Reliance on inpatient BP readings may cause overtreatment

About 14 percent of older adults hospitalized for common, non-cardiac conditions were discharged with more intensive blood pressure medication, according to an analysis published in The BMJ. The concerning part: More than half of those patients actually demonstrated good blood pressure (BP) control in an outpatient setting, suggesting overtreatment from hospital physicians.

“Our findings indicate that decisions to discharge patients with intensified antihypertensive regimens are likely driven by inpatient blood pressure readings and not the overall context of older adults’ health or long-term disease control,” wrote Timothy S. Anderson, MD, and colleagues from the University of California, San Francisco.

Anderson and colleagues studied 14,915 older adults—mostly men; median age 76—who were hospitalized at Veterans Affairs (VA) facilities between 2011 and 2013 for pneumonia, urinary tract infection or venous thromboembolism. They said they chose those conditions because their treatment “doesn’t typically require aggressive blood pressure management.”

By linking VA data from previous visits, the researchers established the individuals’ BP control by taking the median of their three most recent recordings from outpatient visits. BP was considered well-controlled if it was below 140/90 mm Hg.

Then, using pharmacy data, Anderson et al. determined which patients had their hypertension medication intensified either through dose increases of drugs they were already taking or the prescription of additional drugs.

Overall, one in seven patients was discharged with intensified antihypertensive treatment—and 52 percent of those patients had well-controlled outpatient BP.

“Patients with limited life expectancy, dementia, or metastatic malignancy were no less likely to receive intensifications than all other patients, despite having a decreased likelihood of clinical benefit from tight blood pressure control,” the authors noted. “Patients with history of myocardial infarction or cerebrovascular disease were no more likely to receive antihypertensive intensifications, despite having the highest likelihood of clinical benefit.”

Taken together, those findings suggest clinicians are prone to “treat the number” rather than the patient, Anderson and colleagues said—even though transient fluctuations in BP are common during hospital admissions, with acute pain, stress and white-coat hypertension possibly contributing to higher measurements in those settings.

This is particularly notable considering this study was conducted in the VA system, the authors pointed out. The largest integrated health system in the U.S., the VA contains a national electronic health record with long-term data on patients’ blood pressure and outpatient clinical notes.

“As this information may not be easily accessible in other healthcare systems, we speculate that outpatient blood pressure control may be even less likely to factor into clinical decision making in other settings,” the authors wrote.

Anderson and coauthors suggested the decision to boost blood pressure treatment may come from applying outpatient guidelines to inpatient recordings. A safer strategy, they said, could be to inform outpatient providers of elevated inpatient BP recordings and turn over longitudinal BP management to those clinicians, rather than intensifying antihypertensive treatment at discharge.

The authors of an accompanying editorial support a re-evaluation of treatment intensification just before discharge along with prompt follow-up with a primary care provider. They said the study highlights “the need for a more judicious approach to the in-hospital management of chronic diseases, especially for older adults.”

“Clinicians would be wise to adopt Sin City’s famous tagline, ‘What happens in Vegas, stays in Vegas.' Often the safest approach to inpatient chronic disease management should be to let what happens in hospital stay in hospital,” wrote Nathan M. Stall, MD, and Chaim M. Bell, MD, PhD.