Zucker, Jason MS, MD; Gillen, Jennifer MD; Ackrivo, Jason; Schroeder, Robin MD; Keller, Steven PhD
Hypertension, which affects about one in three adults, is one of the most prevalent disorders in the United States.1 In 2009, the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System reported that in the state of New Jersey, 28% of residents have been told that they have high blood pressure.1 More males than females have hypertension, and hypertension is increased in African Americans and in people of lower-income populations.1 Because uncontrolled blood pressure has been linked to stroke, congestive heart failure, and chronic kidney disease, it poses a considerable risk for a significant portion of the population.1 According to the American Heart Association, hypertension was responsible for 46,284,000 ambulatory care visits in 2007, and some health economists estimated that this condition would be either directly or indirectly responsible for $76.6 billion in health care costs in 2010.1 The morbidity and mortality associated with uncontrolled hypertension make initiatives to improve the quality of care in this area important in any outpatient practice.
The Liaison Committee on Medical Education requires medical schools to provide adequate service learning opportunities for students, and many medical schools have opted to support student-run clinics as part of their service learning. Today, there are over 110 student-run free clinics throughout the United States.2 Previously published research on student-run free clinics includes articles on the number and types of student-run free clinics,2 patient satisfaction with the care received at such clinics,3 the insurance status of patients who visit these clinics,4 the quality of diabetes care received at student-run free clinics,5 and the ethics of these clinics.6 Two other articles describe, respectively, a student-run free clinic in general and the unique services at such clinics.7,8 However, on the basis of our literature review, we believe this is the first quality assessment study of hypertension management in a student-run free clinic.
The Student Family Health Care Center (SFHCC), in existence since 1967, is the student-run free clinic at the University of Medicine and Dentistry of New Jersey (UMDNJ), New Jersey Medical School (Newark, New Jersey). The care provided at the clinic includes management of hypertension, diabetes, dyslipidemia, and many other chronic diseases; hypertension is the most common diagnosis among the clinic's patients. The patients, who are between the ages of 18 and 65, come from the city of Newark and the surrounding area. Most are uninsured, and the SFHCC serves as their primary care provider. The clinic operates three hours per night (6 pm to 9 pm), two nights per week (Tuesday and Thursday), and six to eight patients are scheduled per night. A team of five first- through fourth-year medical students sees each patient, and usually at least one student represents each class level. Volunteer attending physicians supervise the teams, and currently 10 physicians are rotating through as volunteers. Although the students and attendings refer patients to specialists as necessary, they do not transfer patient care elsewhere.
The SFHCC has adopted as its own goals for managing patients with hypertension the goals of Healthy People 2010, and the clinic uses the treatment guidelines recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC 7). In 2000, the United States Department of Health and Human Services released the Healthy People 2010 initiative, which is a “statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats.”9 The Healthy People 2010 goal for hypertension is to increase the number of adults with hypertension at goal blood pressure from 18% to 50%. Preceding Healthy People 2010, the JNC 7 was released in 2003. Since then, it has become the most widely accepted guideline for managing hypertension. The JNC 7 guidelines recommend using five main classes of antihypertensive medications in a stepwise approach: thiazide-type diuretics, beta-blockers, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers.10 These medications all work in different ways to lower blood pressure: Thiazide-type diuretics act mainly on the kidneys; calcium channel blockers, ACEIs, and ARBs act primarily on the blood vessels; and beta-blockers work primarily on the heart.
