患者收缩压升高了4.8 mmHg。
在特定的老年男性人群中，许多人的血压控制不佳。接受更强化药物治疗的患者控制情况更好。许多医生在治疗高血压时不够积极。
