Interpractice audit of diagnosis and management of hypertension in primary care: educational intervention and review of medical records

Approach to hypertension among primary care physicians in the West Region of Cameroon: substantial room for improvement

OBJECTIVE

This study was conducted to assess the knowledge and approach of primary care physician (PCP) towards the management of hypertension in Cameroon.

METHODS

In 2012 we surveyed 77 PCPs among the 111 working in the West region of Cameroon. We used a standardized questionnaire assessing practices regarding the detection, evaluation and treatment of hypertension, and source of information about updates on hypertension.

RESULTS

Participants had a mean duration of practice of 10.1 (SD 7.6) years, and received an average of 10.5 (SD 5.8) patients daily. Most of the PCPs (80.5%, n=62) measured blood pressure (BP) for all adult patients in consultation, however, only 63.6% (n=49) used correct BP thresholds to diagnose hypertension. Sixty-seven PCPs (87.0%) ordered a minimal work-up for each newly diagnosed hypertensive patient, but only the work-up offered by 8 (10.4%) PCPs was adequate. Regarding treatment, the most commonly prescribed medications as monotherapy were loop diuretics (49.3%). Bitherapy mostly included the combination of a diuretic with other drug classes. Most of PCPs used incorrect target BP, with a general tendency of using higher target levels. PCPs received updates on hypertension management mostly through drug companies representatives (53.2%, n=41). Up to 97.4% were willing to receive continuing medical training on hypertension.

CONCLUSIONS

PCPs' knowledge and management of hypertension is poor in this region of Cameroon. Our data point to a need for continually updating the teaching curricula of medical schools with regard to the management of hypertension, and physicians in the field should receive continuing medical education.

Implementation of oral health recommendations into two residential aged care facilities in a regional Australian city

Background  Residents of aged care facilities usually have a large number of oral health problems. Residents who suffer from dementia are at particular risk. A systematic review of the best available evidence with regard to maintaining the oral health of older people with dementia in residential aged care facilities provided a number of recommendations. Objectives  The aim of the implementation project was to introduce evidence-based oral hygiene practices for patients with dementia in two publicly funded residential aged care facilities and monitor for changes in nursing awareness, knowledge, documentation and practice to improve patient outcomes and ensure appropriate accreditation standards were met. An additional aim was to identify barriers and strategies to overcome barriers to implementation of evidence-based recommendations. Methods  Two facilities, a 40-bed facility and a 71-bed facility in the health service district of the regional Australian city of Toowoomba, provided the setting. A quality improvement approach was taken, using a number of strategies from the National Health and Medical Research Council guidelines for implementation studies. The implementation involved a number of stages, including project development, interactive oral health education, oral audits of residents, changes to oral hygiene practice via care plans and critical reflection. Results  The multidisciplinary approach to improving oral healthcare appeared to improve knowledge and awareness and move oral health practices in facilities closer to best practice. Specialised training in oral health was provided to a Clinical Nurse Consultant. Regular oral audits were introduced and facility staff were trained in the use of the oral audit tool. Care plans at one facility were of better quality and more comprehensive than before the intervention. Comments made during critical reflection suggested improvements in the oral health of residents, increased use of oral swabs and saliva substitutes, improved care of dentures and mention of the use of mouth props in resident care plans. There was also some evidence that changes brought about by the implementation are sustainable. Conclusion  The majority of recommendations provided in the systematic review of oral healthcare for dementia patients were applicable to the applied context. The importance of day-to-day leaders was highlighted by the apparently varied outcomes across target facilities. The quality improvement approach would appear to have considerable advantages when applied to improving practice in residential aged care.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systemsOutcomes assessed were: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook.

MAIN RESULTS

72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73).

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation.

[Durability of the effects of a quality improvement intervention in hypertensive patients on long-term follow-up (CICLO-RISK study)]

OBJECTIVE

To evaluate the durability of the effects achieved with a quality improvement intervention on cardiovascular risk factors and cardiovascular risk, as intermediate outcomes, in hypertensive patients on long-term follow-up long time primary health care.

