Treatment Intensification for Hypertension in US Ambulatory Medical Care

J Am Heart Assoc. 2016 Oct 22;5(10):e004188. doi: 10.1161/JAHA.116.004188.


Background: Hypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all-cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.

Methods and results: Using the nationally representative National Ambulatory Medical Care Survey (2005-2012) and National Hospital Ambulatory Medical Care Survey (2005-2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005-2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2-7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.

Conclusions: US hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension-related morbidity and mortality nationwide.

Keywords: blood pressure; hypertension medication; medication addition; medication initiation.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Ambulatory Care*
  • Antihypertensive Agents / therapeutic use*
  • Blood Pressure
  • Drug Substitution
  • Drug Therapy, Combination
  • Female
  • Health Care Surveys
  • Humans
  • Hypertension / drug therapy*
  • Male
  • Middle Aged
  • Odds Ratio
  • Practice Patterns, Physicians'*
  • Primary Health Care*
  • United States
  • Young Adult


  • Antihypertensive Agents