Malignant hypertension in general practice

A diagnosis of malignant hypertension was recorded for 165 patients in the national morbidity study between 1970 and 1973. Three patients with benign hypertension were selected as age- and sex-matched controls for each case. The general practitioners in the study were asked to complete a further questionnaire about the patients and 66% of the practices agreed to take part. Information about the retinal findings for the patients was requested and less than half of those in the national morbidity study proved to have a strict diagnosis of accelerated or malignant hypertension although they were originally recorded as patients with malignant hypertension. Of those patients originally classified as having benign hypertension 5% had the retinal appearance of accelerated or malignant hypertension.Patients had been diagnosed as having hypertension for a mean of more than five years prior to entry into the national morbidity study and the survival of patients with both benign and accelerated or malignant hypertension was good. Thirtyfour per cent of those with confirmed benign hypertension and 62% of those with definite accelerated or malignant hypertension died in the follow-up period which was on average 10 years from entry into the national morbidity study.The survival of patients registered with doctors who did not collaborate and of patients whose clinical details were missing was similar to the survival of patients for whom full details were provided.Blood pressure control was only fair with a mean of 172/101 mmHg for the group with benign hypertension and 177/107 mmHg for the group with accelerated or malignant hypertension. Blood pressure control was the poorest for those who died from a stroke. A high proportion (78%) of deaths in association with accelerated or malignant hypertension were from cardiovascular or renal causes.     

Criteria for the diagnosis of hypertension in general practice

An accurate age-sex register was used to identify patients in a practice who might be suffering from hypertension and to record the criteria on which the diagnosis was based. Information about blood pressure readings, diagnostic labels and treatment at the time of diagnosis were noted. The definition of hypertension sufficient to require treatment was a recorded diastolic pressure of 110 mm Hg or more on three occasion. Using these criteria, only 12 per cent of patients qualified.     

The severity of depression in patients treated in general practice

The severity of depression, the presence and intensity of suicidal feelings, and the outcome of depressive illness treated in general practice were studied. The results suggest that a consideration of the relatively good outcome at 16 to 18 weeks alone is misleading. At least one in six new patients is suffering from a depression of moderately severe intensity and a similar proportion experience suicidal ideas that are persistent and require active rejection. A sample of patients with chronic depression had only a slightly smaller morbidity. The presence of moderately severe symptoms of depression in both groups of patients has important implications for treatment.     

Audit of screening for hypertension in general practice

An audit of a practice which has a policy of opportunistic screening for raised blood pressure showed that 80 per cent of patients born between 1930-44 had been screened in the last five years. Patients who had not been screened were identified and contacted; this increased the percentage screened to 87 per cent. Only four possible new hypertensives were identified. It is suggested that the effort and expense of achieving this result was not worthwhile and that opportunistic screening is the cheapest and easiest method of screening for high blood pressure.     

Home blood pressure monitoring: its effect on the management of hypertension in general practice.

BACKGROUND: Ambulatory and home blood pressure monitoring have been shown to improve the management of hypertension. Either can be used to diagnose 'white coat hypertension' (WCH), which affects 10% to 20% of hypertensives and usually does not require drug treatment. Home monitoring has been used little in primary care. AIM: To investigate the use and acceptability of home monitoring, and to establish the incidence of WCH as diagnosed in a primary care setting. METHOD: Twenty practices were asked to monitor hypertensive patients, in particular those about to start drug treatment and those who were poorly controlled. RESULTS: A total of 660 patients were monitored. Sixty-four (27%) of the 236 untreated patients had WCH and no medication was started in 60 (94%) of this group. Forty-five (17%) of the 258 poorly-controlled patients had WCH and, of these, 34 (76%) continued with the same medication and 11 (24%) either reduced or stopped it. Compliance with recording was high. Questionnaires and focus groups with doctors and nurses showed that home monitoring represented a valuable enhancement of their management of hypertensive patients. Patients reported a high degree of interest and satisfaction with monitoring. CONCLUSIONS: Patients, doctors, and nurses found monitoring valuable, and found the instruments easy to use with few problems. The feasibility of screening for WCH with home blood pressure monitoring was demonstrated, and, for this specific purpose, it is recommended as the preferred alternative to ambulatory monitoring in primary care.     

Chronic kidney disease in patients with diabetes mellitus type 2 or hypertension in general practice

Background

The prevalence and severity of chronic kidney disease (CKD) in primary care patients with diabetes or hypertension is unknown.

Aim

To assess the prevalence and severity of CKD in patients with diabetes and hypertension; and identify whether age, sex, diabetes, and hypertension are associated with CKD.

Design of study

Cross-sectional survey.

Setting

Two Dutch primary health care centres (15 954 enlisted patients).

Method

Patients, aged ≥25 years, with known diabetes type 2 (n = 471) or hypertension (n = 960), were selected on 1 October 2006. Initial screening uptake rates were assessed from the electronic patient records, and patients were invited when blood or urine measurements were missing. The presence of albuminuria was determined, glomerular filtration rate estimated, and clinical characteristics extracted.

Results

Initial screening uptake rates were 93% and 69% for diabetes and hypertension, respectively, and increased to 97% (n = 455) and 87% (n = 836) after active invitation. The prevalence of CKD was 28% in diabetes and 21% in hypertension only. The presence of diabetes was independently associated with albuminuria (odds ratio [OR] 4.23; 95% confidence interval [CI] = 2.67 to 6.71), but not with decreased estimated GFR (eGFR) (OR 0.75; 95% CI = 0.54 to 1.04). Age showed the strongest association with decreased eGFR (OR 2.73; 95% CI = 2.02 to 3.70).

