Epidemiology/Health Services/Psychosocial Research

O R I G I N A L

A R T I C L E

Hypertension Management in Patients

With Diabetes
The need for more aggressive therapy
DAN R. BERLOWITZ, MD, MPH1,2
ARLENE S. ASH, PHD2,3
ELAINE C. HICKEY, RN, MS1,2

MARK GLICKMAN, PHD3

ROBERT FRIEDMAN, MD2,3
BORIS KADER, PHD1

OBJECTIVE Clinical trials have demonstrated the importance of tight blood pressure
control among patients with diabetes. However, little is known regarding the management of
hypertension in patients with coexisting diabetes. To examine this issue, we addressed 1)
whether hypertensive patients with coexisting diabetes are achieving lower levels of blood
pressure than patients without diabetes, 2) whether there are differences in the intensity of
antihypertensive medication therapy provided to patients with and without diabetes, and 3)
whether diabetes management affects decisions to increase antihypertensive medication therapy.
RESEARCH DESIGN AND METHODS We abstracted medical records to collect
detailed information on 2 years of care provided for 800 male veterans with hypertension. We
compared patients with and without diabetes on intensity of therapy and blood pressure control.
Intensity of therapy was described using a previously validated measure that captures the likelihood of an increase in antihypertensive medications. We also determined whether increases in
antihypertensive medications were less likely at those visits in which the diabetes medications
were being adjusted.
RESULTS Of the 274 hypertensive patients with diabetes, 73% had a blood pressure
140/90 mmHg, compared with 66% in the 526 patients without diabetes (P 0.04). Diabetic
patients also received significantly (P 0.05) less intensive antihypertensive medication therapy
than patients without diabetes. Less intensive therapy in diabetic patients could not be explained
by clinicians being distracted by the treatment for diabetes.
CONCLUSIONS There is an urgent need to improve hypertension care and blood pressure control in patients with diabetes. Additional information is required to understand why
clinicians are not more aggressive in managing blood pressure when patients also have diabetes.
Diabetes Care 26:355359, 2003

linical trials have convincingly demonstrated the importance of intensive treatment of hypertension among
patients with diabetes. Among older hypertensive patients receiving placebo
while enrolled in studies such as the Systolic Hypertension in the Elderly Program
(SHEP) and the Systolic Hypertension in

Europe Study (Syst-Eur), those with coexisting diabetes had an approximate

doubling in cardiovascular morbidity and
mortality (1,2). The Hypertension Optimal Treatment (HOT) study and the U.K.
Prospective Diabetes Studies (UKPDS)
have shown the benefits of achieving
tighter blood pressure control (3,4). For

From the 1Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial
Veterans Hospital, Bedford, Massachusetts; the 2Boston University Schools of Public Health and Medicine,
Boston, Massachusetts; the 3Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts; the 4Department of Mathematics, Boston University, Boston, Massachusetts.
Address correspondence and reprint requests to Dr. Berlowitz, CHQOER, Bedford VA Hospital, 200
Springs Rd., Bedford, MA 01730. E-mail: dberlow@bu.edu.
Received for publication 14 May 2002 and accepted in revised form 27 September 2002.
Abbreviations: HOT, Hypertension Optimal Treatment; VA, Department of Veterans Affairs.
A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
factors for many substances.

See accompanying editorial, p. 534.

