Failure of evidence-based medicine in the treatment of hypertension in older patients

OBJECTIVE: Throughout the 1990s, the Joint National Committee on Detection. Evaluation, and Treatment of High Blood Pressure recommended initial antih ypertensive therapy with a thiazide diuretic or a P-blocker based on eviden ce from randomized, controlled trials, unless an indication existed for ano ther drug class. The committee also recommended beta -blockers in hypertens ive patients with a history of myocardial infarction (MI), and angiotensin- converting enzyme (ACE) inhibitors in patients with congestive heart failur e (CHF). Our objective was to determine whether prescribing practices for o lder hypertensive patients are consistent with evidence-based guidelines. METHODS: We examined prescription patterns from January 1, 1991 through Dec ember 31, 1995 for 23,748 patients 65 years or older with a new diagnosis o f hypertension from the New Jersey Medicaid program and that state's Pharma cy Assistance for the Aged and Disabled program (PAAD), We linked drug use data with information on demographic variables and comorbid medical conditi ons. RESULTS: During the study period, calcium channel blockers were the most co mmonly prescribed Initial therapy for hypertension (41%), followed by ACE i nhibitors (24%), thiazide diuretics (17%), and beta -blocbers (10%). Elimin ating patients with diabetes mellitus, CHF, angina. or history of Mi did no t substantially affect these results. Overall, initial use of a thiazide de clined from 22% in 1991 to 10% in 1995, while initial use of a calcium chan nel blocker Increased from 28% to 43%, despite publication during these yea rs of studies demonstrating a benefit of thiazides In older patients. Only 15% of older hypertensive patients with a history of MI received beta -bloc kers. CONCLUSIONS: Prescribing practices for older hypertensive patients are not consistent with evidence-based guidelines. Interventions are needed to enco urage evidence-driven prescribing practices for the treatment of hypertensi on.