The JNC 7 algorithm for the treatment of hypertension begins with lifestyle modifications. If patients are not at goal blood pressure after diet and exercise, then the guidelines recommend starting pharmacotherapy. Patients with compelling indications, such as diabetes, should receive pharmacotherapy customized to their comorbid condition. Patients without compelling indications who have stage I hypertension should be started on thiazide-type diuretics and given additional drugs as needed. The guidelines recommend, for patients without compelling indications who have stage II hypertension, a two-drug regimen: a thiazide and an additional antihypertensive. Finally, the guidelines recommend, for all patients not at goal blood pressure, that medication dosages should be increased and additional drugs added until goal blood pressure is achieved.10
The SFHCC provides all five classes of JNC 7 guideline-recommended antihypertensive medications, and these drugs are available, free of charge, to patients. The SFHCC purchases these and receives sample medication donations for patient use. In addition, when patients need medications not available at the clinic, the SFHCC makes every effort to prescribe a medication that is available via the $4/month programs so that these medications are not prohibitively expensive. After each appointment, patients receive enough medication to last until their next appointment. Patients are able to call and schedule medication refills if necessary.
The purpose of this analysis was to evaluate, using the JNC 7 guidelines and the Healthy People 2010 target blood pressure goals, the quality of hypertension management provided at the SFHCC.
Seven first-, second-, and third-year students responded to a request for volunteers and performed chart reviews for all the patients seen at the SFHCC from June 2008 to June 2009. For those patients who were seen at the clinic more than once during the study period, the students collected data from only the patient's most recent visit. Before beginning the data extraction, the students received 60 minutes of training on how to complete the chart reviews. Patients' charts were distributed randomly, and students were not precluded from reviewing the charts of patients they had seen. The data extraction form that the students used for the chart review included over 75 questions and was over seven pages long. One of the authors (J.Z.) reviewed at least two charts per reviewer for quality control and identified no mistakes. We entered the data from the chart review into an Excel spreadsheet for analysis.
For the purposes of this analysis, we used the data extraction form to collect the following information about patients: diagnosis of hypertension, most recent blood pressure measurement, comorbid conditions, race, gender, specific medications prescribed, free medications dispensed, body mass index, age, smoking status, and number of appointments. Students extracted race and gender from the initial patient registration form which contains self-reported information.
We identified—and included in the study—all the SFHCC patients with hypertension. Next, we divided these patients into two groups: patients with hypertension at goal blood pressure and patients with hypertension not at goal blood pressure. We used the systolic blood pressure value to assess goal blood pressure because it is a more important cardiovascular risk factor in patients over age 50 than diastolic blood pressure.10 The JNC 7 goal systolic blood pressure is 140 mm Hg or less for patients who have hypertension but not diabetes; however, in patients who have both hypertension and diabetes, the recommended goal systolic blood pressure is 130 mm Hg or less because of their higher cardiovascular risk.10 Therefore, we considered patients with only hypertension to be at goal blood pressure if their most recent systolic blood pressure was 140 or less, and patients with both hypertension and diabetes to be at goal blood pressure if their most recent systolic blood pressure was 130 or less. Next, we examined pharmacotherapy to determine the number of patients on thiazide-type medications, because, according to JNC 7 guidelines, these medications are the first-line treatment for uncomplicated hypertension, have been virtually unsurpassed in preventing the cardiovascular complications of hypertension, and should be used in most patients without a contraindication.10 We also examined multidrug regimens because multiple medications are often required for blood pressure control. Because JNC 7 states that diabetes is a compelling reason to prescribe drugs specifically from the ACEI or ARB classes, we extracted information on patients' use of these medications as well.
We completed the data analysis, using, first, Microsoft Excel (Redmond, Washington) to perform the counts and, then, Vassar statistics11 to calculate P values.
The UMDNJ institutional review board on the Newark campus reviewed this quality assurance and quality improvement project and approved its exempt status.
Of the 119 patients who visited the SFHCC between June 2008 and June 2009, 60 patients had a diagnosis of hypertension. We included all 60 patients in this study (Table 1 shows the demographics of the full SFHCC patient population as well as those with hypertension). The 60 patients with hypertension totaled 414 visits (mean 6.9, range 1–18 visits each) from June 2008 to June 2009. Patients with controlled hypertension averaged 6.4 visits, and those with uncontrolled hypertension averaged 7.4 visits, during the study period.