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

example, in HOT, patients with diabetes

randomized to a target diastolic blood
pressure of 80 mmHg or less had a 50%
reduction in major cardiovascular events
compared with those with a target diastolic blood pressure of 90 or less. Moreover, the benefits of tight blood pressure
control in patients with diabetes exceed
the benefits of tight glycemic control and
extend not only to the prevention of macrovascular disease, but also to the prevention of microvascular complications
(4). The need for especially aggressive
blood pressure control in patients with
diabetes has been recognized in clinical
practice guidelines. The American Diabetes Association has long advocated that
hypertension should be treated aggressively to achieve and maintain blood pressure in the normal range (5). Since 1993,
the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure has recommend a
target blood pressure of 130/85 mmHg
in hypertensive patients with diabetes, as
compared with 140/90 in patients without diabetes (6).
A considerable gap exists between
guideline recommendations for hypertension treatment in the general population and achieved levels of blood pressure
control (79). Most patients with hypertension have inadequate blood pressure
control, and surveys indicate that many
physicians would not intensify therapy
despite persistently elevated blood pressures (10 12). In previous work, we
demonstrated that clinician failure to increase antihypertensive medications despite elevated blood pressures contributes
to poor blood pressure outcomes (13).
However, less is known regarding the
treatment of hypertension among patients
with diabetes. Studies consistently demonstrate that most diabetic patients do not
achieve recommended levels of blood
pressure control, and in fact, as with patients without diabetes, the majority have
a blood pressure of 140/90 mmHg (14
16). Despite recommendations for more
aggressive hypertension therapy in the
355

Hypertension management in diabetes

presence of coexisting diabetes, it is unclear whether there are any differences in

how clinicians manage blood pressure in
hypertensive patients with and without
diabetes.
To examine this issue, we have addressed the following three questions.
First, are hypertensive patients with coexisting diabetes achieving lower levels of
blood pressure than patients without diabetes? Second, are there differences in the
intensity of antihypertensive medication
therapy provided to patients with and
without diabetes? Finally, does diabetes
management affect decisions to increase
antihypertensive medication therapy?
RESEARCH DESIGN AND
METHODS
Study subjects and sites
The study sample and sites have been previously described (13). Briefly, we studied men with hypertension receiving
regular medical care at five Department of
Veterans Affairs (VA) sites in New England between 1990 and 1995. Eligible
patients were initially identified through
VA databases and had to meet three criteria. First, they had to have made at least
one visit to a general medicine or medical
subspecialty clinic during a 6-month period beginning 1 January 1990 (three
sites) or 1 January 1993 (two sites). If a
patient had more than one visit during
this period, we randomly selected one as
the index visit. Second, they had to have
made an outcome visit 1.52.5 years after the index visit. This visit was randomly
selected from among all general medical
and medical subspecialty visits during
this period. Third, the patients had to
have made at least one visit between the
index and outcome visits. As VA outpatient databases contained neither diagnoses nor provider-specific information,
we reviewed the medical records of eligible patients to determine whether two additional criteria were met. First, both the
index and outcome visit had to be with a
physician. Second, hypertension had to
be deemed an active problem during the
year preceding the index visit. Hypertension was deemed active if it was listed as a
problem in any note or if it had ever been
diagnosed and the patient was receiving
antihypertensive therapy. In creating our
final sample, we oversampled patients
with coexisting diabetes so that the prevalence of diabetes among hypertensive
356

patients in our sample is somewhat higher

than among all hypertension patients.
Presence of diabetes was based on a chart
diagnosis of diabetes from before the index visit. As diabetes precludes military
service, most diabetes patients in the VA
system have type 2 diabetes.
Data collection
We collected data from all visits to general
medicine clinics, medical subspecialty
clinics, and unscheduled visits to the
emergency room or walk-in clinic starting
with the index visit and ending with the
outcome visit. Study nurses reviewed
medical records to obtain clinical information including dates of the visits, reasons for visits, physical examination
findings, diagnoses, and test results. We
recorded up to four blood pressure measurements per visit. Only one measurement was available, however, for 80.5%
of the visits in which a blood pressure was
recorded. When multiple measurements
were available at a single visit, we used the
average. Additional data on demographic
characteristics and coexisting medical
conditions were obtained from entries before the index visit.
Information on changes in antihypertensive and diabetes medications was abstracted from three sources: clinicians
progress notes, medical orders, or computerized pharmacy records. We considered an increase in antihypertensive
medications to have occurred at a visit
anytime a new medication was started or
the dose of an existing medication was
increased. Substitutions among medications in the same class, such as from one
ACE inhibitor to another, were not considered as an increase because such
changes often reflect formulary changes.
Analyses
In comparing the management of hypertension for diabetic versus nondiabetic
patients, we considered both an outcome
and a process measure. Our outcome
measure was the level of blood pressure
control for each patient at the time of the
outcome visit. If no blood pressure measurement was available for the outcome
visit, we used the blood pressure closest
in date to the outcome visit, provided it
was within 90 days. We calculated the
mean systolic and diastolic blood pressure for patients with and without diabetes and compared them using a t test. We
also calculated the percentage of hyper-