Conclusion

In primary care, more than one-quarter of patients with diabetes and about one-fifth of patients with hypertension have CKD. The high prevalence justifies longitudinal follow-up in order to evaluate whether intensified cardiovascular risk management is beneficial in this primary care population.     

Personal continuity and the care of patients with epilepsy in general practice.

BACKGROUND: So far no study has shown that patients with a chronic illness benefit from seeing the same doctor in general practice although many believe this to be so. AIM: Epilepsy was chosen as an example to test the hypothesis that if patients see the same doctor more often in general practice they are more likely to discuss personally important aspects of their illness. METHODS: In this cross-sectional survey 99 patients aged 15-84 years with active epilepsy were interviewed at home and then their records were reviewed. The patients came from four large Southampton group practices, one with a strict personal list system and three with combined lists. Outcome measures included reported discussion of feelings about stopping medication, stigma and concealment and the patient's relationship with practice doctors. Continuity was assessed from the records. RESULTS: Discussion of epilepsy was not significantly associated with continuity of doctor but was significantly associated with ease of talking to one or more doctors. CONCLUSION: Encouraging patients with epilepsy to see the same doctor may be less important than improving doctors' communication skills and paying specific attention to the psychosocial aspects of epilepsy as well as to seizure control. It is recommended that a simple checklist including these items is used when a patient's care is reviewed.     

Cost-effectiveness of implementing new guidelines for treatment of hypertension in general practice.

BACKGROUND: Hypertension is a major public health concern and, as the population ages, the size of the problem is likely to increase. However, detection rates and treatment of hypertension have been low. The introduction of new guidelines for the detection and treatment of hypertension have been encouraged but without any consideration to their cost-effectiveness. AIM: To assess the potential cost-effectiveness of implementing new guidelines for the treatment of hypertension in general practice. Design of study: Model examining the incremental costs and effects of the new guidelines compared with the old. SETTING: A large general practice in north Yorkshire. METHOD: Two thousand and twenty-three patients reporting for a new health patient check had the costs and outcomes under the old and new guidelines estimated. RESULTS: Implementing new guidelines for the detection, management, and treatment of hypertension in a primary care setting is more costly than the implementation of previous guidelines, but more effective in reducing the risk of cardiovascular disease. The incremental cost per cardiovascular disease event avoided is ?30 000, although sensitivity analysis shows that the estimate is subject to considerable uncertainty. CONCLUSIONS: Compared with previous guidelines, introducing new guidelines for the management and treatment of hypertension in new patients in general practice is likely to be cost-effective. However, the workforce implications for general practitioners (GPs) and practice nurses should be considered.     

Audit of the care of patients with epilepsy in general practice.

BACKGROUND: Previous studies have shown that there is great potential for improving the management of patients with epilepsy. AIM: To identify all patients with epilepsy, to evaluate and audit their care in relation to an annual review, to document seizure frequency and appropriateness of daily therapy to aid compliance and to propose strategies to improve these and other aspects of epileptic care. METHOD: An audit of the care of patients with epilepsy was undertaken in two King's Lynn practices with a combined population of 22,500. Principles for the management of epilepsy were established. From these principles, the following standards were agreed: 75% of patients on treatment for epilepsy should be seen every year, 75% of patients should have their seizure frequency documented, and 75% of patients should take their anti-epileptic drugs no more than twice daily. As a result of the first audit cycle, changes were made in the documentation and advice regarding treatment relating to these standards. RESULTS: The first audit cycle showed that 83% of patients had been seen at least once in the previous year, that documentation of seizure frequency existed for 51% of patients in the past year, and that 63% of patients were taking their treatment no more than twice daily. The evaluation was repeated 22 months later and an overall improvement was demonstrated in the first two results: 95% of patients had been seen in the past year, 93% had had their seizure frequency documented; however, only 66% of patients were taking their treatment twice daily or less. CONCLUSION: Call and recall, and documentation of seizure frequency were improved by this clinical audit. However, alterations in daily therapy appeared difficult for a variety of reasons; for example, therapy might have been initiated by a hospital specialist, and patients in a stable condition might have been apprehensive about changes. In order to improve the care of patients with epilepsy, a primary care team approach is desirable within a structure of good specialist services.     

Predictors of patient-initiated reconsultation for lower respiratory tract infections in general practice

Reconsultation for lower respiratory tract infection (LRTI) is common in general practice, but those who reconsult rarely have more significant illness warranting antibiotics. Knowledge of factors that predict patient-initiated reconsultation may allow clinicians to address specific issues during the initial consultation that could reduce reconsultations. Thirty-three per cent of a cohort of 431 LRTI patients in a randomised controlled trial reconsulted. Excluding 35 patients with GP-requested reconsultation left 28% (112/396) with a patient-initiated reconsultation during 28-day follow-up. Patient-reported dyspnoea and concerns that persisted after the initial consultation independently predicted patient-initiated reconsultation.     

Effectiveness of general practice interventions for patients with harmful alcohol consumption.

Harmful alcohol consumption can have severe consequences for both the individual and society. A review of the six published studies on the effectiveness of general practitioner interventions for individuals with harmful alcohol consumption suggests that between five and 10 minutes of advice leads to reductions of alcohol consumption of around 25-35% at follow up six months or one year later. Two of the three studies which failed to demonstrate an intervention effect had inadequate sample sizes and in two of the studies the control group was a comparison group which received minimal advice to reduce alcohol consumption. There was greater evidence for an intervention effect among men than women. The methodological problems of the studies are discussed.