Recidivism in hypertensive patients in the emergency department

Study objectives: Fifty million Americans are known to be hypertensive, with 64% uncontrolled. Uncontrolled hypertension results in substantial morbidity and utilization of health care resources. The emergency department (ED) is increasingly becoming a portal of entry into the health care system, as well as the primary care provider for the uninsured hypertensive patient. We sought to evaluate recidivism in hypertensive patients in the ED and correlate this with barriers to care, the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) classification (stage 1: systolic blood pressure 140 to 159 mm Hg or diastolic blood pressure 90 to 99 mm Hg; stage 2: systolic blood pressure 160 to 179 mm Hg or diastolic blood pressure 100 to 109 mm Hg; stage 3: systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg), and compliance. Methods: This is a retrospective medical record review conducted on patients who enrolled in a multicenter study on hypertension and barriers to care in January 2002. This study was conducted at an urban Level I trauma center with a census greater than 110,000. For 2 years after enrollment, patientsʹ records were reviewed for repeated visits to the ED for hypertension or complications, follow-up appointments, compliance with appointments, compliance with medications, substance abuse, or illnesses affecting compliance. Results: During 1 week, 672 patients were defined as hypertensive by a blood pressure greater than 140/90 mm Hg and completed the questionnaire, which accounted for 23% of total ED visits for that week. In the retrospective medical record review, it was found that of these patients only 41% had follow-up appointments scheduled on ED discharge (JNC-VI 1 39%, JNC-VI 2 42%, and JNC-VI 3 45%). Of patients with appointments, 79% kept their follow-up appointment (JNC-VI 1 77%, JNC-VI 2 81%, and JNC-VI 3 82%). Fourteen percent of all patients had a repeated visit to the ED in the 2 years after enrollment (range 1 to 39, mean 4.9 visits; JNC-VI 1 38%, JNC-VI 2 19%, and JNC-VI 3 43%). Medication compliance was only 38%, whereas clinic compliance was 59%. Drug screens were positive in 60% of patients screened. Forty-seven percent of patients who had repeated ED visits had major end organ effect (cerebrovascular accident/respiratory failure/congestive heart failure). Conclusion: Hypertension is a serious ED problem with major utilization of hospital and ED resources. Despite identification of hypertension in the ED, not all patients had arrangements for follow-up care. Repeated ED visits for hypertension are a common occurrence and are often related to compliance with medications, substance abuse, or end organ effects.