1. Beth Wallace, BSN, RN-BC, FNP-S Fairfield University Summer 2010
Hypertension Management Southwest Community Health Center - MARINA VILLAGE Bridgeport, CT
Beth Wallace, BSN, RN-BC, FNP-S
Fairfield University
Summer 2010

2. Background
Southwest Community Health Center Bridgeport, CT

3. Background Hypertension
31.3% of U.S. adults, about 75 million, has high blood pressure
About 25% of U.S. adults has prehypertension
Hypertension is a major risk factor for heart disease, stroke, heart failure, and kidney disease
Heart disease and stroke are the first and third leading cause of death in U.S.

4. Background Hypertension
Highest incidence among African Americans, occurs at earlier age, average BP much higher
Among African Americans, highest rates middle aged or older, less educated, overweight, physically inactive, with diabetes
2006 death rates per 100,000 pop from hypertension: 15.6 white males, 51.1 black males, white females, 37.7 black females

5. Background Hypertension
Estimated to cost U.S. $76.6 billion in health care services, medications and missed days of work in 2010
The most common primary diagnosis in the United States
44 million office visits
9 million hospitalizations (primary or secondary diagnosis)

6. Background Hypertension 78.7% aware of diagnosis
69.1% under current treatment
45.4% controlled, 54.6% uncontrolled
Most will require two or more medications to achieve BP goal

7. Background Hypertension Healthy People 2010
Disease prevention and health promotion
Overarching goals to increase quality and years of healthy life and eliminate health disparities
Hypertension goals
Reduce proportion of adults with hypertension
Increase proportion whose blood pressure is in control to 50%

8. Background
Hypertension Guidelines

9. Background Hypertension Guidelines
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), December 2003
JNC 8 due Fall 2011

10. Background Hypertension Guidelines
JNC 7 created by coalition of 39 major professional, public, voluntary organizations and seven federal agencies
U.S. Department of Health and Human Services
National Institutes of Health
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program

11. Background Hypertension Guidelines JNC 7 classification BP
Systolic BP
mmHG
Diastolic BP
Normal
< 120
and < 80
Prehypertension
or 80-89
Stage 1
Hypertension
or 90-99
Stage 2
>160
or > 100

12. Background Hypertension Guidelines JNC 7 management recommendations BP
Classification
Lifestyle
Modification
Initial Drug Therapy
Without Compelling Indication
Normal < 120/80
Encourage
No antihypertensive drug indicated
Prehypertension
120/80 – 139/89
Yes
Stage 1
Hypertension
140/90 – 159/99
Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination
Stage 2
> 160/100
Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

13. Background Hypertension Guidelines JNC 7 management recommendations BP
Classification
Lifestyle
Modification
Initial Drug Therapy
With Compelling Indication
Normal < 120/80
Encourage
Prehypertension
120/80 – 139/89
Yes
Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80
Stage 1
Hypertension
140/90 – 159/99
Stage 2
> 160/100

14. Background Hypertension Guidelines JNC 7 management recommendations
Compelling Indication
Initial Drug Therapy
Heart failure
Diuretic, BB, ACEI, ARB, Aldo Ant
Postmyocardial infarction
BB, ACEI, Aldo Ant
High coronary disease risk
Diuretic, BB, ACEI, CCB
Diabetes
Diuretic, BB, ACEI, ARB, CCB
Chronic kidney disease
ACEI, ARB
Recurrent stroke prevention
Diuretic, ACEI

15. Objectives
To measure the proportion of SWCHC patients that meet best practice hypertension guidelines
Compare Marina Village homeless
with non-homeless
Compare diabetic with non-diabetic
Create action plan based on findings

16. Method Chart review Special populations included Other characteristics
Random selection of patients with hypertension
18 years or older
Seen within last 12 months
3rd or more visit since hypertension diagnosis
Special populations included
Diabetic
Homeless
Other characteristics
Sex, BMI, antihypertensive medications

17. Method 39 charts reviewed Female 22 56% Male 17 44% Homeless 21 54%
Diabetic 17 44%

18. Findings Compliance with hypertension guidelines Total Marina Patients
(39) 100%
Homeless
Patients
(21) 100%
Non-Homeless
(18) 100%
At BP goal
(25) 64%
(13) 62%
(12) 67%
Above BP goal
(14) 36%
(8) 38%
(6) 33%

19. Findings Compliance with hypertension guidelines Total Marina Patients
(39) 100%
Diabetic
Patients
(17) 100%
Non-Diabetic
(22) 100%
At BP goal
(25) 64%
(11) 65%
(14) 64%
Above BP goal
(14) 36%
(6) 35%
(8) 36%

20. Findings Compliance with hypertension guidelines Total Marina Patients
(39) 100%
Homeless
Patients
(21) 100%
Diabetic Non-DM
(10) 100% (11) 100%
Non-Homeless
(18) 100%
Diabetic Non-DM
(7) 100% (11) 100%
At BP goal
(25) 64%
(6) 60%
(7) 64%
(5) 71%
Above BP goal
(14) 36%
(4) 40%
(4) 36%
(2) 29%

21. Findings Compliance with hypertension guidelines Medications
Total Marina Patients
(39) 100%
At goal Above (25) (14)
100% %
Homeless
Patients
(21) 100%
At goal Above
(13) (8)
Non-Homeless
(18) 100%
At Goal Above
(12) (6)
100% %
One med
(9) 36%
(2) 14%
(7) 54%
(2) 25%
(2) 17% -
Two meds
(12) 48%
(3) 21%
(4) 31%
(3) 37.5%
(8) 66%
> Three meds
(4) 16%
(9) 65%
(2) 15%
(6) 100%

22. Findings Compliance with hypertension guidelines
64% of all Marina patients at BP goal
Compliance among special populations
62% of Homeless patients at BP goal
(67% of non-homeless)
65% of Diabetic patients at BP goal
60% of Homeless Diabetics at BP goal
(71% of non homeless diabetics)

23. Findings Antihypertensive medications needed to reach BP goal
84% of patients at goal take one or two medications
65% of patients above goal are uncontrolled
on 3 or more medications

24. Conclusions SWCHC Marina meeting hypertension guidelines
Overall, 64% at BP goal
Above Healthy People 2010 goal of 50% at goal
Special populations also at goal including Homeless and Diabetic
Utilizing combination medication therapy
Future emphasis on lifestyle modification, particularly among those uncontrolled on three or more medications

25. References
American Heart Association. (2010). Heart disease & stroke statistics: 2010 update at-a-glance. Retrieved February 27, 2010, from %20HeartStrokeUpdate_2010.pdf American Heart Association. (2010). High blood pressure statistics. Retrieved July 18, 2010, from Centers for Disease Control and Prevention. (2010). High blood pressure facts. Retrieved July 19, 2010, from Landon, B. E., Hicks, L. S., O’Malley, A. J., Lieu. T. A., Keegan, T., McNeil, B. J., et al. (2007). Improving the management of chronic disease at community health centers. The New England Journal of Medicine, 356(9), Milchak, J. L., Carter, B. L., James, P. A., & Ardery, G. (2004). Measuring adherence to practice guidelines for the management of hypertension: An evaluation of the literature. Hypertension, 44(5), U.S. Department of Health and Human Services. (2003). Reference card from the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC 7). Retrieved July 19, 2010, from U.S. Department of Health and Human Services. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved July 19, 2010, from