Levels of detection of hypertension in primary medical care and interventions to improve detection: a systematic review of the evidence since 2000

Does shortage of GPs matter? A cross-sectional study of practice population life expectancy

BACKGROUND

There are not enough GPs in England. Access to general practice and continuity of care are declining.

AIM

To investigate whether practice characteristics are associated with life expectancy of practice populations.

DESIGN AND SETTING

A cross-sectional ecological study of patient life expectancy from 2015-2019.

METHOD

Selection of independent variables was based on conceptual frameworks describing general practice's influence on outcomes. Sixteen non-correlated variables were entered into multivariable weighted regression models: population characteristics (Index of Multiple Deprivation, region, % White ethnicity, and % on diabetes register); practice organisation (total NHS payments to practices expressed as payment per registered patient, full-time equivalent fully qualified GPs, GP registrars, advanced nurse practitioners, other nurses, and receptionists per 1000 patients); access (% seen on the same day); clinical performance (% aged ≥45 years with blood pressure checked, % with chronic obstructive pulmonary disease vaccinated against flu, % with diabetes in glycaemic control, and % with coronary heart disease on antiplatelet therapy); and the therapeutic relationship (% continuity).

RESULTS

Deprivation was strongly negatively associated with life expectancy. Regions outside London and White ethnicity were associated with lower life expectancy. Higher payment per patient, full-time equivalent fully qualified GPs per 1000 patients, continuity, % with chronic obstructive pulmonary disease having the flu vaccination, and % with diabetes with glycaemic control were associated with higher life expectancy; the % being seen on the same day was associated with higher life expectancy in males only. The variable aged ≥45 years with blood pressure checked was a negative predictor in females.

CONCLUSION

The number of GPs, continuity of care, and access in England are declining, and it is worrying that these features of general practice were positively associated with life expectancy.

Cascade of care for hypertension among apparently healthy and unhealthy individuals of 25-64 years in the Czech Republic

BACKGROUND

Despite accessible diagnostics and treatment of hypertension, a high proportion of patients worldwide remain unaware of their diagnosis, and even more remain untreated. Several studies suggest that absence of comorbidities is a predictive factor for unawareness and consequently non-treatment of hypertension. There are only a few studies that have assessed the hypertension prevalence and management among apparently healthy individuals.

OBJECTIVE

The aim of the study was to assess and compare hypertension prevalence, awareness, treatment and control among apparently healthy individuals, patients with internal diseases, and patients with non-internal diseases.

METHODS

Data from standardised blood pressure measurements conducted during the Czech European Health Examination Survey 2014 and information on health status and health care use collected during the Czech European Health Interview Survey 2014 were analyzed. We focused on participants aged 25-64. Data were weighted on sex and age to ensure an appropriate sex and age structure of the population. The χ2-test and binary logistic regression analyses were used to compare distribution of cascade of care for hypertension between the health-status groups of respondents.

RESULTS

The final eligible sample consisted of 1121 participants. The prevalence of hypertension was 32.8% in the healthy group, 29.8% in the non-internal disease group and 52.4% in the internal disease group, (p < 0.001). Awareness was 54.1%, 59.1% and 85.2% respectively, (p < 0.001). Treatment was 44.2%, 52.6% and 86.4%, respectively, (p < 0.001). Among apparently healthy respondents 62.6% had their blood pressure measured by a medical professional in the last year, compared to 71.1% in the non-internal disease group and 91.7% in the internal disease group, (p < 0.001). Differences in hypertension control were not statistically significant.

CONCLUSIONS

Generally, our data show a discordance in hypertension management within the Czech population. Apparently healthy individuals are the least aware of their diagnosis and the highest proportion of them remain untreated.

Prevalence and demographic variation of cardiovascular, renal, metabolic, and mental health conditions in 12 million english primary care records

BACKGROUND

Primary care electronic health records (EHR) are widely used to study long-term conditions in epidemiological and health services research. Therefore, it is important to understand how well the recorded prevalence of these conditions in EHRs, compares to other reliable sources overall, and varies by socio-demographic characteristics. We aimed to describe the prevalence and socio-demographic variation of cardiovascular, renal, and metabolic (CRM) and mental health (MH) conditions in a large, nationally representative, English primary care database and compare with prevalence estimates from other population-based studies.

METHODS

This was a cross-sectional study using the Clinical Practice Research Datalink (CPRD) Aurum primary care database. We calculated prevalence of 18 conditions and used logistic regression to assess how this varied by age, sex, ethnicity, and socio-economic status. We searched the literature for population prevalence estimates from other sources for comparison with the prevalences in CPRD Aurum.

