title: Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012.
abstract: OBJECTIVE
  The purpose of this study is to describe trends in the utilization of antihypertensive medications, overall and by type of medication, specifically thiazide diuretics, as well as uncontrolled hypertension, in the Palestine refugee population in Jordan between 2008 and 2012.
  
  
  METHODS
  We analyzed aggregate procurement data on antihypertensive medications derived from the United Nations Relief and Works Agency (UNRWA) pharmacy records between 2008 and 2012. Antihypertensive medications were aggregated and utilization was calculated overall and for specific types of antihypertensive medications (e.g. β-blockers, diuretics). We used the WHO (World Health Organization) defined daily dose (DDD) methodology, often used to evaluate drug utilization patterns using aggregate data, to calculate utilization defined as DDDs per 100 persons with hypertension. In addition, UNRWA medical records were used to measure the prevalence of uncontrolled hypertension in the primary care setting. Uncontrolled hypertension was defined as a systolic/diastolic blood pressure ≥140/90 in at least 2 out of 3 readings, one of which is the most recent reading, during the year for a patient diagnosed with hypertension.
  
  
  RESULTS
  Overall, total utilization of antihypertensive medications has not changed between 2008 and 2012; hypertensive patients persistently used at least 2 antihypertensive medications daily (range 200-280 DDDs/100 patients with hypertension) during this five-year period. However, there is significant variation in utilization patterns by type of antihypertensive medication. While Angiotensin Converting Enzyme Inhibitors (ACE-I) were persistently the most commonly used antihypertensive medication, there utilization significantly (P < 0.05) declined by 26%. However, there was a statistically significant increase of 124% in the utilization of thiazide diuretics. Further, the prevalence of uncontrolled hypertension has also declined at a rate of 3% annually between 2008 and 2012.
  
  
  CONCLUSIONS
  Our findings indicate that the STGs for hypertension management implemented in 2009 as part of UNRWA's essential drug program have increased the utilization of thiazide diuretics, and potentially contributed to improvements in hypertension control. This study also demonstrates that feasibility of drug utilization studies in monitoring and evaluating trends in the use of essential medications in low-resource settings.
authors.affiliation: Health Department, United Nations Relief and Works Agency Headquarters, Bayader Wadi Seer, 11814, Amman Jordan.
authors.forename: Rawan
authors.initials: R
authors.lastname: Saadeh
authors.affiliation: Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, 833 South Wood Street, Chicago, Illinois USA.
authors.forename: Dima
authors.initials: D
authors.lastname: Qato
authors.affiliation: Health Department, United Nations Relief and Works Agency Headquarters, Bayader Wadi Seer, 11814, Amman Jordan.
authors.forename: Ali
authors.initials: A
authors.lastname: Khader
authors.affiliation: Health Department, United Nations Relief and Works Agency Headquarters, Bayader Wadi Seer, 11814, Amman Jordan.
authors.forename: Yousef
authors.initials: Y
authors.lastname: Shahin
authors.affiliation: Health Department, United Nations Relief and Works Agency Headquarters, Bayader Wadi Seer, 11814, Amman Jordan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Seita
keywords: Antihypertensives; Essential medicines; Palestine; Refugees