tensive patients that would be considered

poorly controlled using either a threshold
140/90 or 160/90 mmHg and compared diabetic and nondiabetic patients
using a 2 test. Our process measure is
based on our previous work (13) and described the intensity of antihypertensive
medication therapy received by each patient between the index and outcome
visit. It captured whether a patient received more increases in therapy than
the norm, taking into account those characteristics at each visit associated with a
greater likelihood of an increase. Scores
are calculated as the observed number of
increases minus the expected number of
increases, divided by the number of visits
and can range from 1 to 1. We classified a score of 0.05 as more intensive
therapy than average, and a score of
0.05 as less intensive therapy. We
examined whether patients with diabetes
received more intensive therapy using a
linear regression model with intensity of
therapy as the dependent variable and
presence of diabetes as the independent
variable. We controlled for other patient
characteristics possibly associated with
intensity of therapy by including age,
race, coronary artery disease, cerebrovascular disease, peripheral vascular disease,
BMI, and renal insufficiency in the model.
In examining the effect of diabetes
management on hypertension therapy,
we considered only those patients with
both diabetes and hypertension. We divided visits into two groups based on the
presence or absence of a change in diabetes medications. We then compared the
proportion of visits for each group with an
increase in antihypertensive medications
using a 2 test.
RESULTS
Our study sample consisted of 800 male
veterans with hypertension; 274 (34%)
had coexisting diabetes. Patients with diabetes were more likely to be of nonwhite
race, have coronary artery disease, and a
higher BMI but were otherwise similar to
patients without diabetes (Table 1).
Outcome blood pressure determinations were available for 782 hypertensive
patients. Patients with diabetes had worse
blood pressure control than those without diabetes. The mean systolic blood
pressure in diabetic patients was 148.4
mmHg compared with 143.8 in nondiabetic patients (P 0.002). No differences
were noted in the mean diastolic blood

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Berlowitz and Associates

Table 1Baseline characteristics of hypertensive patients with and without diabetes

n
Age (years)
Duration of hypertensive (years)
Nonwhite race (%)
Number of antihypertensive medications (%)
0
1
2
3
Selected coexisting conditions (%)
Coronary artery disease
Cerebrovascular disease
Hyperlipidemia
BMI (kg/m2)
n

Diabetic

Nondiabetic

274
65.9 8.3
12.9 5.2
32 (11.7)

526
65.3 9.5
12.4 5.4
35 (6.7)

0.40
0.28
0.01

27 (9.8)
81 (29.6)
85 (31.0)
81 (29.6)

41 (7.8)
183 (34.8)
169 (32.1)
133 (25.3)

0.32

117 (42.7)
29 (10.6)
65 (23.7)
29.2 4.8
245

180 (34.2)
58 (11.0)
140 (26.6)
27.8 4.3
437

0.02
0.85
0.37
0.001

Data are means SD and n (%).

