Treatment preferences,return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (The General Practitioner Hypertension Practice Study)

Abstract. Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. Design. Mailed case report questionnaires. Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.     

Awareness, treatment and control of hypertension in Denmark. The Inter99 study

Objective. We describe the current status of awareness, treatment and control of hypertension in Denmark and identify predictors for not being optimally treated. Methods. A population-based sample, the Inter99 study, of 6784 individuals aged 30-60 years completed a questionnaire about lifestyle and risk factors for cardiovascular disease and had a physical examination including at least two blood pressure (BP) measurements. Hypertension was defined as BP≥140/90 mmHg or receiving medical treatment for hypertension. Predictors for awareness, treatment and control were analysed in logistic regression models. Results. Nearly 40% were diagnosed with hypertension and more than 60% were not aware of the diagnosis. Half of those aware of the diagnosis did not receive medical treatment and among those who did, only 21% had their hypertension controlled. Only 10% of all persons aware of their hypertension had a BP below 140/90 mmHg. A higher degree of awareness and treatment of hypertension was positively associated with female sex, diabetes, cardiovascular disease, age, contact to general practitioner, healthy diet and increasing body mass index and age. We did not identify predictors for control of hypertension. Conclusion. There is a major gap between how hypertensive patients are managed in Denmark and the current treatment goals and recommendations of hypertension.     

Prevalence, detection and drug treatment of hypertension in a rural Australian population: the Greater Green Triangle risk factor study 2004-2006

Background: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia. Aim: To assess the prevalence, awareness and treatment of hypertension in a rural South‐East Australian population. Methods: Three cross‐sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004–2006 using a random population sample (n = 3320, participation rate 49%) aged 25–74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or on antihypertensive drug treatment. Results: Overall, one‐third of participants had hypertension; of these, two‐thirds, 54% (95% confidence interval (CI) 47–60) of men and 71% (95% CI 65–77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54–67 and 55%, 95% CI 47–64) compared with men (42%, 95% CI 36–49 and 35%, 95% CI 26–44). Monotherapy was used by 55% (95% CI 48–61) of treated hypertensives. Angiotensin‐converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin‐converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women. Conclusion: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.     

中国高血压最佳治疗情况调查难治性高血压亚组分析

目的探讨中国高血压最佳治疗情况调查(HOT-CHINA)研究中难治性高血压患者的比例和特征。方法对HOT-CHINA研究(2001-04-2002-02)中入选患者(n=54590)治疗情况进行再分析。结果 HOT-CHINA研究人群中难治性高血压占1.9%。与非难治性高血压相比,难治性高血压患者男性多见(65.6%比60.2%),年龄较小[(59.5±13.0)比(61.8±12.3)岁],体质量指数较高[(24.8±3.5)比(24.0±3.4)kg/m2],病程长,空腹血糖、总胆固醇、三酰甘油水平高[分别为(6.60±2.69)比(5.99±2.12)、(5.67±1.63)比(5.32±1.24)、(2.15±1.32)比(1.96±1.09)mmol/L],3级高血压多见(71.1%比27.2%)。代谢综合征、糖尿病、心肌梗死、脑卒中患病率均高于非难治性高血压患者(均P<0.01)。结论难治性高血压多合并有其他危险因素或临床情况,难治性高血压患者要尽早联合用药,控制血压达标。     

A computerized intervention to decrease the use of calcium channel blockers in hypertension

Objective

To determine whether a computer-assisted reminder would alter prescribing habits for the treatment of hypertension in accordance with current clinical guidelines in a general internal medicine clinic.

Design

A randomized trial.

Setting

The General Internal Medicine Clinic of the Veterans Affairs Puget Sound Health Care System, Seattle Division.

Patients/Participants

Clinic providers were randomized to a control group (n=35) or intervention group (n=36). We targeted the providers of patients being treated for hypertension with calcium channel blockers, a class of drug not recommended for initial therapy.

Intervention

An automated computer query identified eligible patients and their providers. A guideline reminder was placed in the charts of patients of intervention providers; the charts of patients of control providers received no reminder.

Measurements and main results

During the 5-month study period, 346 patients were seen by the 36 primary care providers (staff physicians, nurse practitioners, residents, and fellows) in the intervention group, and 373 patients were seen by the 35 providers in the control group. Intervention providers changed 39 patients (11.3%) to other medications during the study period, compared with 1 patient (<1.0%) of control providers (p<.0001). For patients whose therapy was unchanged, providers noted angina in 23.1%, indications other than those for hypertension in 9.5%, intolerable adverse effects with first-line therapy in 13.9%, and inadequte control with first-line therapy in 13.9%. Of those patients without provider-indicated contraindications, 23.6% were switched from calcium channel blockers to first-line agents during the intervention period.

