Hypertension in general practice Risk factors for uncontrolled hypertension Maja Skov Paulsen Biostatistic I and Biostatistics II 2009 autumn 19.nov, 2009.

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1 Hypertension in general practice Risk factors for uncontrolled hypertension Maja Skov Paulsen Biostatistic I and Biostatistics II 2009 autumn 19.nov, 2009.

2 APO Audit 19. Nov, 2009Maja Skov Paulsen2 179 practice participated Nov. 2007. 7111 patients included over a 3-week period. ◦ Patients with known hypertension and if the consultation included a blood pressure measurement. 5413 patients completed a questionnaire

3 APO Audit about hypertension The phD study is based on data from: APO Audit about hypertension/Patients included APO Audit about hypertension/General Practice 179 Pratice 7111 patients diagnosed with hypertension included 5413 patient answered questionnaire 5413 patient data registered by the GPs 5878 patient data registrated by the GP 179 GP answered questionnaire about their practice Maja Skov Paulsen19. Nov, 20093

4 Planlagt BT- kontrol Ikke planlagt BT-kontrol Systolisk Diastolisk Familiær disposition Rygning Hyperkolesterolæmi Overvægt DMIngen af førnævnte Myokardieinfakt Anden karkomplikationIngen Non-farmakologisk behandling ACE-hæmmer Kontakt- art Aktuelle BT målt i dag Varighed af hyper- tension 1 X Mindst 1 højst 6 X Cpr nr. Praksis nr. 205 1234 5 6 7 9 10 11 1213 14 16 15 17 18 19 20212223 24 32 1 2 3 4 5 6 7 8 9 10 11 12 Hypertension i almen praksis 2007 Risikofaktorer for iskæmisk hjerte-karsygdom Kardio- vaskulære komplikationer Mindst 1 X 33 A II -antagonist Ca-antagonist Betablokker ®Copyright: Audit Projekt Odense, J.B. Winsløws Vej 9A, 1. 5000 Odense C Diverse Andre antihypertensiva Individuelt behandlingsmål fastlagt Medicinændring d.d. Ingen af førnævnte Mindre end 2 år 29 Behandling Mindst 1X 2 til 5 år Mere end 5 år / / / / / / / / / / / / TCI/apoplexi Diuretika Ingen behandling For lidt motion Læge  Sygeplejerske  Sekretær/laborant/anden  1 X Ny kontrol aftaltForeligger ikke / / / / / / / / / / / / Systolisk Diastolisk Hjemme BT 25 26 2728 30 31 8 Tilfreds med aktuelle regulation 34 19. Nov, 2009Maja Skov Paulsen4

5 Risk factors for the overall risk assessment: ◦ Familial history of cardiovascular disease  yes=1 no=0 ◦ Smoking  yes=1 no=0 ◦ Elevated blood level of cholesterol  yes=1 no=0 ◦ BMI  0=BMI ≤ 25  1=BMI = 26-30  2= BMI ≥ 30 ◦ Too little exercise  yes=1 no=0 ◦ Diabetes  yes=1 no=0 ◦ No risk factors  yes=1 no=0 19. Nov, 20095Maja Skov Paulsen

6 Cardiovascular diseases TCI/apoplexy ◦ yes=1 no=0 Myocardial infarction ◦ yes=1 no=0 Other vascular complication ◦ yes=1 no=0 No cardiovascular disease ◦ yes=1 no=0 19. Nov, 2009Maja Skov Paulsen6

7 Age and gender categories Age:  <40 year  40-49  50-59  60-69  70-79  ≥80 Gender:  0= Female  1=male 19. Nov, 2009Maja Skov Paulsen7

8 I had to recode my age-categori Table 1. Basis characteristics for 5413 patient enrolled in the study n% Gender:Female300555 Male240845 age 0 <40711 1 40-493266 2 50-5990116,7 3 60-69183133 4 70-79154729 5 ≥8073714 Mean age675413 Diabetes84216 Controlled hypertension overall185634 Uncontrolled hypertension overall355766 19. Nov, 2009 Maja Skov Paulsen 8