pressures (83.0 vs. 82.3 mmHg, P

0.35). A total of 73% of diabetic patients
had a blood pressure 140/90 mmHg,
compared with 66% of nondiabetic patients (P 0.04). Among patients with a
blood pressure above this threshold, most
had either elevated systolic blood pressure (57%) or elevated systolic and diastolic blood pressures (38%); only 5%
had an isolated elevation in diastolic
blood pressure. There was no difference
between diabetic and nondiabetic patients in the pattern of blood pressure elevation (P 0.55). The proportions of
patients with blood pressure 160/90
mmHg were similar for patients with and
without diabetes (42 vs. 38%, P 0.26).
Hypertensive patients with diabetes
received less intensive antihypertensive
medication therapy than patients without
diabetes. Mean intensity scores were
0.02 for diabetic patients vs. 0.0 for
those without diabetes (P 0.05). Diabetic patients were more often in the
group receiving less intensive therapy and
less often in the group with more intensive therapy (Table 2, Fig. 1). The presence of diabetes remained significantly
associated with less intensive hypertension therapy in regression models adjusting
for other baseline patient characteristics
(Table 2).
The 274 patients with both hypertension and diabetes had 2,052 medical
clinic visits over the study period. Increases in antihypertensive medications
occurred in 13.5% of the 156 visits where
diabetes medications were changed and

in 9.9% of the 1,896 visits in which there

were no changes in diabetes medications
(P 0.20).
CONCLUSIONS
The importance of aggressive treatment of
hypertension in the setting of diabetes is
well recognized (17). Hypertension patients with diabetes are at considerably
greater risk for cardiovascular events.
Consequently, lowering of blood pressure
will prevent more cardiovascular events
than similar reductions in nondiabetic patients (1,2). Yet, studies suggest that many
diabetic patients do not achieve adequate
blood pressure control. For example, in
Table 2Results of regression model
evaluating association of diabetes with intensity of therapy, adjusting for other patient
characteristics
Patient characteristic
Diabetes
Nonwhite race
Age
Coronary artery disease
Cerebrovascular disease
Peripheral vascular
disease
Renal insufficiency
BMI (kg/m2)

Coefficient*

0.0180
0.04
0.0201
0.18
0.0005
0.25
0.0149
0.08
0.0192
0.14
0.0399 0.001
0.0232
0.0006

0.10
0.57

*A negative coefficient indicates less intensive therapy; mean values were assigned to the 118 patients
with missing BMI; results were essentially unchanged if these patients were dropped from the
regression model.

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

the Third National Health and Nutrition

Examination Survey (NHANES-III), 31%
of all diabetic patients and nearly 60% of
those with previously diagnosed hypertension had a blood pressure 140/90
mmHg (15,18). Among elderly diabetic
patients seen in an academic medical center, 85% had a blood pressure 130/85
(16). We have now performed a comprehensive comparison of hypertension
management between patients with and
without diabetes. Our results highlight
three important findings.
First, diabetic patients with hypertension are not being adequately controlled.
Only 27% had a blood pressure 140/90
mmHg, and fewer had achieved recommendations for a blood pressure 130/
85. Furthermore, blood pressure control,
especially systolic, was worse in diabetic
patients than in those without diabetes.
The importance of controlling systolic
blood pressure, particularly in older patients, has been emphasized in a recent
clinical advisory statement by the Coordinating Committee of the National High
Blood Pressure Education Program (19).
The difficulty of achieving systolic blood
pressure control, however, among hypertensive patients is also being increasingly
recognized (11) While inadequate control
of blood pressure is a national concern
(20), it is particularly problematic among
patients with diabetes.
Second, not only was blood pressure
control worse, but hypertension was being managed less intensively in patients
with diabetes. At individual visits, diabetic patients were less likely to have an
increase in therapy. This effect persisted
even after adjusting for other factors that
could influence the intensity of therapy,
including age, race, and coexisting conditions. This suggests that poor blood pressure control in patients with diabetes may
not be due to physiological factors but
rather reflects differences in management.
Finally, our results begin to explore
why diabetic patients may be receiving
less intensive hypertension therapy. We
hypothesized that clinicians may be busy
managing diabetes and consequently
would not be willing or able to increase
the antihypertensive medications. However, this was not the case. Increases in
antihypertensive medications were no
more likely to occur at those visits in
which hypoglycemic medications were
not changed as in those visits with a
change in the diabetes medications. The
357