Conclusions

The use of a computerized, clinic-based intervention increased compliance with guidelines in the treatment of primary hypertension in general, and decreased the use of calcium channel blockers for the treatment of hypertension in particular.     

On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Attitudes and intentions of UK general practitioners to diabetes care at the time of implementation of their new contract.

Prior to the introduction of their new contract, the intentions of general practitioners in Leeds (UK) towards diabetes care were assessed. All general practices in one Health District (n = 74) were contacted. Assessment was made of 46 (62%), while 28 expressed lack of interest. Of the 46 assessed, 2 (4%) were single-handed, and 44 (96%) were group practices, and list size was 700-15,500. Practice nurses were employed in 44 (96%) practices. There were 35 (76%) practices which expressed an interest in starting a diabetic clinic, while 6 (13%) had established a clinic. Practice facilities necessary to establish and run a clinic were surveyed. Those available were: register of diabetic patients in 12 (26%) (six of which were incomplete); blood sampling facilities in 45 (98%); blood glucose reagent strips in 45 (98%); glucose meters in 21 (46%) (but five with inappropriate test strips). All practices could check urine, blood pressure, and fundi (dark room available in 40 (87%) practices). Access to dietetic and chiropody services on the premises was available in 19 (41%) and 17 (37%) practices, respectively. Some expertise in diabetes was claimed by only 10 (22%) doctors. Staff at all practices desired further training in diabetes. In conclusion, despite the interest of most practices in starting a diabetic clinic, access to dietetic and chiropody services was inadequate. Expertise was generally lacking, but enthusiasm and desire for training were strong.     

Reported treatment of hypertension by family physicians in Sweden and Minnesota: a physician survey of practice habits

Abstract. Objectives. To compare family physicians' reported practice habits on hypertension in Sweden and Minnesota, and to assess to what extent different national guidelines account for differences. Design. Random samples of family physicians were selected for telephone interviews on their practice of hypertension. Setting. Primary care in southern Sweden and in Minnesota. Subjects. Family medicine specialists. Participation rates were 236/264 (89%) in Sweden and 183/209 (88%) in Minnesota. Main outcome measures. Cut-off levels, and non-pharmacological and pharmacological treatment of hypertension, related to three case scenarios: a 48-year-old man, a 65-year-old man and a 65-year-old woman. Results. Swedish physicians reported significantly higher levels of diastolic blood pressure than Minnesota physicians for the institution of treatment of hypertension for all case scenarios. In both countries, physicians adhered to the cut-off levels of their national guidelines in the case of the 48-year-old man. Minnesota physicians did not use age as a modifying factor for treatment cut-off levels, as did Swedish physicians. Swedish physicians emphasized alcohol, fat and stress reduction, and Minnesota physicians weight and salt reduction as non-pharmacological treatment. While Swedish physicians generally preferred beta-blockers, Minnesota physicians chose ACE inhibitors or calcium channel blockers as the first choice drug. Conclusion. Swedish and US guidelines on hypertension were identical except for higher cut-off level for drug treatment in Sweden. Minnesota physicians reported cut-off levels close to national guidelines. For 65-year-old patients, Swedish physicians reported applying a higher cut-off level than indicated by guidelines. Swedish physicians also reported preferring less expensive drugs. As a consequence of the differing national guidelines and the identified physicians' practice habits in the two medical communities, it is likely that the segments of the populations treated and the drug costs differ substantially.     

The management of common gastrointestinal disorders in general practice: A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

BACKGROUND: Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS: We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS: We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION: The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.     

Clinical audit of adherence to hypertension treatment guideline and control rates in hospitals of different sizes in Thailand

A clinical audit of hospitals in Thailand was conducted to assess compliance with the national hypertension treatment guidelines and determine hypertension control rates across facilities of different sizes. Stratified random sampling was used to select sixteen hospitals of different sizes from four provinces. These included community (<90 beds), large (90–120 beds), and provincial (>120 beds) hospitals. Among new cases, the audit determined whether (i) the recommended baseline laboratory assessment was completed, (ii) the initial choice of medication was appropriate based on the patient''s cardiovascular risk, and (iii) patients received medication adjustments when indicated. The hypertension control rates at six months and at the last visit were recorded. Among the 1406 patients, about 75% had their baseline glucose and kidney function assessed. Nearly 30% (n = 425/1406) of patients were indicated for dual therapy but only 43% of them (n = 182/425) received this. During treatment, 28% (198/1406) required adjustments in medication but this was not done. The control of hypertension at six months after treatment initiation was 53% varying between 51% in community and 56% in large hospitals (p < .01). The hypertension control rate at last visit was 64% but varied between 59% in community hospitals and 71% in large hospitals (p < .01). Failure to adjust medication when required was associated with 30% decrease in the odds of hypertension control (OR 0.69, 95% CI 0. 50 to 0.90). Failure to comply with the treatment guidelines regarding adjustment of medication and lost to follow‐up are possible target areas to improve hypertension control in Thailand.     

