title: How well have practices followed guidelines in prescribing antihypertensive drugs: the role of health insurance.
abstract: BACKGROUND
  The US Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure issues guidelines on the optimal first-line drug therapy in treating hypertension. Despite broad dissemination of these guidelines, prescribing practices have long remained discrepant with recommendations. The purpose of this study was to examine the role of insurance type in the selection of drugs for hypertension treatment in light of the JNC guidelines.
  
  
  METHODS
  Subjects were derived from the 1996 Medical Expenditures Panel Survey who had a diagnosis of essential hypertension and who were prescribed a diuretic, beta-blocker, calcium channel blocker (CCB), or ACE inhibitor (ACEI) as monotherapy. Using the nationally representative sample, this study presents the first estimates of the impact of insurance policies on the choice of antihypertensive drugs while controlling for predisposing, enabling, and need variables in the context of a logistic health-care utilization model.
  
  
  RESULTS
  Nationally in 1996, more than twice as many subjects (7.3 million) were taking ACEIs or CCBs compared to diuretics or beta-blockers (3.1 million) as the first-line drug therapy, a sharp contrast to the JNC guidelines. Patients with health maintenance organization (HMO) insurance were much less likely than fee for service (FFS) patients to follow the JNC guidelines in this respect (odds ratio 0.50, P <.01), controlling for all other factors. Individuals with all other public insurance and no insurance were not statistically different from the FFS group in the use of the study drugs. Other significant factors in the regression model were being of African American descent, being unmarried, having higher out-of-pocket payment, being in excellent physical health, having diabetes, and being diagnosed with essential hypertension after 1988. Each was associated with a decreased likelihood of following the JNC recommendations for the use of diuretics or beta-blockers.
  
  
  CONCLUSIONS
  After controlling for other predisposing, enabling, and need variables, patients who had HMO coverage were significantly more likely than FFS patients to receive ACEIs or CCBs. Given a popular public perception of HMOs being most cost conscious in providing health care, further research is needed to understand why prescribing patterns associated with HMOs have poorly followed the JNC recommendations.
authors.affiliation: Pharmaceutical Policy and Evaluative Sciences, University of North Carolina at Chapel Hill, 27599-7360, USA.
authors.forename: Jennifer D
authors.initials: JD
authors.lastname: Guo
authors.forename: Gordon G
authors.initials: GG
authors.lastname: Liu
authors.forename: Dale B
authors.initials: DB
authors.lastname: Christensen
authors.forename: Alex Z
authors.initials: AZ
authors.lastname: Fu
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000145:classification / Q000191:economics / Q000627:therapeutic use*; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D015984:Causality; D003430:Cross-Sectional Studies; D004232:Diuretics / Q000627:therapeutic use; D011307:Drug Prescriptions / Q000592:standards*; D004359:Drug Therapy, Combination; D004363:Drug Utilization / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000191:economics / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000145:classification / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D004232:Diuretics