Hypertension management in diabetes

Figure 1Intensity of hypertension therapy: percentage of diabetic () and nondiabetic (p) patients receiving more or less intensive hypertension
therapy than the norm.

fact that increases in blood pressure medications were more common (albeit not
significantly different) at visits with a
change in diabetes medications may suggest that those clinicians who are aggressive
in managing diabetes are also aggressive
in managing hypertension. Further work
is required to understand why clinicians
are less aggressive in managing hypertension in patients with coexisting diabetes.
We can only speculate as to why clinicians were not more aggressive in their
management of hypertension. They may
have been unfamiliar with published
guidelines or disagreed with their content, particularly on the need to treat mild
elevations of systolic blood pressure.
However, undertreatment of chronic
medical conditions such as hypertension
and diabetes appears to be common, even
when clinicians agree with guideline recommendations. Recently, Phillips et al.
(21) proposed the term clinical inertia
to describe this phenomenon. They ascribed it to three main factors: clinician
overestimation of the intensity of care
they provided, clinician lack of training
and the absence of organizational supports necessary in order to treat to target,
and the use of soft reasons to justify not
intensifying therapy.
In measuring treatment intensity, we
used a previously validated measure that
describes whether a patient received more
increases in antihypertensive medications
than would be expected based on their
clinical presentation (13). It captures the
likelihood that a new antihypertensive
358

medication will be started or the dosage of

an existing medication increased when
confronted with an elevated blood pressure. This study also highlights how our
measure of treatment intensity may be
used to understand hypertension care in
important subgroups of patients. Future
studies could examine care in groups
other than those with diabetes, including
the elderly, ethnic minorities, or in patients with renal disease.
Patients with diabetes were significantly more obese than patients without
diabetes. Hypertension may be especially
difficult to control in obese patients, particularly if they have obstructive sleep apnea (22). Additionally, blood pressure in
obese patients could be falsely elevated
through the use of a sphygmomanometer
cuff that is too small. While this could
possibly explain why diabetic patients
had higher blood pressures, it cannot explain why clinicians were less likely to act
on these elevated readings.
A limitation of this study is that we
used data from 1990 to 1995. While the
need for tighter blood pressure control
among patients with multiple cardiovascular risk factors was recognized during
this period and expert panels were suggesting that blood pressures 140/90
might be appropriate (23,24), it may not
have been widely disseminated among
primary care clinicians. Guidelines published by the Joint National Committee
did not recommend a tighter level of control until 1993 (6). The results today may
be different from those in our study pe-

riod. However, others have suggested that

there have not been any major changes in
physicians hypertension practices over
the past 10 years (11). In a study with
more recent data that evaluated elderly
patients seen between 1996 and 1998, the
mean systolic blood pressure among all
diabetic patients, not just those identified
as hypertensive, was 145 mmHg (16).
Our study was performed in a sample
of male mostly elderly veterans with good
access to medical care and medications.
Patients mostly had type 2 diabetes. Our
results may not be generalizable to other
patient populations and settings. This too
requires further study.
Improving hypertension care is a national concern (20) and is central to the
National Diabetes Education Programs
current effort to enhance cardiovascular
outcomes. Their ABC educational campaign is stressing control of HbA1c (A),
blood pressure (B), and cholesterol (C)
(25). Our results are consistent with this
effort in emphasizing an especially great
need for improved care for hypertensive
patients with diabetes. Yet, effective
methods for improving clinicians practices are poorly defined (26), particularly
in the area of hypertension management.
Given the special issues in managing hypertension among patients with diabetes,
interventions specific to this group of patients likely will need to be developed. We
advocate urgent attention to the development of such interventions so as to minimize complications among a group of

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

Berlowitz and Associates

patients already at exceptionally high risk

for cardiovascular events.
Acknowledgments This work was supported by the Department of VA Health Services Research and Development Service
Grant number SDR 91-011. Results were presented in part at the Annual Meeting of the
Department of VA Health Services Research
and Development Service held in Washington,
DC (March 2000).
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