The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care

BACKGROUND: The new General Medical Services (nGMS) contract was introduced in April 2004 to improve care of chronic diseases such as coronary heart disease (CHD) and reduce differences in treatment between patient subgroups. OBJECTIVE: To determine whether the recording of CHD-related health indicators and prescribing of medicines have increased following the introduction of the nGMS contract and whether differences in the treatment of patients of differing age, gender and deprivation have been affected. METHODS: A serial cross-sectional study carried out with 310 general practices in Scotland. The subjects were patients with CHD as identified by their GP. Main outcome measures were the recording of CHD-related health indicators and prescribing of medicines at pre- and post-contract time points (covariates: gender, age, co-morbidity, deprivation and practice size). RESULTS: The recording of CHD-related quality indicators and prescribing increased dramatically (mean absolute increase of 17.1%) after the introduction of the nGMS contract. Post-contract, disparities between patient subgroups, continued for certain components of care. Women were less likely to be recorded than men in 9 of 11 components of care, with older patients (7 of 11 components of care) and the most deprived (4 of 11 components of care) also less likely to have a record than the youngest and least deprived, respectively. CONCLUSION: The introduction of the new contract was associated with a dramatic rise in the recording of CHD-related quality indicators. However, not all the population benefited equally for certain aspects of care.     

Differences in management of heart attack patients between metropolitan and regional hospitals in the Hunter Region of Australia

OBJECTIVES: To test the hypothesis that among patients with acute myocardial infarction (AMI) length of hospital stay, drug use in hospital and on discharge were different between metropolitan and regional hospitals after adjusting for differences in patient baseline risk. METHODS: A retrospective cohort study using a community-based register of heart attack patients assessed 1,406 patients admitted for definite AMI to three metropolitan and five regional hospitals in the Lower Hunter Region of NSW, between January 1, 1990, and March 31, 1994. RESULTS: Patients in metropolitan hospitals were significantly less likely to stay in hospital for more than seven days (adjusted odds ratio = 0.50; 95% CI 0.34-0.73), significantly more likely to receive ACE inhibitors (adj. OR = 1.47; 1.27-1.71) and less likely to receive calcium channel blocker (adj. OR = 0.70; 0.54-0.98). Regardless of disease severity, metropolitan hospitals had a higher percentage of patients for whom drugs shown to decrease mortality after AMI were used (streptokinase, aspirin, ACE inhibitor); a lower percentage of patients received drugs shown to have no benefit or even a detrimental effect (calcium channel blocker). Both groups had relatively low use of beta blocker, also shown to be of benefit. CONCLUSIONS: Regional hospitals had longer hospital stays than metropolitan hospitals and less use of drugs of proven benefit.     

Combined antihypertensive and antilipemic therapy as one of the pillars in the poly-pharmacologic preventive strategy for patients with high cardiovascular risk

Hypertension is a highly prevalent disease and a strong risk factor for cardiovascular disease in industrialized countries in Europe and North America. About 40-50% of hypertensive patients have some other cardiovascular risk factors as smoking, dyslipidemia, glucose intolerance, metabolic syndrome and diabetes. The realization of optimal therapy of these patients is a difficult task, and reaching target blood pressure values is almost impossible by monotherapy. It was realized that the simultaneous normalization of blood pressure and that of abnormal lipid profil with 2-3 or more drugs have great importance for preventing atherosclerotic complications.We started an open-formed study with about 1000 hypertensive patients complicated with dyslipidemia, visceral obesity, metabolic syndrome and diabetes type 2. The base of our therapeutic strategy was a tipical polypill treatment with ACE inhibitor (lisinopril), calcium antagonist (amlodipin), statin (atorvastatin) and antiplatelet therapy (if it was necessary).     