As Table 1 shows, 34 (57%) of the patients with hypertension were female, and of these, 15 (44%) were at goal systolic blood pressure, whereas 26 (43%) of the patients with hypertension were male, and of these, 15 (58%) were at goal systolic blood pressure. Of the 60 patients with hypertension, 41 (68%) were African American, and of these, 18 (44%) were at goal systolic blood pressure; 15 (25%) of the patients were Hispanic, and of these, 10 (67%) were at goal systolic blood pressure. Twenty-three (38%) of the 60 patients with hypertension were less than 50 years old, and of these, 14 (61%) were at goal systolic blood pressure, whereas 37 (62%) of the patients were 50 years or older, and of these, 16 (43%) were at goal systolic blood pressure. Table 2 shows the distribution of patients with only hypertension and of patients with both hypertension and diabetes.
Overall, 30 patients (50%) with hypertension were at target blood pressure. Twenty-five of the 41 patients (61%) with hypertension only were at target blood pressure, whereas 5 of the 19 patients (26%) with both diabetes and hypertension achieved target blood pressure. Figure 1 shows the distribution of systolic blood pressures.
Table 3 presents patient medication regimens for patients with hypertension. Thirty-eight of the patients (63%) were taking a thiazide-type diuretic. Eighteen patients (47%) on a thiazide-type diuretic were at goal systolic blood pressure as compared with 20 patients (53%) not on this class of medication. Because the JNC 7 recommendations include starting all patients on a thiazide-type diuretic, we further reviewed the charts of the 10 patients with uncontrolled blood pressure who were not on a thiazide-type diuretic. Three patients had hydrochlorothiazide discontinued because they deemed the common side effect of increased urination to be unacceptable. Two patients were diabetics started on an ACEI whose notes indicate that the plan was to start a thiazide in the future if their blood pressure remained uncontrolled. One patient was unable to tolerate the thiazide because of headaches; one patient came from another clinic where he/she was on a different regimen, and we continued that regimen; and one patient with a new diagnosis of hypertension was being treated with lifestyle modifications. The final two patients had been on a thiazide in the past, and their notes did not explain why it was discontinued.
Forty-two patients (70%) were on JNC 7-recommended multidrug regimens consisting of more than one class of medication. Among the 18 (43% of 42) patients with blood pressure at goal who were on a multidrug regimen, there were eight unique combinations of the five common classes of hypertensive medications. Thirteen patients were on a two-drug regimen, 3 patients were on a three-drug regimen, and 2 patients were on a four-drug regimen. The most common combination was a thiazide–diuretic and an ACEI (7 patients, 39% of 18), and no other combination was the same for more than 2 patients. Of the 24 patients with blood pressure not at goal who were on a multidrug regimen, there were 10 unique combinations of the five common classes of hypertensive medications. Fourteen patients were on a two-drug regimen, 6 patients were on a three-drug regimen, and 4 patients were on a four-drug regimen. The most common combination was, again, a thiazide–diuretic with an ACEI (8 patients, 33% of 24). No other combination was the same for more than 3 patients.
An ACEI or ARB was prescribed for all 19 patients with both hypertension and diabetes. Of the 60 SFHCC patients with hypertension, 49 (82%) received at least one free blood pressure medication from the SFHCC formulary.
Table 4 shows comorbidities and risk factors for SFHCC patients with hypertension. The average age for hypertensive patients not at goal blood pressure was higher than that of those at goal blood pressure. The average BMI was approximately 10 kg/m2 higher in the diabetic patients not at goal blood pressure, but BMI did not differ between those hypertensive, nondiabetic patients at goal and those not at goal blood pressure. The additional cardiovascular disease risk factor evaluation revealed that 35 (58%) of the 60 patients also had dyslipidemia and 19 (32%) were smokers. All of the patients identified as smokers had documented smoking cessation counseling at the last visit.