DESIGN

Quasi-experimental study.

SETTING

Two urban primary care health centres.

PARTICIPANTS

The study included 419 and 430 hypertensive patients in the intervention (IG) and control group (CG), respectively.

INTERVENTIONS

Quality improvement intervention consisted of a combined program including, an audit, feedback, training sessions on the main cardiovascular risk factors clinical guidelines.

MEASUREMENTS

Evaluation of intermediate outcomes (blood pressure, LDL-cholesterol, HbA(1c), smoking, BMI and cardiovascular risk), were measured in both groups in March 2002, 2004 and 2006.

RESULTS

The mean of the durability effect (differences between IG and CG means) was: systolic blood pressure decreased from 8.9 to 4.3 and the diastolic from 3.9 to 2.3 mmHg (p<0.05). LDL-cholesterol decreased from 10 to 1.1mg/dl (p>0.05). Coronary risk fell from 2 to 1.2 percentage points and cardiovascular mortality risk from 0.6 to 0.4 percentage points (p<0.05). The percentage of patients with blood pressure<140/90 mmHg and BMI<30 lost statistical significance in the end evaluation and only remains in the percentage of patients with coronary risk less than 20% in the 2004 and 2006 results.

CONCLUSIONS

Quality improvement intervention was associated with reductions in cardiovascular risk factors and cardiovascular risk in post intervention evaluations with a tendency to decrease the effect achieved in the end evaluation.

Characteristics and blood pressure management in patients with and without diabetes in primary care in rural Victoria

AIMS/HYPOTHESIS

This study tested whether diabetic hypertensive patients receive more intensive BP management than hypertensive patients without diabetes.

METHODS

A 12 month retrospective review of BP management was undertaken among 2460 hypertensive patients (335 with diabetes), aged 40-79 years from randomly selected general practices in rural Australia.

RESULTS

Prevalent diagnosed cardiovascular disease (CVD) was commoner among diabetic than non-diabetic patients (27.2% vs. 16.0%, OR 1.82 (1.39-2.39)). The proportion with a BP<130/80 mmHg was low (22.9% vs. 18.6%, p=.069, respectively). BP was monitored more closely among diabetic patients (e.g. quarterly BP measurements in 18.2% vs. 10.5% respectively, p<.001), was treated with more anti-hypertensive agents (1.5+/-1.0 vs. 1.0+/-1.0, p<001) and was more likely to be associated with other CVD medications. Achievement of non-diabetic BP targets was associated with living in the regional centre (vs. smaller rural town: 1.21 (1.02-1.43)) and CVD (1.54 (1.21-1.95)), but not the presence of diabetes (0.94 (0.73-1.19)).

CONCLUSIONS

In this population, hypertension is more aggressively monitored and treated among diabetic than non-diabetic patients, but largely due to their CVD and not to the level recommended in guidelines. Commencing anti-hypertensive treatment earlier (e.g. at diagnosis) and recommending more agents (e.g. in combination) may be needed to improve BP control among diabetic patients on a population basis.

Effectiveness of a two-part educational intervention to improve hypertension control: a cluster-randomized trial

STUDY OBJECTIVE

To measure the effectiveness of a multifaceted educational intervention to improve ambulatory hypertension control.

DESIGN

Cluster-randomized trial.

SETTING

Academic health system using an ambulatory electronic medical record.

SUBJECTS

A total of 10,696 patients with a diagnosis of hypertension cared for by 93 primary care providers.

INTERVENTION

Academic detailing, provision of provider-specific data about hypertension control, provision of educational materials to the provider, and provision of educational and motivational materials to patients.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was blood pressure control, defined as a blood pressure measurement below 140/90 mm Hg, and was ascertained from electronic medical records over 6 months of follow-up. We determined the adjusted odds ratio for the association between the intervention and the achievement of controlled blood pressure. When we accounted for clustering by provider, this adjusted odds ratio was 1.13 (95% confidence interval 0.87-1.47). Adjusted odds ratios were 1.03 (95% confidence interval 0.78-1.36) in patients whose blood pressure was controlled at baseline and 1.25 (95% confidence interval 0.94-1.65) in those whose blood pressure was not. These odds ratios were not significantly different (p=0.11).