Hypertension in a primary care setting

In their cross-sectional analysis of computerized GP data, Pearset al. found that male hypertensive patients were more likelythan females to receive an ACE inhibitor or a statin.¹ Theyalso found elderly     

Population mobility: characteristics of people registering with general practices

OBJECTIVES: The aim of this study was to examine the characteristics of patients joining general practitioners' (GP) lists, and the time taken to register after a move of residence. STUDY DESIGN: Questionnaire study. METHODS: Staff in six London general practices administered the questionnaire to 642 newly registering adults. RESULTS: Nearly 40% of participants took longer than 6 months to re-register with a GP after a change of address. About one in eight participants (13%) took longer than 1 year and one in 14 (7%) took longer than 3 years to register. The overall median time to register after a move was 4 months. The amount of time taken to register appeared to be influenced by a number of factors, including gender, age and geographical location. CONCLUSIONS: Population mobility and the time taken to register with a new GP is likely to have a major impact on access to health care and the effectiveness of local preventative health programmes. Primary care trusts need to encourage their local residents to register with a GP soon after a change of address, and develop initiatives to encourage participation in preventative health programmes amongst mobile groups. Additional measures to strengthen primary care provision, such as walk-in centres, may be required in areas with the highest levels of population turnover.     

Trends in the hospital management of unstable angina

STUDY OBJECTIVE: To examine the hospital management of unstable angina (UAP) in 1996 and 1998, according to patient demographic variables and disease severity. DESIGN: Medical record review. SETTING: 37 hospitals across New South Wales, Australia, representative of the secondary and tertiary care hospitals in the State. PARTICIPANTS: All patients (or a random sample of patients) with UAP admitted to these hospitals during five months in 1996 and six months in 1998 (1872 and 1368 patients respectively). MAIN RESULTS: In the two years between 1996 and 1998, there was an increase in the use of beta blockers and a corresponding decrease in the use of calcium channel blockers, as well as a decrease in the use of intravenous nitrates. Those aged 75 or more were roughly half as likely as those aged less than 65 to be prescribed heparin, aspirin and heparin, beta blockers, intravenous nitrates, and only one third as likely to be offered coronary angiography in hospital. They were one and a half times as likely to be prescribed calcium channel blockers compared with the youngest age group. A similar pattern was seen for gender, where men were more likely than women to be given aspirin, aspirin and heparin, and coronary angiography, and less likely to be given calcium channel blockers. Those with a past history were less likely, and those with more severe disease were more likely than others to be given most interventions. CONCLUSIONS: In view of the low use of evidence-based management of UAP among women and the elderly, it would seem appropriate for disease management guidelines to target these groups.     

Clinical inquiries. Which combination drug therapies are most effective for hypertension?

Insufficient evidence exists to determine which specific combinations most effectively decrease cardiovascular morbidity and mortality, although combinations of hypertension medications at lower doses generally reduce cardiovascular outcomes (stroke, coronary heart disease) more than monotherapy (strength of recommendation [SOR]: A, large meta-analyses).The combination of benazepril and amlodipine reduces the composite endpoint of cardiovascular events and deaths more than benazepril plus hydrochlorothiazide with similar rates of adverse effects (SOR: A, randomized controlled trial [RCT]).Combining an angiotensin converting enzyme inhibitor (ACE-I) with a thiazide, ?-blocker, or calcium channel blocker produces side effects similar to monotherapy, as does combining an angiotensin receptor blocker (ARB) with a thiazide or calcium channel blocker (SOR: A, meta-analyses). However, an ACE-I combined with an ARB increases the risk of renal complications and death more than monotherapy (SOR: A, RCT)..     

Results of a national asthma campaign survey of primary care in Scotland.

