Authors reply: Adherence to guideline-recommended care of late-onset hypertension in females versus males: A population-based cohort study

IF 9 2区 医学 Q1 MEDICINE, GENERAL & INTERNAL Journal of Internal Medicine Pub Date : 2024-09-09 DOI:10.1111/joim.20010
Ann Bugeja, Gregory L. Hundemer, Daniel I. McIsaac
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引用次数: 0

Abstract

Dear Editor,

We thank Dr. Huang et al. for their thoughtful response to our published manuscript [1, 2]. Their first concern addresses our interpretation of the adjusted hazard ratio (aHR 0.98 [95% CI 0.96, 0.99]) for antihypertensive medication prescription by sex. Although statistically significant, its clinical significance remains uncertain, though we acknowledge its relevance at the population level in the discussion section of our manuscript. To explore potential effect modifiers, we tested a priori interactions between sex and several plausible variables—age, diabetes status, era of hypertension diagnosis, and preexisting cardiovascular disease—by incorporating these multiplicative terms into our model. We then reported aHRs of each stratum from stratified analyses for those variables that were statistically significant on the multiplicative scale. However, we did not report measures of relative excess due to interaction [3]. It is certainly possible that other covariates may have been effect modifiers of the association between sex and prescription of antihypertensive medication.

Second, misclassification bias is a recognized issue in observational studies utilizing administrative data. Nonetheless, the case definition for hypertension used in our study has been validated, showing a sensitivity of 75%, specificity of 94%, positive predictive value of 81%, and negative predictive value of 92%, as detailed in our methods section [4]. As the authors correctly note, administrative data do not capture nuances related to gender and patient preferences that can influence hypertension treatment, which may introduce residual confounding [5].

Third, although the aHR for the prescription of guideline-recommended antihypertensive medication is statistically significant (aHR 0.995, 95% CI [0.994, 0.997]), determining its clinical significance is challenging. We acknowledge that this effect may be clinically relevant at the population level, as discussed in our manuscript. Evaluating antihypertensive medication prescriptions over time, alongside data on actual blood pressure management and drug intolerance, would offer additional insights beyond our current findings.

Lastly, we aimed to address the observation that better cardiovascular outcomes in females compared to males do not appear to be linked to the completion of hypertension-related investigations or the prescription of antihypertensive medication [6]. We proposed that females might benefit more from antihypertensive treatment compared to males, but we recognize that we cannot draw definitive conclusions due to limitations such as insufficient data on treatment adherence, gender-specific issues, and potential residual confounding. More detailed data would enhance our study and support the development of targeted implementation strategies for older populations.

The authors declare no conflicts of interest.

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作者回复:女性与男性对晚期高血压指南推荐护理的依从性:一项基于人群的队列研究。
亲爱的编辑,我们感谢黄博士等人对我们发表的稿件[1, 2]的深思熟虑的回应。他们提出的第一个问题涉及我们对按性别分列的降压药处方调整危险比(aHR 0.98 [95% CI 0.96, 0.99])的解释。虽然在统计学上有意义,但其临床意义仍不确定,尽管我们在手稿的讨论部分承认了其在人群水平上的相关性。为了探索潜在的效应调节因子,我们测试了性别与年龄、糖尿病状况、高血压诊断时间和既往心血管疾病等几个可能变量之间的先验交互作用,并将这些乘法项纳入模型。然后,我们报告了分层分析得出的各层的 aHRs,这些变量在乘法尺度上具有统计学意义。但是,我们没有报告交互作用导致的相对过量[3]。当然,其他协变量也可能是性别与抗高血压药物处方之间关系的效应调节因素。其次,误分类偏差是利用行政数据进行观察研究中公认的问题。尽管如此,我们研究中使用的高血压病例定义已经过验证,显示灵敏度为 75%,特异性为 94%,阳性预测值为 81%,阴性预测值为 92%,详见我们的方法部分[4]。正如作者正确指出的那样,行政数据并不能捕捉到与性别和患者偏好有关的细微差别,而这些因素可能会影响高血压的治疗,因此可能会带来残余混杂因素[5]。第三,尽管指南推荐的降压药物处方的 aHR 具有统计学意义(aHR 0.995,95% CI [0.994,0.997]),但确定其临床意义却具有挑战性。我们承认,正如我们手稿中讨论的那样,这种效应在人群水平上可能具有临床相关性。最后,我们的目标是解决这样一个问题:与男性相比,女性更好的心血管预后似乎与完成高血压相关检查或开具降压药处方无关[6]。我们认为,与男性相比,女性可能会从降压治疗中获益更多,但我们认识到,由于治疗依从性数据不足、性别特异性问题以及潜在的残余混杂因素等限制因素,我们无法得出明确的结论。更详细的数据将加强我们的研究,并支持为老年人群制定有针对性的实施策略。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Internal Medicine
Journal of Internal Medicine 医学-医学:内科
CiteScore
22.00
自引率
0.90%
发文量
176
审稿时长
4-8 weeks
期刊介绍: JIM – The Journal of Internal Medicine, in continuous publication since 1863, is an international, peer-reviewed scientific journal. It publishes original work in clinical science, spanning from bench to bedside, encompassing a wide range of internal medicine and its subspecialties. JIM showcases original articles, reviews, brief reports, and research letters in the field of internal medicine.
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