Independent predictors of effective blood pressure control in patients with hypertension on drug treatment in Brazil

Population assessment of effective blood pressure (BP) control is fundamental for reducing the global burden of hypertension, especially in low‐ and middle‐income countries. The authors evaluated the effectiveness of BP control and determined independent predictors associated with effective control among patients with hypertension on drug treatment in a large cross‐sectional study performed in two metropolitan areas in Brazil's southeast region. A total of 43 647 patients taking antihypertensive treatment were identified. Less than half of the patients (40.9%) had controlled BP (systolic BP <140 mm Hg and diastolic BP <90 mm Hg). Independent predictors of BP control were age, eating fruit daily, physical activity, previous cardiovascular disease, male sex, diabetes mellitus, ethnicity, and obesity. Simple variables associated with BP control may be utilized for knowledge translation strategies aiming to reduce the burden of hypertension.     

Perceived needs of general practitioners and practice nurses for the care of diabetic patients.

This study compared the aims and needs of General Practitioners (GPs) and practice nurses who wished to improve the service they provided for non-insulin-treated diabetic patients. Contact was made with 242 GPs in 110 practices in Central and North Nottingham, and a questionnaire was sent to the 149 (62%) who requested one. Completed questionnaires were returned by 110 (74%) of these, and by 48 (80% of 60) of their practice nurses. Only 19 GPs ran a specific diabetic clinic, but nearly all (95%) wanted to improve the service they provided for diabetes care. In doing so, many wished for involvement of opticians, chiropodists, and dietitians, and all wished to involve the practice nurse. The need for involvement of hospital-based diabetes specialist nurses was perceived by only 37% GPs. More than two-thirds (69%) of practice nurses wanted more input into the care of diabetes. Both GPs and practice nurses felt that the role of the practice nurse should include screening for complications, although there was some disagreement about the extent of this involvement. GPs envisaged that patient education would be a major problem in establishing a diabetes service, but only 58% identified education as a task that could be accomplished by the practice nurse.     

Development of a questionnaire for identification of the risk factors for osteoarthritis of the knees in developing countries. A pilot study in Iran and Bangladesh. An ILAR–COPCORD phase III study

Background: Knee osteoarthritis (OA) is one of the most prevalent rheumatic disorders in the Asia‐Pacific region. Identification of modifiable risk factors is important for development of strategies for primary and secondary prevention of knee OA. Objective: Developing a core questionnaire for identification of risk factors of knee OA at the community level. Methods: Steps performed: (1) item generation from literature, existing knee OA questionnaires and patient focus group discussions; (2) development of a preliminary APLAR‐COPCORD English questionnaire; (3) translation into target language, back translation and development of a pre‐final target language version; (4) adaptation of the pre‐final target language version through tests of comprehensibility, content validity, test–retest reliability; and (5) finalization of the English questionnaire. Investigators in Bangladesh, Iran, China, Philippines and Indonesia participated in steps 1 and 2. Subsequent steps were carried out by Bangladeshi and Iranian investigators. Results: Fifty‐three items were generated. Fourteen were obtainable from physical examination and placed in an examination sheet. Two radiological items were not included. A preliminary English questionnaire comprising the remaining 37 items was constructed and translated into Bengali and Persian. The preliminary Bengali and Persian versions were adapted as a result of tests of comprehensibility, content validity and test–retest reliability. The English questionnaire was adapted through repeated exchange of ideas and experiences among participating investigators. A 35‐item English core questionnaire was finally developed. Conclusion: The questionnaires may be used to identify risk factors of knee OA in Asia‐Pacific communities after validation and further adaptation. From these data strategies for primary and secondary prevention of knee OA can be developed.     

Assessment of diabetes screening by general practitioners in France: the EPIDIA Study.

AIM: To audit Type 2 diabetes screening in general practice in France and to determine the frequency of undiagnosed diabetes in patients at high risk, after systematic screening and diagnosis. METHODS: For this study, 288 general practitioners volunteered to include all consecutive non-diabetic patients aged < 65 years who had at least two risk factors for diabetes, whatever the reason for consultation. If a plasma glucose had not been recorded in the previous 12 months, a fasting plasma glucose (FPG) was performed, with a second test if FPG >or= 7.0 mmol/l. RESULTS: There were 5950 patients included. The most frequent diabetes risk factors were: age >or= 40 years, 92%; overweight [body mass index (BMI) >or= 27 kg/m2], 59%; treated hypertension, 48%; treated dyslipidaemia, 37%; family history of diabetes, 24%. Of these subjects at high risk for diabetes, 88% had a FPG measurement in their medical record (75% measured during the preceding 12 months). In the 1499 patients in whom FPG was measured, diabetes was diagnosed in 40 patients (2.7% 95% CI 1.9-3.5) and 22% had impaired fasting glucose (IFG). Thus, the frequency of undiagnosed diabetes in the 5950 high-risk patients was 0.67% (0.46-0.88). CONCLUSION: Screening for diabetes by general practitioners in France appears to be adequate and undiagnosed diabetes is rare in patients with risk factors for diabetes, at least in those consulting the general practitioners studied.     