CONCLUSIONS

These results were consistent with no effect or, at best, a relatively modest effect of the intervention among patients with hypertension. Had we not included a concurrent control group, the data would have provided an unduly optimistic view of the effectiveness of the program. The effectiveness of future interventions may be improved by focusing on patients whose blood pressure is uncontrolled at baseline.

Patients' evaluation of the appropriateness of their hypertension management--a qualitative study

BACKGROUND

The existing appropriateness measures for prescribing used in the United States and the United Kingdom use clinical attributes. Treatment and care from a patient's perspective need to be evaluated in terms of whether they are more likely to lead to an outcome of a life worth living, in social, psychological, and physical terms. However, it is unclear whether patients specifically evaluate their prescribed medication and treatment. If so, do they use only clinical attributes or a combination of clinical and nonclinical attributes?

OBJECTIVES

The aim of this study was to explore if patients evaluated their hypertension management, and if they did, investigate what attributes were involved in the evaluation.

METHODS

Semistructured interviews, which focused on personal experiences of hypertension and its management were undertaken with patients (n=28). The aim of the interviews was to obtain, in a narrative format, the experiences, beliefs, and information that patients considered important when discussing the management of hypertension. Data analysis used a constant comparative method.

RESULTS

All patients considered their hypertension management regimen appropriate, but were able to mention only 2 categories of attributes to justify their decision (the relationship with their General Practitioner and lowering of their blood pressure). Further series attributes were mentioned by the patient during the course of their interview; these attributes were considered to be involved in their evaluation. These implicit attributes were categorized as anxieties and concerns regarding treatment and diagnosis, explanation of the consequences of treatment, choice of antihypertensives, and the side effects experienced.

CONCLUSIONS

Patient's evaluation of appropriateness was constructed from both explicit and implicit attributes. Implicit attributes, those not consciously known to the patient still, could be involved in the process of evaluating hypertension, its treatment, and care. Although the nonmedical attributes that are considered by patients can be categorized, it has to be remembered that it is the inherent meaning held by each individual patient involved when an evaluation is made.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems. Outcomes assessed were: (1) mean systolic and diastolic blood pressure( 2) control of blood pressure (3) proportion of patients followed up at clinic.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.

MAIN RESULTS

56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels.

Systematic review of published multi-practice audits from British general practice

BACKGROUND

Audit has been a major part of attempts to improve patient care in Britain, with substantial resources devoted to it since the 1990 National Health Service reforms. Systematic reviews have considered audit to be of variable, but often moderate, effectiveness. However, these have included few studies from British primary care, and as quality improvement activities may be context specific, it is hard to judge how effective audit has been here.

RESULTS

A search for audits published in peer-reviewed journals revealed 48 two-stage projects carried out in British general practice, of which 27 principally concerned chronic disease management and nine prescribing. Most audits showed some improvements in performance, and those using controls showed 27/56 (48%) parameters had changed significantly (P < 0.05).

CONCLUSIONS

This review adds further evidence that audit can often be moderately effective. However, it is frequently used as one of a complex set of interventions making precise evaluation difficult. Those responsible for clinical governance will need to choose carefully the subjects they audit in order to use their limited resources to maximum effect. These projects are illustrative examples but once again do not identify any 'magic bullets' that would be highly likely to improve professional performance.

Nursing documentation in nursing homes - state-of-the-art and implications for quality improvement

This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients' (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients' needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n=332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients' independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients' functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.

Evaluating the treatment of hypertension in diabetes mellitus: a need for better control?

OBJECTIVES

To determine how well and to what extent blood pressure (BP) is controlled in diabetic hypertensive patients treated by primary care doctors, and to evaluate drug therapy in the backdrop of risk factors and laboratory findings.