OBJECTIVE: To identify within primary care in Scotland how far procedures for asthma review and patient education match guideline recommendations. DESIGN AND SETTING: Telephone survey of a one in four stratified random sample of all 1058 general practices in Scotland. PARTICIPANTS: Practice nurses, general practitioners. MAIN OUTCOME MEASURES: Number of practices matching guideline recommendations for asthma review, targeting of care, use of structured asthma records, provision of management plans, education, and regular audit. RESULTS: Of 276 general practices contacted 91% (251) completed the questionnaire; 93% (228) ran an asthma review service; 74% (166) employed a specially trained asthma nurse; 39% (106) had a policy for providing action plans; 63% (155) had carried out an asthma audit in the previous 3 years; 76% (218) used a structured tool in consultations, 46% with use of computer technology, 34% used only a manual stamp. Sixty-six per cent (173) had searched for patients overusing beta2 agonists; 32% (79) had searched for patients on medication treatment step 3 and above. Single- or two-partner practices were less likely to follow guideline recommendations but neither rurality nor deprivation was related to guideline compliance. CONCLUSIONS: Three-quarters of Scottish general practices have trained asthma nurses and offer patients asthma review, but only a minority have proactive care procedures for targeting patients or a policy for providing patients with action plans. Practice systems are underused for identifying 'at-risk' patients. There is a need for proactive procedures and provision of self-management materials to patients. Access to trained asthma nurses needs to be improved.     

高血压患者治疗后血压昼夜节律及影响因素的调查

目的了解高血压病患者经治疗血压达标后血压昼夜节律及影响因素.方法采用横断面调查的方法,采用进入法进行非条件logistic回归分析.结果共纳人208例患者,呈勺型曲线者79例(占38%),非勺型曲线者129例(占62%).logistic回归分析显示,年龄在70岁以上及60～69之间者24 h动态血压曲线呈非勺型的比例分别是60岁以下者的3.3倍(P=0.009)和2.3倍(P=0.031);有早发心血管疾病家族史的患者,其动态血压曲线形态呈非勺型的比例为无相应家族史患者的3.7倍(P=0.029);超重(BMI＜28)与肥胖(BMI≥28)者24 h动态血压曲线呈非勺型的比例分别是正常体重(BMI＜24)者的3.0倍(P=0.003)和4.8倍(P=0.009);与单独应用长效钙离子拮抗剂(CCBs)治疗相比,单用血管紧张素转换酶抑制剂(ACEIs)或血管紧张素Ⅱ受体阻滞剂(ARBs)治疗者动态血压曲线呈非勺型的机会较少(OR=0.139,P=0.010),采用包含ACEIs或ARBs(但不包括利尿剂)的联合用药方案的患者有较少非勺型曲线的趋势,但二组之间差异无显著性(OR=0.453,P=0.118);采用包括利尿剂(但无ACEIs或ARBs)的联合用药方案以及同时包含利尿剂与ACEIs或ARBs的联合用药方案的患者均有较少非勺型曲线的机会(OR值分别为0.378和0.273,P值分别为0.030和0.011).结论高血压患者经治疗血压达标后,有近三分之二的患者呈异常的血压昼夜节律.年龄、早发心血管疾病的家族史、超重或肥胖、降压药物治疗方案等4个因素与24 h血压曲线形态有关.与单用长效CCBs比较,利尿剂、ACEIs或ARBs可能有利于保持正常的血压昼夜节律.     

Treating hypertension is more important than the choice of agent; results from the largest clinical trial until now

During the past few years, several randomised trials have compared the effects of older blood-pressure lowering drugs (diuretics, beta-blockers) with those of newer ones (angiotensin converting enzyme (ACE) inhibitors, calcium entry blockers) on the long-term prognosis. In general, no significant differences were found between these regimes. Recently, the ALLHAT trial, which was the largest hypertension trial ever and in which over 40,000 patients with hypertension participated, was completed. The initial treatment consisted of either the diuretic chlorthalidone, the calcium entry blocker amlodipine, the ACE inhibitor lisinopril, or the alpha-blocker doxazosin. The latter arm was prematurely discontinued because of a higher incidence of the secondary endpoint heart failure and stroke. Based on an intention-to-treat analysis, the other types of treatment proved to be equivalent in terms of the primary endpoint, a composite of fatal coronary heart disease and non-fatal myocardial infarction. Although the investigators conclude that ALLHAT suggests that thiazide diuretics should be first choice in the treatment of hypertension, there are several caveats that tend to lessen the strength of this conclusion.     