RESULTS

Depression (16.0%, 95%CI 16.0-16.0%) and hypertension (15.3%, 95%CI 15.2-15.3%) were the most prevalent conditions among 12.4 million patients. Prevalence of most conditions increased with socio-economic deprivation and age. CRM conditions, schizophrenia and substance misuse were higher in men, whilst anxiety, depression, bipolar and eating disorders were more common in women. Cardiovascular risk factors (hypertension and diabetes) were more prevalent in black and Asian patients compared with white, but the trends in prevalence of cardiovascular diseases by ethnicity were more variable. The recorded prevalences of mental health conditions were typically twice as high in white patients compared with other ethnic groups. However, PTSD and schizophrenia were more prevalent in black patients. The prevalence of most conditions was similar or higher in the primary care database than diagnosed disease prevalence reported in national health surveys. However, screening studies typically reported higher prevalence estimates than primary care data, especially for PTSD, bipolar disorder and eating disorders.

CONCLUSIONS

The prevalence of many clinically diagnosed conditions in primary care records closely matched that of other sources. However, we found important variations by sex and ethnicity, which may reflect true variation in prevalence or systematic differences in clinical presentation and practice. Primary care data may underrepresent the prevalence of undiagnosed conditions, particularly in mental health.

The rate of occupational noise-induced hearing loss among male workers in Israel and implication on hearing surveillance frequency

OBJECTIVES

To investigate the annual rate of NIHL in Israel, a modern economy with relatively low industrial hazardous noise exposure. To review international protocols of hearing surveillance. To recommend an effective, efficient, hearing screening frequency protocol.

METHODS

A historical cohort study was conducted. Audiometric surveillance data from the Jerusalem occupational medicine registry of male employees in various industries from 2006 to 2017 were used. Mean individual annual threshold shifts simulating 1-8 checkup interval years were calculated. Joinpoint regression analysis was used to assess the interval in which the slope of the calculated ATS variability moderates significantly.

RESULTS

A total of 263 noise-exposed workers and 93 workers in the comparison group produced 1913 audiograms for analysis. Among the noise-exposed workers, using the 1-4 kHz average, threshold shifts stabilized from 3 years onwards at around 1 dB per year in all age groups and 0.83 dB in the stratum younger than 50 years. No enhanced decline was detected in the first years of exposure.

CONCLUSION

Although most countries conduct annual hearing surveillance, hearing threshold shifts of noise-exposed workers become more accurate and show less variability when calculated at 3-year checkup intervals onwards than shorter intervals. Since margins of errors of the test method are much larger than the annual shift found, screening schedule that enables each subsequent test to identify a real deterioration in hearing is necessary. Triennial audiometric screening would be a better surveillance frequency for noise-exposed workers younger than 50 years of age in the category of 85-95 dBL_Aeq,8 h without other known risk factors.

Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research

Cardiovascular diseases are the world’s leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders’ views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

Direct cost of systemic arterial hypertension and its complications in the circulatory system from the perspective of the Brazilian public health system in 2019

INTRODUCTION

Systemic arterial hypertension (SAH), a global public health problem and the primary risk factor for cardiovascular diseases, has a significant financial impact on health systems. In Brazil, the prevalence of SAH is 23.7%, which caused 203,000 deaths and 3.9 million DALYs in 2015.

OBJECTIVE

To estimate the cost of SAH and circulatory system diseases attributable to SAH from the perspective of the Brazilian public health system in 2019.

METHODS

A prevalence-based cost-of-illness was conducted using a top-down approach. The population attributable risk (PAR) was used to estimate the proportion of circulatory system diseases attributable to SAH. The direct medical costs were obtained from official Ministry of Health of Brazil records and literature parameters, including the three levels of care (primary, secondary, and tertiary). Deterministic univariate analyses were also conducted.

RESULTS

The total cost of SAH and the proportion of circulatory system diseases attributable to SAH was Int$ 581,135,374.73, varying between Int$ 501,553,022.21 and Int$ 776,183,338.06. In terms only of SAH costs at all healthcare levels (Int$ 493,776,445.89), 97.3% were incurred in primary care, especially for antihypertensive drugs provided free of charge by the Brazilian public health system (Int$ 363,888,540.14). Stroke accounted for the highest cost attributable to SAH and the third highest PAR, representing 47% of the total cost of circulatory diseases attributable to SAH. Prevalence was the parameter that most affected sensitivity analyses, accounting for 36% of all the cost variation.

CONCLUSION

Our results show that the main Brazilian strategy to combat SAH was implemented in primary care, namely access to free antihypertensive drugs and multiprofessional teams, acting jointly to promote care and prevent and control SAH.

NHS Health Checks: an observational study of equity and outcomes 2009-2017

Background

The NHS Health Check cardiovascular prevention programme is now 10 years old.