METHODS

A therapeutic audit of the medical records of diabetic hypertensives from nine primary care health centres in Bahrain.

RESULTS

In 266 diabetic hypertensives (82 males and 184 females), the recommended target BP < 130/< 85 mmHg (WHO/ISH guidelines, 1999) was achieved in 20 (9.8%) with a BP of 119 +/- 4/76 +/- 5 mmHg. Among those who did not achieve target BP, 70 (34.5%) lacked systolic BP control (BP = 153 +/- 17/79 +/- 3 mmHg), four (2%) lacked diastolic BP control (BP = 123 +/- 3/86 +/- 3 mmHg) and 109 (53.7%) lacked both systolic and diastolic BP control (BP = 158 +/- 20/94 +/- 7 mmHg). The mean age of the group achieving target BP was significantly lower than the group which lacked systolic BP control (51.6 +/- 9 vs. 63.5 +/- 9 years; P < 0.0001). While there were no significant differences in fasting blood glucose, glycosylated haemoglobin, triglycerides, urea, creatinine, uric acid and serum electrolytes between the group achieving target BP vs. groups without target BP, a significant difference in total cholesterol was seen.

PATIENTS

with ischaemic heart disease and/or isolated systolic hypertension did not achieve the target BP. Antihypertensive monotherapy was prescribed in 145 (54.5%) patients, whereas two- and three-drug combinations were prescribed in 32.3 and 8.2% of patients, respectively. As monotherapy, angiotensin-converting enzyme (ACE) inhibitors were the most frequently prescribed drugs followed by beta-blockers, calcium channel blockers (CCBs) and diuretics. As two-drug combinations, an ACE inhibitor with a beta-blocker/diuretic and a beta-blocker with a CCB/diuretic were usually prescribed.

CONCLUSIONS

According to the WHO/ISH 1999 guidelines, approximately one out of 10 diabetic hypertensives achieved target BP control. In many instances, the drug therapy prescribed was inappropriate considering the comorbidity in patients and their laboratory findings. Improved BP control is needed in treating high-risk groups such as patients with diabetes mellitus, and efforts should be made to improve the treatment of hypertension in the primary care setting.

Hypertension control and medication increase in primary care

Over half of treated patients with hypertension are not well controlled. However, little is known about physicians' prescribing behaviour for these patients. Our objective was to clarify whether physicians increase antihypertensive medication in patients with poorly controlled hypertension and what characteristics are predictors of medication increase. This was a retrospective cohort study by surveying medical records in primary care clinics in Tochigi, Japan. Twenty-nine of 79 randomly selected physicians agreed to select 20 consecutive hypertensive patients. This resulted in 547 patients (women 60%; mean (s.d.) age, 68 (12) years) who had blood pressure measurements taken in 1998 and prescription of antihypertensive medication in 1998 and 1999. Mean (s.d.) systolic/diastolic blood pressure was 142 (12)/81 (9) mm Hg and the percentage of patients in good control (<140/90 mm Hg), fair (140-159/90-94) and poor (> or =160/95) were 42%, 47%, and 11%, respectively. Physicians increased medication in 28% of poorly controlled patients (95% confidence interval (CI), 17-41%), which was more than those in fair (12%, 95%CI 8-16%) or good control (7%, 95%CI 4-12%). Multivariate logistic regression analysis showed that systolic and diastolic blood pressures were positively, and the number of kinds of antihypertensive medications and the age of the physician were negatively, associated with an increase in medication. In conclusion, primary care physicians did not increase antihypertensive medication adequately for patients with uncontrolled hypertension. Attempts to understand and to change physicians' prescription behaviour could reduce the burden of uncontrolled hypertension among treated hypertensive patients.

Clinical governance in Scotland: an educational model

The concepts underpinning clinical governance are similar throughout the United Kingdom but models for its implementation will differ widely. This model aims to enable practices to identify areas for further learning and development against specific outcomes. Criteria sets and standards are suggested and a governance plan is used to allow practices to prioritise their objectives. Resourcing will always be a major issue and such a model should be fully evaluated.

