社区医院年轻成人高血压诊断不足

洛杉矶——美国心脏协会(AHA)年会上公布的一项研究显示，定期到初级保健诊所就诊的年轻成人高血压患者初诊高血压的几率显著低于老年患者。

Heather M. Johnson博士

在这项研究中，威斯康星大学麦迪逊分校的心脏病学家Heather M. Johnson博士及其同事分析了13,593例2008年~2011年定期到初级保健诊所就诊的年龄≥18岁患者的电子病历，所有患者符合国家指南制订的高血压诊断标准。

在为期4年的定期就诊后，在具有明确高血压病历记录的18~24岁患者中，仍有67.4%未被诊断。在具有明确高血压病历记录的25~31岁患者中，有65%未被诊断。未诊断率显著高于同样在初级保健诊所就诊的老年高血压患者。

校正年龄、性别、体重、母语、合并症、医生专业和其他变量后发现，4年后，18~24岁的高血压患者初诊高血压的几率比年龄≥60岁患者低28%，25~31岁的高血压患者初诊高血压的几率比年龄≥60岁患者低26%。

随着年龄增加，高血压未诊断率稳步降低。然而，在具有明确高血压病历记录的年龄≥60岁高血压患者中，仍有54%在4年后未被诊断。

有趣的是，在4年内被诊断高血压的不同年龄组患者中，至诊断的平均时间无显著差异，平均为5~6个月左右。

Johnson博士表示，医生、患者和医疗系统因素是年轻成人中高血压诊断率低下的关键决定因素。多因素分析显示，年轻成人中初始高血压诊断推迟的关键独立预测因素是患者人种。黑人高血压年轻成人被诊断高血压的几率比白人患者高39%。Johnson博士表示，既往研究已发现美国黑人的高血压及其合并症患病率较高，特别是在较年轻的组中。该研究结果表明医生已认识到这点。

当前使用烟草或经常暴露于二手烟的年轻成人被诊断高血压的几率比未曾吸烟者低29%。基线血压140~159/90~99 mmHg的患者在4年内被诊断高血压的几率比基线血压160~179/100~109 mmHg的患者低35%。

从医生角度而言，医生性别是年轻成人中高血压诊断推迟的明显独立预测因素。女性初级保健医生对年轻成人患者迅速作出高血压诊断的几率比男性医生高23%。

家庭医生对年轻成人患者作出高血压诊断的几率比普通内科医生、妇产科医生或其他初级保健医生低16%。该结果具有边缘统计学显著性(P=0.047)。研究者未据此得出任何确凿结论。

该研究获美国国立心肺和血液研究所资助。Johnson博士声明无相关经济利益冲突。

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By: BRUCE JANCIN, Cardiology News Digital Network

LOS ANGELES – Young adults with high blood pressure who regularly saw a primary care physician were substantially less likely to receive a hypertension diagnosis than were older affected patients – and some of the reasons for the greater delay in initial diagnosis are eye opening, said Dr. Heather M. Johnson.

The 18- to 31-year-olds met standard diagnostic criteria for hypertension. Their regularly elevated blood pressure measurements were dutifully entered into their medical records. Yet in a study conducted in a large multispecialty academic group practice, the majority of hypertensive young adults remained undiagnosed after 4 years of regular utilization of primary care, she reported at the annual scientific sessions of the American Heart Association.

That’s consistent with findings from other studies showing that young adults with hypertension have lower rates of diagnosis and hypertension control than middle-aged and elderly patients with high blood pressure, Dr. Johnson noted. Her study went farther, however, exploring possible explanations for the disparity.

The study involved analysis of the electronic medical records of 13,593 patients aged 18 years or older, all of whom regularly utilized primary care services during 2008-2011 and fulfilled national guideline–based criteria for the diagnosis of hypertension.

After 4 years of regular primary care, 67.4% of 18- to 24-year-olds with clear evidence of hypertension in their charts remained undiagnosed. So did 65% of affected 25- to 31-year-olds. These rates were significantly higher than in the older hypertensive patients seen in primary care.

Indeed, after 4 years, 18- to 24-year-olds with high blood pressure were 28% less likely to have received an initial hypertension diagnosis than were affected adults aged 60 years or older. Affected 25- to 31-year-olds were 26% less likely to have been diagnosed than patients aged 60 and up. These results were adjusted statistically for age, sex, race, body weight, primary spoken language, comorbid conditions, provider specialty, and other variables, explained Dr. Johnson, a cardiologist at the University of Wisconsin, Madison.

Rates of undiagnosed hypertension declined steadily with advancing age. Nonetheless, 54% of hypertensive patients aged 60 or older remained undiagnosed after 4 years, despite the objective evidence in their charts.

Intriguingly, the average time to diagnosis for patients whose hypertension was diagnosed within 4 years didn’t vary significantly by age: It was 5-6 months, regardless, she added.

Dr. Johnson pointed to provider, patient, and health care system factors as all being critical determinants of the poor rates of hypertension diagnosis among young adults.

One key independent predictor of delay to initial hypertension diagnosis in young adults identified in her multivariate analysis was patient race. Black young adults with hypertension were 39% more likely to have received the diagnosis than white patients.

"African Americans are known to have a higher prevalence of hypertension and its comorbidities, especially at younger age groups. Our data suggest providers are aware of this," Dr. Johnson said.

Young adults who were current users of tobacco or were regularly exposed to secondhand smoke were 29% less likely than never users to have their hypertension diagnosed.

Those with baseline blood pressures of 140-159/90-99 mm Hg were 35% less likely to receive a hypertension diagnosis within 4 years than those with baseline readings of 160-179/100-109 mm Hg.

On the provider side, physician gender emerged as a major independent predictor of delayed diagnosis in young adults. Female primary care providers were 23% more likely to promptly diagnose hypertension in affected young adults than were their male colleagues.

Family physicians were 16% less likely than general internists, ob.gyns., or other primary care providers to make the diagnosis in affected young adults. This was a finding of borderline statistical significance (P = 0.047), and Dr. Johnson said she doesn’t draw any strong conclusions from it.

She and her coworkers are conducting interviews with primary care providers in the group practice to learn how to improve hypertension diagnosis rates in young adults within the time constraints of a busy practice. The findings from this study will be used to develop tailored primary care interventions. This will entail provider education programs as well as upgraded electronic medical record notification systems.

Her work is funded by the National Heart, Lung, and Blood Institute. She reported having no relevant financial disclosures.