A randomized trial using computerized decision support to improve treatment of major depression in primary care

OBJECTIVE: To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression. DESIGN: Randomized controlled trial. SETTING: Academically affiliated primary care practice in Pittsburgh, PA. PATIENTS: Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria. INTERVENTION: PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: "active care" (AC), "passive care" (PC), or "usual care" (UC). MEASUREMENTS AND MAIN RESULTS: Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D /=3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P =.09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P =.3). CONCLUSIONS: Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.     

Rationale and design of a multicenter randomized study comparing the efficacy and safety of esaxerenone versus trichlormethiazide in patients with uncontrolled essential hypertension: EXCITE-HT study

The next-generation mineralocorticoid receptor blocker (MRB) esaxerenone has favorable antihypertensive effects in patients who do not respond to treatment with first-line antihypertensive agents and may be beneficial as a second-line treatment. However, MRBs are currently considered a fourth-line treatment as there is no clinical evidence comparing the efficacy of esaxerenone with other classes of antihypertensive agents. The multicenter, randomized, open-label, parallel-group EXCITE-HT study will evaluate the efficacy and safety of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension. After a 4-week run-in period, patients will receive either esaxerenone or trichlormethiazide for 12 weeks per the package insert and the Japanese Society of Hypertension Guidelines for the Management of Hypertension. At Weeks 4 and 8, the dose of esaxerenone or trichlormethiazide may be increased. Blood pressure (home [morning and bedtime] and office), serum biomarkers, and urinary biomarkers will be measured. The primary efficacy endpoint is the change from baseline in morning home systolic blood pressure/diastolic blood pressure to the end of treatment. The EXCITE-HT study is expected to validate the non-inferiority of esaxerenone to trichlormethiazide and provide the first evidence for the early use of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension instead of its current use as a fourth-line agent.     

Progression from impaired fasting glucose and impaired glucose tolerance to diabetes in a high-risk screening programme in general practice: the ADDITION Study,Denmark

AIMS/HYPOTHESIS: To estimate the 1-year progression rates from both IFG and IGT to diabetes in individuals identified in a pragmatic diabetes screening programme in general practice (the ADDITION Study, Denmark [Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care]). METHODS: Persons aged 40-69 years were screened for type 2 diabetes based on a high-risk, stepwise strategy. At baseline, anthropometric measurements, blood samples and questionnaire data were collected. A total of 1,160 persons had IFG or IGT at baseline: 811 (70%) accepted re-examination after 1 year. Glucose tolerance classification was based on the 1999 WHO definition. At follow-up, diabetes was based on one diabetic glucose value of fasting blood glucose or 2-h blood glucose. RESULTS: At baseline, 308 persons had IFG and 503 had IGT. The incidence of diabetes was 17.6 and 18.8 per 100 person-years in the two groups, respectively. CONCLUSIONS/INTERPRETATION: IFG and IGT identified in general practice during a stepwise, high-risk screening programme for type 2 diabetes have high 1-year progression rates to diabetes. Consequently, intensive follow-up and intervention strategies are recommended for these high-risk individuals.     

A prospective study of the association between total sleep duration and incident hypertension

The aim of this prospective study was to evaluate total sleep duration as a potential risk factor for the development of hypertension after a mean of 2.6 years of follow‐up. The study participants comprised 1715 Korean adults aged 40 to 70 years. The participants were without hypertension at baseline (2005–2008) and during follow‐up (2008–2011) to determine the incident cases of hypertension. Based on a self‐reported questionnaire, the individuals were stratified according to total sleep duration (<6 hours, 6–7.9 hours, 8–9.9 hours, ≥10 hours). Hypertension was defined according to the Eighth Joint National Committee (JNC 8) guidelines. After an average of 2.6 years of follow‐up, 164 (9.56%) participants developed hypertension. In multivariate adjusted models, the odds ratio for new‐onset hypertension was 1.71 (95% confidence interval, 1.01–2.89) in participants with a short sleep duration (<6 hours) compared with those who reported 6 to 7.9 hours of sleep. Long sleep duration (more than 8 hours) did not have any significant difference on incident hypertension. Among middle‐aged and elderly Korean adults, short sleepers were independently associated with a higher risk of developing hypertension.