The management of severe hypertension in Australian general practice

Abstract

BackgroundSevere hypertension (SHT) (Blood Pressure, BP ≥ 180/110 mmHg) is associated with considerable morbidity and mortality, yet little is known about how it is managed. The purpose of this study is to examine the management of SHT by Australian general practitioners (GPs) and to explore its variance across patient characteristics and clinical practices.MethodsReview of electronic medical records for a year before and after a recorded measure of SHT in 7,499 patients by 436 GPs in 167 clinics throughout Australia during 2008–2009. Outcome measures included follow-up, referral, changes to antihypertensive drug treatment, and BP control (normotensive reading, BP < 140/90 mmHg, and whether subsequent recorded measures were also in the normal range - sustained normotension).ResultsOf 7,499 patients with an electronic BP record of SHT, 94% were followed up (median time 14 days); 8% were referred to an appropriate specialist (median time 89 days – 2% within 7 days) and 86% were managed by GPs. GPs initiated or changed antihypertensive drugs in 5,398 patients (72% of cohort); of these, 46% remained hypertensive (4% with SHT) and 7% achieved sustained normotension; 6% had no further electronic BP records. The remaining 14% had no medication changes; among these, 43% remained hypertensive (5% with SHT) and 3% achieved sustained normotension; 32% had no further electronic BP records. Some outcome measures displayed a variance across GP clinics that was mostly unexplained by patient or practice characteristics.ConclusionsMost patients with SHT had at least one follow-up visit and 72% had initiation of, or changes to, antihypertensive drug treatment. Although most of the patients experienced some improvement, blood pressure control was poor. Some clinics showed better performance. Suggestions are made for the development of clinical standards to facilitate appropriate management of this dangerous condition.

Services aimed at achieving desirable clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative review

“…The need for prompt follow-up and referral, combined with appropriate medications to achieve a BP control (<140/90 mm Hg), is important and emphasised in Australian guidelines. 56 Even with guidelines, previous studies 11 , 58 – 60 have highlighted that treatment is often inadequate. Most guidelines for HT management and studies concerning control have mainly concentrated on the outpatient setting.…”

“… 8 – 10 Clinical inertia is when the clinician fails to escalate care in the presence of competing demands from multiple co-morbidities. 11 – 13 It has been reported 14 that clinical inertia is a major factor that contributes to inadequate chronic disease care in patients with DM, HT, and CKD. Despite evidence that intensified therapy is usually needed to achieve and maintain evidence-based chronic disease care goals, a number of studies document high levels of clinical inertia in patients with DM 15 and demonstrate that more active clinical management improves HbA1c 14 and systolic blood pressure (SBP) control.…”

Blood pressure control in Australian general practice: analysis using general practice records of 1.2 million patients from the MedicineInsight database

“…Studies on hypertension management and control in primary care are limited [12][13][14][15][16][17][18][19][20][21][22] with a majority of these studies undertaken in Europe. Previous studies in Australia have focused on trends in BP levels of all patients over time [23], management of severe hypertension in general practice [24], prescription of physical activity for hypertension management [25] and hypertension management among groups with specific conditions [26]. Studies that identify factors influencing BP control, prescribing patterns for hypertension management, or if those with a recent or past diagnosis are managed differently, are lacking.…”