Background
Methods
Study participants
Diagnostic criteria for “Appropriate Clinical Action”
Comorbidities
Markers of potential overtreatment
Statistical analysis
Results
Population characteristics and degree of control
Poorly controlled Hypertension (n = 391) | Poorly controlled Dyslipidemia (n = 231) | Poorly controlled diabetes Mellitus (n = 59) | ||||
---|---|---|---|---|---|---|
Demographic
| ||||||
Age, years Mean, (SD) | 64.5 | (8.1) | 62.9 | (7.7) | 62.8 | (8.6) |
n
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%
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n
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%
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n
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%
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Age | ||||||
< 65 years | 193 | 49 | 130 | 56 | 32 | 54 |
≥ 65 years | 198 | 51 | 101 | 44 | 27 | 46 |
Sex | ||||||
Female | 159 | 41 | 99 | 43 | 22 | 37 |
Baseline medications
| ||||||
Medication for each condition
| ||||||
0 medications | 67 | 17 | 165 | 71 | 15 | 25 |
1 medications | 92 | 24 | 64 | 28 | 18 | 31 |
2 medications | 115 | 29 | 2 | 1 | 25 | 42 |
3 medications | 74 | 19 | 0 | 0 | 1 | 2 |
≥4 medications | 43 | 11 | 0 | 0 | 0 | 0 |
Medication for others of the 3 conditions
| ||||||
0 medications | 109 | 28 | 60 | 26 | 9 | 15 |
1 medications | 98 | 25 | 37 | 16 | 14 | 24 |
2 medications | 85 | 22 | 52 | 23 | 10 | 17 |
3 medications | 46 | 12 | 30 | 13 | 13 | 22 |
≥4 medications | 53 | 14 | 52 | 23 | 13 | 22 |
All medications
| ||||||
0 medications | 17 | 4 | 22 | 10 | 3 | 5 |
1 medications | 42 | 11 | 34 | 15 | 6 | 10 |
2 medications | 52 | 13 | 36 | 16 | 3 | 5 |
3 medications | 57 | 15 | 42 | 18 | 12 | 20 |
≥4 medications | 223 | 57 | 97 | 42 | 35 | 59 |
Citizenship
| ||||||
Switzerland | 171 | 44 | 97 | 42 | 22 | 37 |
Europe/USA | 80 | 20 | 48 | 21 | 10 | 17 |
Eastern Europe | 83 | 21 | 46 | 20 | 19 | 32 |
Africa | 26 | 7 | 18 | 8 | 5 | 8 |
Latin America | 15 | 4 | 9 | 4 | 2 | 3 |
Asia/Middle-East | 14 | 4 | 13 | 6 | 1 | 2 |
Civil status
| ||||||
Single | 51 | 13 | 34 | 15 | 3 | 5 |
Divorced/separated | 87 | 22 | 63 | 27 | 17 | 29 |
Widowed | 46 | 12 | 22 | 10 | 6 | 10 |
Married | 203 | 52 | 111 | 48 | 33 | 56 |
Occupation
| ||||||
Social aid | 46 | 12 | 25 | 11 | 7 | 12 |
Unemployed | 40 | 10 | 20 | 9 | 8 | 14 |
Employed | 92 | 24 | 73 | 32 | 10 | 17 |
Retired | 159 | 41 | 86 | 37 | 26 | 44 |
At home | 45 | 12 | 25 | 11 | 7 | 12 |
Other | 2 | 1 | 0 | 0 | 1 | 2 |
Co-Conditions and Co-Morbidities | ||||||
---|---|---|---|---|---|---|
Hypertension poor control (n = 391) | Dyslipidemia poor control (n = 231) | Diabetes mellitus poor control (n = 59) | ||||
n | % | n | % | n | % | |
Conditions
| ||||||
all three conditions | 141 | 36 | 60 | 26 | 41 | 69 |
+ hypertension | 187 | 81 | 51 | 86 | ||
+ dyslipidemia | 294 | 75 | 48 | 81 | ||
+ diabetes mellitus | 169 | 43 | 70 | 30 | ||
Comorbidities
| ||||||
Cerebrovascular Disease (TIA, CVA) | 56 | 14 | 20 | 9 | 6 | 10 |
Coronary Artery Disease | 75 | 19 | 37 | 16 | 9 | 15 |
Congestive Heart Failure | 28 | 7 | 11 | 5 | 3 | 5 |
End Stage Renal Disease | 2 | 1 | 1 | 0 | 0 | 0 |
Dementia | 9 | 2 | 2 | 1 | 1 | 2 |
COPD | 50 | 13 | 28 | 12 | 10 | 17 |
Asthma | 16 | 4 | 6 | 3 | 3 | 5 |
Gastric Ulcer | 13 | 3 | 12 | 5 | 5 | 8 |
Breast Cancer | 6 | 2 | 4 | 2 | 0 | 0 |
Colorectal Cancer | 8 | 2 | 0 | 0 | 1 | 2 |
Prostate Cancer | 16 | 4 | 8 | 3 | 2 | 3 |
Depression | 68 | 17 | 46 | 20 | 12 | 20 |
Number of Comorbidities
| ||||||
Mean, (SD) | 2.3 (1.0) | 1.9 (1.1) | 2.7 (1.0) | |||
Distribution | ||||||
0 | 0 | 0 | 17 | 7 | 0 | 0 |
1 | 87 | 22 | 72 | 31 | 3 | 5 |
2 | 158 | 40 | 81 | 35 | 25 | 42 |