To our knowledge, this is the first published report on hypertension control in the student-run free clinic setting. Our results (overall, 50% of our patients were at target blood pressure) are as good as, or better, than those reported elsewhere. Nationally, National Health and Nutrition Examination Survey data from 2003 to 2006 reported that 44% of those older than 20 years had their hypertension under control.1 And, according to other studies—each of specific populations—the percentage of patients at goal blood pressure varied from 30% to 60%.12–14 The majority of studies report control rates near 30%. One study, which achieved control rates near 60%, was conducted on clinic patients (demographics not provided) who agreed to participate in a university-affiliated hypertension management study at the University of Iowa.15
The blood pressure of diabetic hypertensive patients is consistently more difficult to control than that of nondiabetic patients and presents a challenge in clinical practice.16,17 The SFHCC's results (26% of patients with both hypertension and diabetes were at target blood pressure) are comparable with the results of McFarlane and colleagues,18 who found, in their study of patients with hypertension and diabetes at two urban medical centers (Brooklyn and Detroit), that 26.7% of patients were at goal blood pressure.
Further, our results of hypertensive patients with and without diabetes (61% of patients with only hypertension were at target blood pressure, whereas 26% of patients with diabetes were at the target) align closely with those of another nationwide study of medical provider groups and managed care organizations that took place after the release of JNC 7; in that study, 60.9% of patients with hypertension but not diabetes were at goal, and 29.4% of patients with both hypertension and diabetes were at goal.19
As mentioned, less hypertension control is associated with patients from poor, uninsured, and African American populations.1 Additionally, older age and higher BMIs are associated with poorer hypertension control.20 These characteristics (i.e., lower income, lack of insurance, African American race, older age, and higher BMI) are common among the SFHCC patients; nonetheless, the SFHCC achieved the goal blood pressure in 50% of its hypertensive patients.
The Healthy People 2010 goal was set at 50% of the nation at target blood pressure, which, considering the critical complications of uncontrolled hypertension, may seem less than ambitious; however, many factors negatively influence blood pressure control. Clinical inertia, a physician's failure to make changes in treatment regimens despite the patient's blood pressure not reaching clinical goals, is one provider-dependent factor.21 Other factors are more patient-specific, including patients' struggles to make lifestyle modifications or pay for their medications. Lifestyle change, including diet plans such as DASH (Dietary Approaches to Stopping Hypertension) and increased exercise, are pivotal in all treatment plans, but are particularly so in plans for patients with mildly elevated blood pressure.10,22 Further analysis of SFHCC patients with hypertension who were not at goal blood pressure is needed. Some patients may have had secondary causes of hypertension such as sleep apnea.22 Others may not have been properly taking their prescribed medications. Possible improvements must include lower thresholds for altering pharmacotherapy by physicians, better and more practical education on nutrition and exercise for patients, screening for sleep apnea, and careful review of medication compliance barriers.
Published research of studies in traditional clinical settings (i.e., those not run by students) has shown that the level of blood pressure control is directly related to JNC 7 guideline adherence.23 Sixty-three percent of SFHCC patients were on, as recommended by JNC guidelines, a thiazide diuretic, exceeding the rate (40.6%) reported in a nationwide, post-JNC 7 study of medical provider groups and managed care organizations.19 We performed a detailed review of the charts of the 10 patients who were not at goal blood pressure and not prescribed a thiazide diuretic, and found a reasonable explanation for 8 of the 10. The other 2 patients had been on a thiazide diuretic, but the medication was discontinued without clear explanation in the chart. The SFHCC should put into place processes to ensure that all medication discontinuations are documented. Because diabetic patients are at increased risk for cardiovascular events, continuing to work toward goal blood pressure for these patients is critically important. One national, post-JNC 7 study found that only 75.6% of patients with both hypertension and diabetes received ACEIs or ARBs19; McFarlane and colleagues'18 study found that only 64.1% of patients with hypertension and diabetes were on an ACEI; and a third study found that only 43% of such patients nationally whose diagnoses indicated ACEIs or ARBs were receiving them.24 In contrast, all of the SFHCC diabetic hypertensive patients were taking an ACEI or an ARB, as per the JNC 7 recommendation. However, the majority of SFHCC patients with diabetes were not at goal blood pressure. Attention to the management of this high-risk group of patients is imperative.
