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Original Research |

Effect of Unrelated Comorbid Conditions on Hypertension Management

Barbara J. Turner, MD, MSEd; Christopher S. Hollenbeak, PhD; Mark Weiner, MD; Thomas Ten Have, PhD; and Simon S.K. Tang, MPH
[+] Article, Author, and Disclosure Information

From the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Penn State College of Medicine, Hershey, Pennsylvania; and Pfizer, New York, New York.

Presented in part at the 26th Annual Meeting of the Society of General Internal Medicine, New Orleans, Louisiana, 12–14 May 2005.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Hollenbeak (e-mail, chollenbeak@psu.edu). Data set: Access to the database is completely restricted but could be made available if approved by the University of Pennsylvania institutional review board.

Grant Support: From Pfizer to the University of Pennsylvania.

Potential Financial Conflicts of Interest:Employment: S.S.K. Tang (Pfizer). Stock ownership or options (other than mutual funds): S.S.K. Tang (Pfizer). Grants received: B.J. Turner (Pfizer), C.S. Hollenbeak (Pfizer), M. Weiner (Pfizer). Receipt of payment for manuscript preparation: B.J. Turner (Pfizer), C.S. Hollenbeak (Pfizer), M. Weiner (Pfizer).

Requests for Single Reprints: Barbara J. Turner, MD, MSEd, University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, bturner@mail.med.upenn.edu.

Current Author Addresses: Dr. Turner: University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Hollenbeak: Department of Public Health Sciences, Penn State College of Medicine, 600 Centerview Drive, A210, Hershey, PA 17033.

Dr. Ten Have: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Blockley Hall, 6th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Weiner: University of Pennsylvania School of Medicine, 1116 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Mr. Tang: Pfizer, 235 East 42nd Street, New York, NY 10017.

Author Contributions: Conception and design: B.J. Turner, M. Weiner, S.S.K. Tang.

Analysis and interpretation of the data: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have.

Drafting of the article: B.J. Turner, C.S. Hollenbeak.

Critical revision of the article for important intellectual content: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have, S.S.K. Tang.

Final approval of the article: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have, S.S.K. Tang.

Provision of study materials or patients: B.J. Turner.

Statistical expertise: B.J. Turner, C.S. Hollenbeak, T. Ten Have.

Obtaining of funding: B.J. Turner, S.S.K. Tang.

Administrative, technical, or logistic support: B.J. Turner, M. Weiner.

Collection and assembly of data: M. Weiner.

Ann Intern Med. 2008;148(8):578-586. doi:10.7326/0003-4819-148-8-200804150-00002
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The study did not follow a protocol but was designed to address an a priori hypothesis raised by several groups of experts concerning the negative effect of unrelated comorbid conditions on achieving quality-of-care goals (2, 5). To test this hypothesis, we used intensification of antihypertensive treatment for uncontrolled blood pressure as an example of a quality-of-care measure. The final analysis plan was accomplished by an iterative process. The University of Pennsylvania institutional review board approved the use of the database for our research via an expedited review procedure.

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Grahic Jump Location
Figure 1.
Study flow diagram.

*82% of patients had ≥1 hypertension diagnosis and a prescribed antihypertensive medication, 83% had ≥1 hypertension diagnosis and elevated blood pressure, and 92% had ≥2 elevated blood pressure readings at separate visits.

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Grahic Jump Location
Figure 2.
Adjusted association of unrelated comorbid conditions with management of uncontrolled hypertension.

Data are adjusted for all variables in Table 2.

Grahic Jump Location




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Measuring the impact of comorbid conditions: cautionary notes
Posted on May 1, 2008
Jose M Valderas
NIHR School of Primary Care Research. University of Manchester
Conflict of Interest: None Declared

In their study on the "Effect of unrelated comorbid conditions on Hypertension Management", Tuner et al. conclude that patients with more unrelated comorbidities were less likely to have their hypertension addressed. Two relevant limitations of the study make it necessary to handle this statement with due caution.

Firstly, Turner et al. equate intensification with "better quality of care" and non intensification with "poor performance" (p.584). The authors fail to acknowledge that raised blood pressure measurements may be due to reasons other than non response to medical treatment, making other approaches available to the clinician more appropriate than treatment intensification. Patients may have not adhered to the drug regime, or they may have made minimal temporary adjustments to their lifestyles (diet, exercise), making an emphasis on adherence to current management rather intensification a better approach. Alternatively, there may be an intercurrent problem explaining a the apparently uncontrolled hypertension, and again treating that problem may prove a better approach than intensification (incidentally, this may very well explain, at least in part, the negative association observed for some non related diseases associated with chronic-recurrent pain). Even if the patient is compliant, the physician may use the raised figure to stress the need for lifestyle changes. This may be particularly the case if the patient is on maximal dose of a number of drugs and pharmacological interactions and possibly medical contraindications that not allow for additional drugs. Although it is not possible to determine it from the data presented by the authors, some of these situations may occur more frequently among patients with non related comorbidities and may at least in part explain the differences observed.