>2 | 146 | 37 | 61 | 26 | 31 | 53 |
Therapy modifications during 6-month and 12-month periods
Patients with poorly controlled hypertension | Patients with poorly controlled dyslipidemia | Patients with poorly controlled diabetes mellitus | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
6 Months | 12 Months | 6 Months | 12 Months | 6 Months | 12 Months | |||||||
n | % | n | % | n | % | n | % | n | % | n | % | |
Appropriate clinical action
| 211 | 54.0 | 240 | 61.4 | 67 | 29.0 | 87 | 37.7 | 46 | 78.0 | 50 | 84.7 |
Any therapy modification | 193 | 49.4 | 238 | 60.9 | 55 | 23.8 | 77 | 33.3 | 44 | 74.6 | 50 | 84.7 |
Increase class | 121 | 30.9 | 153 | 39.1 | 43 | 18.6 | 64 | 27.7 | 26 | 44.1 | 30 | 50.8 |
Increase dose | 103 | 26.3 | 135 | 34.5 | 15 | 6.5 | 23 | 10.0 | 31 | 52.5 | 36 | 61.0 |
Switch class†
| 30 | 7.7 | 49 | 12.5 | 0 | 0.0 | 2 | 0.9 | 6 | 10.2 | 10 | 16.9 |
Several modifications | 55 | 14.1 | 88 | 22.5 | 3 | 1.3 | 11 | 4.8 | 19 | 32.2 | 26 | 44.1 |
Return to control WO modification‡
| 18 | 4.6 | 2 | 0.5 | 12 | 5.2 | 10 | 4.3 | 2 | 3.4 | 0 | 0.0 |
Inappropriate clinical action
| 180 | 46.0 | 151 | 38.6 | 164 | 71.0 | 144 | 62.3 | 13 | 22.0 | 9 | 15.3 |
No modification, return to near control‡
| 25 | 6.4 | 9 | 2.3 | 38 | 16.5 | 27 | 11.7 | 1 | 1.7 | 3 | 5.1 |
No modification, no return‡
| 120 | 30.7 | 134 | 34.3 | 40 | 17.3 | 40 | 17.3 | 7 | 11.9 | 2 | 3.4 |
No measurement, no modification | 35 | 9.0 | 8 | 2.0 | 86 | 37.2 | 77 | 33.3 | 5 | 8.5 | 4 | 6.8 |
Multivariable analysis of factors associated with appropriate clinical action
Poorly controlled hypertension (n = 391) | Poorly controlled dyslipidemia (n = 231) | Poorly controlled diabetes Mellitus (n = 59) | |||||||
---|---|---|---|---|---|---|---|---|---|
Proportion | OR | 95% CI | Proportion | OR | 95% CI | Proportion | OR | 95%CI | |
(%) | (%) | (%) | |||||||
Age
| |||||||||
<65 years | 59.0 | 35.8 | 98.2 | ||||||
≥65 years | 66.6 | 1.38 | (0.86-2.22) | 31.9 | 0.84 | (0.41-1.71) | 97.9 | 0.86 | (0.14-5.23) |
Sex
| |||||||||
Female | 64.5 | 40.5 | 98.5 | ||||||
Male | 61.8 | 0.89 | (0.56-1.43) | 29.7 | 0.62 | (0.29-1.30) | 97.6 | 0.60 | (0.09-3.99) |
Co-occurrence of other conditions
| |||||||||
no co-occurrence of HT, DL, DM | 62.0 | 42.0 | NA | ||||||
HT and DL | 67.1 | 1.25 | (0.64-2.41) | 30.8 | 0.62 | (0.19-1.98) | |||
HT and DM | 62.8 | 1.03 | (0.35-3.06) | 76.3 | ref | ||||
DL and DM | 9.4 | 0.14 | (0.01-1.43) | 100.0 | NA | ||||
All 3 conditions | 58.7 | 0.87 | (0.41-1.86) | 43.6 | 1.07 | (0.23-5.00) | 90.1 | 2.81 | (0.27-29.11) |
Number of other conditions
| |||||||||
increase 1 co-morbidity | 1.23 | (0.93-1.63) | 0.92 | (0.57-1.49) | 0.63 | (0.19-2.09) | |||
Risk status
| |||||||||
No target organ disease | 61.4 | 17.9 | NA | ||||||
Target organ disease (except CAD) | 65.4 | 1.19 | (0.56-2.52) | 49.0 | 4.41 | (1.59-12.19)** | 97.6 | ref | |
CAD | 56.0 | 0.80 | (0.31-2.07) | 51.0 | 4.78 | (1.27-18.02)* | 99.3 | 3.27 | (0.12-87.75) |
Baseline level of each condition
| |||||||||
Systolic BP | |||||||||
140-159 mmHg | 59.9 | ||||||||
160-179 mmHg | 62.6 | 1.12 | (0.67-1.88) | ||||||
≥180 mmHg | 93.0 | 8.86 | (1.06-73.98)* | ||||||
Diastolic BP | |||||||||
90-99 mmHg | 59.9 | ||||||||
100-109 mmHg | 73.7 | 1.88 | (0.87-4.08) | ||||||
≥110 mmHg | 91.0 | 6.78 | (0.71-65.14) | ||||||
LDL cholesterol level | |||||||||
3.4-4.1 mmol/L (130–159 mg/dL) | 22.5 | ||||||||
4.2-4.9 mmol/L (160–189 mg/dL) | 44.6 | 2.77 | (1.15-6.68)* | ||||||
≥5.0 mmol/L (≥190 mg/dL) | 54.2 | 4.08 | (1.32-12.62)* | ||||||
Haemoglobin A1c | |||||||||
8.0-8.9% | 98.1 | ||||||||
9.0-9.9% | 99.0 | 2.75 | (0.12-31.21) | ||||||
≥10.0% | 96.0 | 0.45 | (0.07-3.07) |