Eighty percent (no. = 24) of patients at the SFHCC not at goal blood pressure were on a multidrug regimen; however, 14 (58%) of these patients were on only a two-drug regimen. As per the JNC 7 algorithm, these patients need to be evaluated for optimal medication dosage of each medication, and further antihypertensives should be added until goal blood pressure is achieved. Factors such as cost and medication side effects must be considered. The six patients not on multidrug therapy who were not at goal blood pressure need reassessment to determine a better treatment plan.
Despite the use of low-cost ($4/month) or free medications, 50% of SFHCC patients were still not at goal blood pressure. The use of free (formulary) medications did not seem to affect hypertension control in this group of patients. We did not expect this finding and are further evaluating this group of patients.
We found that many patients in the SFHCC clinic had additional cardiovascular disease risk factors: Some were smokers, some had a higher BMI, and some had dyslipidemia. These patients require special focus to ensure that their blood pressure is controlled. Despite receiving counseling, 32% of the clinic's hypertensive patients remained smokers. Smoking not only increased their risk for complications but also may have contributed to their lack of control of blood pressure.1 Higher BMI in diabetic patients at the SFHCC was associated with poorer control of blood pressure. This finding is not surprising and reinforces the need to address weight management as a critical component of blood pressure (and diabetes) control.
Additionally, the blood pressure of the SFHCC's younger patients was controlled at better rates than the blood pressure of older patients. This finding is consistent with the literature that indicates older patients' blood pressure is more difficult to control than that of younger patients.24 Because 49% of SFHCC patients were age 50 or older, this group must receive special attention.20 The Hispanic population of the SFHCC had better blood pressure control than the African American population, another finding that aligns with the literature. JNC 7 reports that “[t]he prevalence, severity, and impact of hypertension are increased in African Americans” and that diuretics and calcium channel blockers are more effective monotherapies than other classes of drugs for this population.10 A study at six urban, academic primary care practices found that whereas African American populations had lower rates of blood pressure goal achievement than Caucasian populations, no difference existed in the intensity of treatment, but African Americans had increased “hypertension awareness.”25 This finding suggests that African Americans may require a greater focus on medication adherence rather than a simple intensification of pharmacological treatments.
Patients at the SFHCC receive significant education and counseling regarding lifestyle changes. Student volunteers working together (in groups of four) present educational sessions to groups of patients on specific aspects of common conditions; for example, patients receive training on practical methods to increase their daily exercise, ideas for practical alternatives for food shopping on a budget, and information on the most healthful options when eating at fast food establishments. Medical students receive motivational counseling training during their third year of medical school so that they can help patients make these lifestyle changes.
This study has some limitations. Because it involves only one student-run free clinic in an urban setting, our findings may not be generalizable to similar clinics in different settings. Additionally, limited data on quality of care in student-run or free clinics are available, so an accurate comparison with similar clinics is not possible. Finally, students may have reviewed the charts on patients whom they had seen, potentially leading to an underreporting of high blood pressure readings.
The SFHCC has met the published averages for prescribing patterns and the national goals for blood pressure goal achievement. The quality of care in this student-run free clinic does not seem to differ from that reported in studies performed in more traditional settings. At New Jersey Medical School, the SFHCC is able to provide a service learning opportunity for students while providing a high level of care, comparable with or exceeding national quality standards and care guidelines, for underserved patients in the community. We encourage other student-run clinics to analyze their patient outcomes to determine whether they, too, are providing not only service learning opportunities for students but also the highest quality of care for patients.
The authors wish to thank the following New Jersey Medical School students for their efforts: Brandis Belt, Arun Gurunathan, Jasneet Kaur, Christine White, Sarah Park, James Zasadzinski, and Kai Zhao.
There was no funding directly related to this project; however, the Student Family Health Care Center is generously supported by the New Jersey Medical School Department of Medicine, the New Jersey Medical School Alumni Association, the New Jersey Medical School Student Council, as well as by private donations and fundraising efforts.