Secondly, the concept of related disease is intuitive, but difficult to generalize. The lack of an explicit definition in this study makes it difficult to understand why some vascular diseases were considered related and some other not (e.g., collagen vascular disease, or pulmonary circulation disorders). As a matter of fact, although related diseases were expected to show a positive association with treatment intensification, one did not (chronic renal insufficiency) and another one even showed a strong reverse association (diabetes). Even those showing a positive association correspond to disease groups (single vs multiple vascular disease) that have not previously defined in relation to the related diseases. The interactions between comorbid conditions in terms of diagnosis, prognosis, and treatment and their impact on health care seems far too complicated to accomodate in these two categories.

Conflict of Interest:

None declared

What are the statistical factors inducing the reduction of uncontrolled hypertension?
Posted on May 7, 2008
Liu Hong
Institute of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi¡¯an, China
Conflict of Interest: None Declared

To the editor:

We read with interest the article by Turner BJ and colleagues [1]. They clearly show that patients with more unrelated comorbid conditions are less likely to have uncontrolled hypertension addressed at a visit. The study is based on the data from electronic medical records. However, the authors don't evaluate the compliance of patients by follow up. Patients may have not adhered to the antihypertensive medication as the electronic medical records described. Furthermore, the patients with more unrelated comorbid conditions may receive other medication, which may affect blood presure or enhance (or weaken) the effect of antihypertensive medication. In our opinions, the reduction in the rate of uncontrolled hypertension may result from other factors except for antihypertensive treatment intensification. Could the authors comment on the statistical factors which induce the differences observed? In addition, this study is based on the participants living in the United States, so the results may not be applicable for Asians. Could the authors comment on the effect of racial diversify on hypertension management?


1. Turner BJ, Hollenbeak CS, Weiner M, Ten Have T, Tang SS. Effect of unrelated comorbid conditions on hypertension management. Ann Intern Med. 2008 Apr 15;148(8):578-86.

Conflict of Interest:

None declared

Quality of Care for Hypertension
Posted on May 28, 2008
Barbara J Turner
University of Pennsylvania
Conflict of Interest: None Declared

This letter raises concerns about evaluating quality of care for uncontrolled hypertension at only one visit, just as we do in our paper. We concur that a physician should not intensify treatment when a patient has been poorly adherent. Recommendations about lifestyle changes may also be reasonable depending on the blood pressure. Because of these short-term factors, Kerr and colleagues suggested that quality of care should be evaluated only after two consecutive visits with an elevated blood pressure (1). In light of this recommendation, we examined hypertension management in two urban primary care practices for patients aged 18 or older with moderately elevated blood pressure at two consecutive visits (i.e., at least 10 mmHg systolic or 5 mmHg diastolic) (2). We considered only patients whose treatment was not intensified at the first visit and withover one month between visits. We selected the first pair of eligible visits for patients with multiple sets. Our sample of 239 patients was primarily female (67%) and African-American (86%) with an average age of 66.7 years. Treatment was not intensified at the second visit or at any time until the third visit in 50.1%. Among the 120 patients without intensification, chart review revealed that, for 37 of these second visits (31%), a legitimate excuse was recorded such as the patient ran out of medication. Thus, even in a pair of visits with uncontrolled hypertension, an analysis of medication intensification alone overestimates poor quality of care.

So we agree with the observation in this letter and suggest that future work could consider a longer window to assess management of uncontrolled hypertension such as 6 months to a year to allow the physician to address patient factors. In regard to the second point , our "˜related' conditions are those included in most studies of hypertension management (i.e., coronary artery disease, stroke, and peripheral vascular disease). Physicians would not immediately think of hypertension as a key factor affecting collagen vascular disease or pulmonary circulation disorders. Therefore, we considered these to be "unrelated" diseases along with others occurring more commonly in the outpatient setting (e.g., gastroesophageal reflux, arthritis). Given that most studies consider only "˜related' comorbidities, we believe that our attempt to look at other unrelated competing comorbidities is a major advance. Again, future work needs to consider how to deal with diabetes and chronic renal insufficiency where the blood pressure standard is stricter.

1. Kerr EA, Krein SL, Vijan S, Hofer TP, Hayward RA. Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures. Am J Manag Care. 2001 Nov;7(11):1033-43

2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72

Conflict of Interest:

Dr Turner has received unrestricted research funding from Pfizer, Inc. Mr Tang is employed by Pfizer, and Mr. St. Michel has no conflicts to declare

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