Drug treatment considerations for the hypertensive black patient

In prior years the major differences noted between hypertension in black and white patients have been mostly epidemiological, with some suggestion that the differences were primarily quantitative and probably not qualitative. Recently, certain pathophysiological aberrations in hypertensive patients have been shown to be different in blacks and whites. Whether these differences are primary (genetic) or secondary has yet to be resolved. Nevertheless, certain racial differences may have therapeutic implications. Diuretics remain the mainstay of therapy for most hypertensive black patients. beta-Blockers and angiotensin-converting enzyme (ACE) inhibitors have not shown great efficacy when used as monotherapy in black hypertensive patients. The combination of a diuretic with beta-blockers or ACE inhibitors, however, has been shown to abolish black-white differences in drug response. More recently, the calcium channel blockers have been shown to be potentially effective in black hypertensive patients. In spite of the effective drug therapy that is available for hypertensive patients in general, economic and social considerations continue to contribute to the low rate of detection, treatment, and control of hypertension in the black population.     

Relevance and practical use of the Consultation and Relational Empathy (CARE) Measure in general practice

BACKGROUND: The Consultation and Relational Empathy (CARE) Measure has been developed as a tool for assessing the patients' perceptions of relational empathy in the consultation. OBJECTIVES: The present paper provides performance data on the CARE measure in a large sample of general practice consultations in areas of high and low deprivation. METHODS: The CARE Measure was included in a self-completed questionnaire study involving 3044 patients attending 26 GPs in 26 different practices (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). RESULTS: GPs and patients, in both high and low deprivation settings, endorsed the relevance of the CARE Measure. Overall, 76% of patients rated the measure as being 'very important' to their current consultation. Higher rating of importance were observed in older patients, patients consulting with psycho-social problems, patients with long-standing illness or disability, and patients with significant emotional distress. Few patients rated individual CARE Measure items as being 'not applicable' to their current consultation; only 3.1% of patients felt that more than 2 of the 10 items in the measure did not apply to their current consultation. Mean values were not influenced by deprivation, gender, reason for consulting, chronic illness, or emotional distress. Correlational analysis indicated that a sample size of 50 patients is sufficient to reliably estimate mean CARE score for an individual GP. CONCLUSIONS: These results indicate that the CARE Measure is considered by GPs and patients alike as being of direct relevance to everyday consultations in general practice, in both high and low deprivation settings. The measures is stable across patient groups and a reliable estimate of perceived GP empathy requires 50 completed questionnaires per doctor.     

Gender Differences in Hispanic Patients of Mexican Origin Hospitalized with Heart Failure

BackgroundMore than 3 million women in the United States die of heart failure (HF) annually. Women are significantly underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite the associated negative outcomes. HF is common in Hispanic people, the largest ethnic minority group in the United States, who are mostly of Mexican origin. There are no studies of gender differences in Mexican-Hispanic persons hospitalized for HF. We sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF.MethodsWe conducted a secondary analysis of data collected for a study examining readmission in patients hospitalized with HF in a 107-bed community; hospital near the U.S.–Mexico border.ResultsOf 155 self-identified Hispanic patients, 43.2% (n = 67) were women. Compared with men, women were equally affected by obesity, on average 6 years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure.ConclusionsKey gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.     

The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland

OBJECTIVE: To assess the prevalence of ear, nose and throat (ENT) symptoms experienced by individuals living in Scotland, and their use of GP or hospital services for these problems. METHODS: A cross-sectional postal self-completed questionnaire was sent to a random sample of 12,100 households throughout Scotland. 15,788 individuals aged 14+ years living in the 7244 households who returned the questionnaire (adjusted response rate 64.2%) participated in the study. RESULTS: Roughly a fifth of respondents reported currently having hearing difficulties, including difficulty following conversations when there is background noise and hearing problems causing worry or upset; few wore a hearing aid regularly. A fifth reported noises in head or ears (tinnitus) lasting more than five minutes. In the previous year, between 13 and 18% of respondents reported persistent nasal symptoms or hayfever, 7% sneezing or voice problems and 31% had at least one episode of severe sore throat or tonsillitis. Nearly 21% of all respondents reported ever having had dizziness in which things seemed to spin around the individual; 29% unsteadiness, light-headedness or feeling faint; 13% dizziness in which the respondent seemed to move. Important gender, age, occupation and deprivation differences existed in the occurrence of these ENT symptoms. There was considerable variation in the proportion of individuals consulting their GP or being referred to hospital for different problems. CONCLUSIONS: ENT problems occur frequently in the community, and most are managed without consulting medical services. Whilst reasonable for many problems, there are likely to be important groups in the community with ENT problems that might benefit from modern interventions.     