Aim

To describe NHS Heath Check attendance, new diagnoses, and treatment in relation to equity indicators.

Design and setting

A nationally representative database derived from 1500 general practices from 2009–2017.

Method

The authors compared NHS Health Check attendance and new diagnoses and treatments by age, sex, ethnic group, and deprivation.

Results

In 2013–2017, 590 218 (16.9%) eligible people aged 40–74 years attended an NHS Health Check and 2 902 598 (83.1%) did not attend. South Asian ethnic groups were most likely to attend compared to others, and females more than males. New diagnoses were more likely in attendees than non-attendees: hypertension 25/1000 in attendees versus 9/1000 in non-attendees; type 2 diabetes 8/1000 versus 3/1000; and chronic kidney disease (CKD) 7/1000 versus 4/1000. In people aged ≥65 years, atrial fibrillation was newly diagnosed in 5/1000 attendees and 3/1000 non-attendees, and for dementia 2/1000 versus 1/1000, respectively. Type 2 diabetes, hypertension, and CKD were more likely in more deprived groups, and in South Asian, Black African, and Black Caribbean ethnic groups. Attendees were more likely to be prescribed statins (26/1000) than non-attendees (8/1000), and antihypertensive medicines (25/1000 versus 13/1000 non-attendees). However, of the 117 963 people with ≥10% CVD risk who were eligible for statins, only 9785 (8.3%) were prescribed them.

Conclusion

Uptake of NHS Health Checks remains low. Attendees were more likely than non-attendees to be diagnosed with type 2 diabetes, hypertension, and CKD, and to receive treatment with statins and antihypertensives. Most attendees received neither treatment nor referral. Of those eligible for statins, <10% were treated. Policy reviews should consider a targeted approach prioritising those at highest CVD risk for face-to-face contact and consider other options for those at lower CVD risk.

Association between access to health-promoting facilities and participation in cardiovascular disease (CVD) risk screening among populations with low socioeconomic status (SES) in Singapore

BACKGROUND

Low socioeconomic status (SES) is a barrier for cardiovascular disease (CVD) risk screening and a determinant of poor CVD outcomes. This study examined the associations between access to health-promoting facilities and participation in a CVD risk screening program among populations with low SES residing in public rental flats in Singapore.

METHODS

Data from Health Mapping Exercises conducted from 2013 to 2015 were obtained, and screening participation rates of 66 blocks were calculated. Negative binomial regression was used to test for associations between distances to four nearest facilities (i.e., subsidized private clinics, healthy eateries, public polyclinics, and parks) and block participation rate in CVD screening. We also investigated potential heterogeneity in the association across regions with an interaction term between distance to each facility and region.

RESULTS

The analysis consisted of 2069 participants. The associations were only evident in the North/North-East region for subsidized private clinic and park. Specifically, increasing distance to the nearest subsidized private clinic and park was significantly associated with lower [incidence rate ratio (IRR) = 0.88, 95% confidence interval (CI): 0.80-0.98] and higher (IRR = 1.93, 95%CI: 1.15-3.25) screening participation rates respectively.

CONCLUSIONS

Our findings could potentially inform the planning of future door-to-door screenings in urban settings for optimal prioritization of resources. To increase participation rates in low SES populations, accessibility to subsidized private clinics and parks in a high population density region should be considered.

Patients' and health professionals' attitudes and perceptions towards the initiation of preventive drugs for primary prevention of cardiovascular disease: protocol for a systematic review of qualitative studies

INTRODUCTION

Lipid-lowering drugs and antihypertensive agents can be prescribed for the primary prevention of cardiovascular disease. In some cases, patients eligible for primary prevention of cardiovascular disease according to the European guidelines are not always started on preventive drugs. Existing research explores the attitudes of health professionals and patients towards cardiovascular preventive drugs but does not always differentiate between the attitudes towards drug initiation for primary or secondary prevention. We aim to systematically review qualitative studies assessing health professionals' and patients' attitudes and perceptions towards drug initiation for primary prevention of cardiovascular disease.

METHODS AND ANALYSIS

MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, CINAHL, Applied Social Sciences Index and Abstracts, Conference Proceedings Citation Index (Web of Science), Healthcare Management Information Consortium, and Open Grey will be searched without restrictions on date or language of publication. Searches will be limited to studies of qualitative design, standalone or in the context of a mixed-method design, focusing on cardiovascular drug initiation for primary prevention. The primary outcome is the attitudes of health professionals and patients towards drug initiation for primary prevention of cardiovascular disease. Two reviewers will independently carry out the study selection, data extraction and quality assessment. The Critical Appraisal Skills Programme Qualitative Research Checklist will be used to assess the quality of included studies. The findings will be analysed using Thomas and Harden's thematic synthesis approach.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42018095346.