Treatment strategy to control blood pressure optimally in hypertensive patients

Pharmacological treatment of hypertension significantly reduces the incidence of cardiovascular diseases. Unfortunately, only a fraction of hypertensive patients benefit maximally from the protection afforded by the blood pressure lowering, mainly because the blood pressure control achieved during antihypertensive therapy remains often insufficient. One way to improve this situation is to individualize the treatment in determining for each patient the most simple drug regimen, which is at the same time efficacious and well tolerated. To this end, combining small doses of drugs acting by different mechanisms is often required. It is also essential that physicians develop skills to motivate their patients to comply lifelong with the treatment.

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand

OBJECTIVES

Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

DESIGN

A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995-9.

SETTING

General practice based care in the UK, Australia, and New Zealand. Main outcome measures-Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study.

RESULTS

Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction.

CONCLUSIONS

This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand

OBJECTIVES

Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

DESIGN

A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995-9.

SETTING

General practice based care in the UK, Australia, and New Zealand. Main outcome measures-Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study.

RESULTS

Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction.

CONCLUSIONS

This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Blood pressure control in treated hypertensive patients: clinical performance of general practitioners

BACKGROUND

The blood pressure of many treated hypertensive patients remains above recommended target levels. This discrepancy may be related to general practitioners' (GPs') actions.

AIM

To assess clinical performance of GPs in blood pressure control in treated hypertensive patients and to explore the influence of patient and GP characteristics on clinical performance.

DESIGN OF STUDY

Cross-sectional study conducted on 195 GPs with invitations to participate made via bulletins and by letter.

SETTING

One hundred and thirty-two practices in the southern half of The Netherlands from November 1996 to April 1997.

METHOD

Performance criteria were selected from Dutch national hypertension guidelines for general practice. GPs completed self-report forms immediately after follow-up visits of hypertensive patients treated with antihypertensive medication.

RESULTS

The GPs recorded 3526 follow-up visits. In 63% of these consultations the diastolic blood pressure (DBP) was 90 mmHg or above. The median performance rates of the GPs were less than 51% for most of the recommended actions, even at a DBP of > or = 100 mmHg. Performance of non-pharmacological actions increased gradually with increasing DBP; prescribing an increase in antihypertensive medication and making a follow-up appointment scheduled within six weeks rose steeply at a DBP of > or = 100 mmHg. Patient and GP characteristics contributed little to clinical performance. Action performance rates varied considerably between GPs.

CONCLUSION

GPs seem to target their actions at a DBP of below 100 mmHg, whereas guidelines recommend targeting at a DBP of below 90 mmHg.

Development of an audit instrument for nursing care plans in the patient record

OBJECTIVES

To develop, validate, and test the reliability of an audit instrument that measures the extent to which patient records describe important aspects of nursing care.

MATERIAL

Twenty records from each of three hospital wards were collected and audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model--a model designed to structure nursing documentation. (VIPS is an acronym formed from the Swedish words for wellbeing, integrity, prevention, and security.)

METHODS

An audit instrument was developed by determining specific criteria to be met. The audit questions were aimed at revealing the content of the patient for nursing assessment, nursing diagnosis, planned interventions, and outcome. Each of the 60 records was reviewed by the three auditors independently and the reliability of the instrument was tested by calculating the inter-rater reliability coefficient. Content validity was tested by using an expert panel and calculating the content validity ratio. The criterion related validity was estimated by the correlation between the score of the Cat-ch-Ing instrument and the score of an earlier developed and used audit instrument. The results were then tested by using Pearson's correlation coefficient.

RESULTS

The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p < 0.0001, 95% CI 0.57 to 0.76) between the two audit instruments.

CONCLUSION

The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.