9 Outcome variable Uncontrolled blodpressure  No=0 (not uncontrolled)  Yes=1 (uncontrolled) The values was coded as: ◦ 1. Home blood pressure measurement ◦ 2. Consultations blood pressure measurement 19. Nov, 2009Maja Skov Paulsen9

10 Outcome variable Limits ◦ Home and consultations blood pressure  Controlled: <140/90 mmHg  Uncontrolled ≥ 140/90 mmHg ◦ Diabetes patients  Controlled: < 130/80 mmHg  Uncontrolled: ≥ 130/80 mmHg 19. Nov, 2009Maja Skov Paulsen10

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12 Table 2 Crude odds. Crude odds adjusted for age, gender and cluster at practice level (179 practices) nOdds(Conf.int)p-values Familial history of cardiovascular disease Yes17880.90(0.79-1.03)0.119 SmokingYes10471.15(0.10-1.33)0.053 Elevated level of cholesterolYes22790.86(0.76-0.97)0.017 BMI<2519451- 25-3021241.07(0.93-1.22)0.342 ≥3013441.48(1.28-1.73)0.000 Too little exerciseYes18451.12(0.98-1.28)0.100 DiabetesYes8423.70(2.91-4.72)0.000 No risk factors8090.85(0.73-0.99)0.041 TCI/apoplexyYes4190.68(0.55-0.83)0.000 Myocardial infarctionYes3060.59(0.47-0.73)0.000 Other vascular diseaseYes4970.99(0.81-1.22)0.958 No vascular disease40011.26(1.10-1.45)0.001 19. Nov, 2009Maja Skov Paulsen12

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14 Table 3 Logistic regression model Odds ratio for uncontrolled hypertension adjusted for all including cluster at practice level (179 practices) nOdds(Conf.int)p-values Age 370-7915471.31(1.00-1.72)0.050 4≥807371.53(1.15-2.04)0.003 Smoking10471.17(1.01-1.35)0.031 Elevated level of cholesterol 22790.80(0.69-0.92)0.002 BMI<2519451- 25-3021241.00(0.88-1.15)0.995 >3013441.25(1.06-1.48)0.006 Diabetes8423.67(2.86-4.70)0.000 TCI/apoplexy4190.65(0.50-0.86)0.003 Myocardial infarction 3060.57(0.43-0.76)0.000 19. Nov, 2009Maja Skov Paulsen14

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16 Antal risikofaktorer: Table 4. The total number of risk factors and the groups association to uncontrolled hypertension adjusted for age and gender. The following risk factors are included: Familial history of cardiovascular disease, smoking, cholesterol, too little exercise, diabetes and BMI (coded as BMI≤30 and BMI>30) nOdds( 95%Conf.int)p-values 0 risk factors9551- 1 risk factors16441- 2 risk factors15111- 3 risk factors8461.23(1.06-1.44)0.008 4 risk factors3581.86(1.42-2.42)0.000 5 risk factors853.01(1.67-5.42)0.000 6 risk factors143.52(0.78-15.91)0.101 19. Nov, 2009Maja Skov Paulsen16

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18 Table 5 Testparm The following interactions were included in the logistic model to investigate if they should be included in the model. Interactionchi2(1)Prob> chi2 Included (Yes/No) SmokingCholesterol0.190.6641No Familial history of cardiovascular disease 0.680.4087No Myocardial infarction 0.200.6562No TCI/apoplexy0.330.5655No CholesterolDiabetes0.000.9859No MI3.090.0786OBS TCI/apoplexy0.440.5083No BMIDiabetes3.690.0547OBS Cholesterol0.060.8018No MI0.010.9035No 19. Nov, 2009Maja Skov Paulsen18

19 Interactioner BMI og diabetes:  Odds ratio 1.48 (0.99-2.21) p=0.055 Cholesterol og AMI:  Odds ratio 1.51 (0.95-2.40) p=0.079 19. Nov, 2009Maja Skov Paulsen19