Prophylactic treatment after myocardial infarction in primary care: how far can we go?

BACKGROUND: Despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs or side effects. OBJECTIVE: Our aim was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction. METHODS: We conducted a survey of consecutive patients with a hospital diagnosis of first acute myocardial infarction during 1997 who were identified from discharge books from four hospitals and interviewed at their primary health centre 2 years after admission. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment excluding those that for one justified reason or another were off medication. RESULTS: Three hundred and sixty-nine patients were interviewed in the follow-up. Aspirin or another antiplatelet regimen was prescribed in 86.9 patients, beta-blockers in 50.2%, angiotensin-converting enzyme (ACE) inhibitors in 32.5% and lipid-lowering drugs in 52%. The estimated achievable standards for those prescribed drugs were 94.5, 71,8, 50.5 and 69.8%, respectively. CONCLUSIONS: There is an underuse of prophylactic drug therapies after myocardial infarction. The standards established in this study for secondary preventive drug treatment might be achieved through a reasonable effort by GPs working in primary care committed to improving the quality of care.     

Fixed combinations in the management of hypertension: patient perspectives and rationale for development and utility of the olmesartan-amlodipine combination

Although the awareness and control of hypertension has increased, only 37% of hypertensive patients in the US achieve the conservative goal of <140/90 mmHg. Achieving optimal blood pressure (BP) control is the most important single issue in the management of hypertension, and in most hypertensive patients, it is difficult or impossible to control BP with one drug. Blocking two or more BP regulatory systems provides a more effective and more physiologic reduction in BP, and current guidelines have recommended the use of combination therapy as first-line treatment, or early in the management of hypertension. Fixed combination therapy is an efficacious, relatively safe, and may be cost-effective method of decreasing BP in most patients with essential hypertension. Similar to other combinations, fixed-dose combination tablets containing the dihydropyridine calcium channel blocker amlodipine and the angiotensin II receptor blocker olmesartan bring together two distinct and complementary mechanisms of action, resulting in improved BP control and potential for improved target organ protection relative to either class of agent alone.     

The costs of alternative types of routine antenatal care for low-risk women: shared care vs care by general practitioners and community midwives

OBJECTIVES: To compare the costs to the health service, women and their families of routine antenatal care provided by either traditional obstetrician-led shared care or general practitioner (GP)/community midwife care. METHOD: A multicentre randomized controlled trial in 51 general practices linked to nine maternity hospitals in Scotland: 1667 low-risk pregnant women provided information on costs to the health service. 704 of these women provided information on non-health service costs. RESULTS: GP/midwife antenatal care was found to cost statistically significantly less than shared care. This was the case for investigations carried out at routine antenatal visits (GP/midwife = 87.25 Pounds, shared care = 91.15 Pounds, P = 0.05), staffing costs at routine antenatal visits (GP/midwife = 127.76 Pounds, shared care = 131.09 Pounds, P = 0.001), and non-health service costs incurred by women and their companions (GP/midwife = 118.53 Pounds, shared care = 133.49 Pounds, P = 0.001). While non-routine care in the GP/midwife arm of the trial costs less than in the shared care arm, the difference was not statistically significant (GP/midwife = 83.74 Pounds, shared care = 94.43 Pounds, P = 0.46). The total societal cost of antenatal care was 417.28 Pounds per women in the GP/midwife arm of the trial and 450.19 Pounds in the shared care arm of the trial. This difference was statistically significant (P < 0.001). The application of sensitivity analysis did not change these results. CONCLUSIONS: GP/midwife antenatal care is a satisfactory option for low-risk pregnant women in Scotland provided that clinical outcomes and women's satisfaction are at least the same as those of women with shared care.