The University of Medicine and Dentistry of New Jersey institutional review board (Newark campus) deemed this project exempt.
Pieces of this report were presented in Jacksonville, Florida, at the 2010 Society of Student-Run Free Clinics National Conference.
1Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation. 2010;121:e46–e215.
2Simpson SA, Long JA. Medical student-run health clinics: Important contributors to patient care and medical education. J Gen Intern Med. 2007;22:352–356.
3Ellett JD, Campbell JA, Gonsalves WC. Patient satisfaction in a student-run free medical clinic. Fam Med. 2010;42:16–18.
4Niescierenko ML, Cadzow RB, Fox CH. Insuring the uninsured: A student-run initiative to improve access to care in an urban community. J Natl Med Assoc. 2006;98:906–911.
5Ryskina KL, Meah YS, Thomas DC. Quality of diabetes care at a student-run free clinic. J Health Care Poor Underserved. 2009;20:969–981.
6Buchanan D, Witlen R. Balancing service and education: Ethical management of student-run clinics. J Health Care Poor Underserved. 2006;17:477–485.
7Hastings J, Zulman D, Wali S. UCLA mobile clinic project. J Health Care Poor Underserved. 2007;18:744–748.
8Morello CM, Singh RF, Chen KJ, Best BM. Enhancing an introductory pharmacy practice experience at free medical clinics. Int J Pharm Pract. 2010;18:51–57.
10Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003;289:2560–2572.
12Bonds DE, Hogan PE, Bertoni AG, et al. A multifaceted intervention to improve blood pressure control: The Guideline Adherence for Heart Health (GLAD) study. Am Heart J. 2009;157:278–284.
13Drawz PE, Bocirnea C, Greer KB, Kim J, Rader F, Murray P. Hypertension guideline adherence among nursing home patients. J Gen Intern Med. 2009;24:499–503.
14Holder KK. Interventions to improve blood pressure control in patients with hypertension. Am Fam Physician. 2007;76:373–374.
15Milchak JL, Carter BL, Ardery G, Dawson JD, Harmston M, Franciscus CL. Physician adherence to blood pressure guidelines and its effect on seniors. Pharmacotherapy. 2008;28:843–851.
16DeJesus RS, Chaudhry R, Leutink DJ, Hinton MA, Cha SS, Stroebel RJ. Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: A pilot study. Vasc Health Risk Manag. 2009;5:705–711.
17Frank J. Managing hypertension using combination therapy. Am Fam Physician. 2008;77:1279–1286.
18McFarlane SI, Jacober SJ, Winer N, et al. Control of cardiovascular risk factors in patients with diabetes and hypertension at urban academic medical centers. Diabetes Care. 2002;25:718–723.
19Jackson JH, Sobolski J, Krienke R, Wong KS, Frech-Tamas F, Bightengale B. Blood pressure control and pharmacotherapy patterns in the United States before and after the release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines. J Am Board Fam Med. 2008;21:512–521.
20Lloyd-Jones DM, Evans JC, Larson MG, O'Donnell CJ, Rocella EJ, Levy D. Differential control of systolic and diastolic blood pressure: Factors associated with lack of blood pressure control in the community. Hypertension. 2000;36:594–599.
21Philips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825–834.
22Viera AJ, Hinderliter AL. Evaluation and management of the patient with difficult-to-control or resistant hypertension. Am Fam Physician. 2009;79:863–869.
23Asch SM, Kerr EA, Lapuerta P, Law A, McGlynn EA. A new approach for measuring quality of care for women with hypertension. Arch Intern Med. 2001;161:1329–1335.
24Rosen AB. Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002. J Gen Intern Med. 2006;21:315–319.
25Umscheid CA, Gross R, Weiner MG, Hollenbeak CS, Tang SS, Turner BJ. Racial disparities in hypertension control, but not treatment intensification. Am J Hypertension. 2010;23:54–61.