Educational input and patient outcomes: exploring the gap

Over the last two decades, the health care professions in the United Kingdom have seen an unparalleled expansion of continuing professional education (CPE) and development (CPD) programmes; however, there is little empirical evidence that these enhance the care delivered to patients. Further research is also needed to demonstrate that these initiatives are linked to improved patient outcomes. If health care educators are to move towards an 'evidence-based curriculum', some restructuring of courses may be needed. Priorities should be set and decisions made, based on the results of reliable and valid research into the clinical outcomes of CPE. To evaluate courses and demonstrate educational effectiveness solely in terms of student satisfaction is not enough; to survive in the world of evidence-based care, educators must also demonstrate their contribution to clinical effectiveness. However, the neoteric field of impact evaluation lacks not only validated research methods, but also an agreed agenda for future research. Drawing on interviews undertaken with nurses who have participated in education evaluations and the relevant literature, this paper discusses the available data collection instruments and the development of viable research designs and methods, which are urgently needed to assess the outcomes of professional education programmes.

Management of hypertension in patients developing end-stage renal failure

The benefits of treating hypertension include preventing or delaying the progression of chronic renal failure, and reducing the cardiovascular complications of patients with renal disease. We examined how well hypertension had been managed in all 145 patients from a single health district who started dialysis during a 3-year period. Data relating to management of hypertension, including all blood pressure readings, were obtained from their general practice and hospital case notes. The anonymized data were reviewed by two independent assessors against a set of standards based on the British Hypertension Society guidelines. There was close agreement between the assessors. Complete records were obtained in 98.5% of cases. Of the 145 patients, 107 (76.4%) were hypertensive before developing end-stage renal failure. There were departures from standards in all categories of care: 24.3% in detection/diagnosis, 29% in investigation, 22.4% in referring to a nephrologist, and 17% in follow-up. The British Hypertension Society recommended standard for diastolic blood pressure of 90 mmHg was achieved in only 45%. In 32%, the assessors independently concluded that poor blood pressure control might have affected adversely the progression of renal failure. New methods of dealing with these problems are required and possible approaches are discussed.

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.

The management of hypertension in the elderly by general practitioners in Merseyside: the rule of halves revisited

BACKGROUND

Treatment of hypertension in the elderly significantly reduces cardiovascular events and confers greater absolute benefit compared with treating younger adults. However, this group has been undertreated in the past.

AIM

To perform a reliable and valid multipractice audit of the current management of elderly hypertensive patients.

METHOD

An observational study conducted as multiple standardized audits in general practices. The notes of 6139 patients aged 65 years or over from 76 general practices in Merseyside were examined to determine the percentage of elderly patients who had their blood pressure recorded. The percentages of hypertensive patients who were diagnosed, treated, and controlled was also recorded.

RESULTS

Eighty-one per cent of the sample had their blood pressure recorded. Fifty-three per cent of patients over the age of 65 were identified as hypertensive; 64% of hypertensive patients are receiving antihypertensive medication and 54% of treated hypertensive patients can be considered controlled. However, very small changes in the criteria used to define blood pressure control have dramatic effects on the results. Digit preference and the number of available blood pressure recordings also significantly affect the results.

CONCLUSION

The management of hypertension in the elderly by Merseyside general practitioners (GPs) gives better results than predicted by the 'rule of halves'. Elderly hypertensive patients are more likely to be detected and treated, but only half achieve control to 160/90. The results are particularly sensitive to the degree of digit preference, the number of available recordings, and to the precise definition used for control.

Clinical guidelines and the management of hypertension: a between-practice and guideline comparison

It has previously been demonstrated that individual general practitioners (GPs) diagnose and treat at different levels of blood pressure and according to different risk factor profiles. This study sought to examine the variation in the achievement of control of hypertension in a sample of 20 treated hypertensive patients in 18 UK general practices. There was a marked between-practice variation in the percentage of patients with controlled hypertension. Practices appear to apply different hypertension guidelines to patients consistently, with significant correlations across practices in seven out of ten possible guideline combinations. There remains marked variation in the management of hypertension between different general practices in the UK. Factors other than recommendations in guidelines appear to be responsible for this variation.