Hypertension In General Practice Research Articles

Optimized treatment of elderly patients with type 2 diabetes mellitus and hypertension in general practice

Optimized treatment of elderly patients with type 2 diabetes mellitus and hypertension in general practice

The impact of communication training on the clinical care of hypertension in general practice: a cluster randomized controlled trial in China

BackgroundHypertension is one of the most common chronic diseases with a low control rate globally. The effect of communication skills training contributing to hypertension control remains uncertain. The aim of the present study was to assess the effectiveness of an educational intervention based on the Calgary-Cambridge guide in improving hypertensive management.MethodsA cluster randomized controlled trial enrolled 27 general practitioners (GPs) and 540 uncontrolled hypertensive patients attending 6 community health centers in Chengdu, China. GPs allocated to the intervention group were trained by an online communication course and two face-to-face workshops based on Calgary-Cambridge guides. The primary outcome was blood pressure (BP) control rates and reductions in systolic and diastolic BP from baseline to 3 months. The secondary outcome was changes in GPs’ communication skills after one month, patients’ knowledge and satisfaction after 3 months. Bivariate analysis and the regression model assessed whether the health provider training improved outcomes.ResultsAfter the communication training, the BP control rate was significantly higher (57.2% vs. 37.4%, p < 0.001) in the intervention groups. Compared to the control group, there was a significant improvement in GP’s communication skills (13.0 vs 17.5, p < 0.001), hypertensive patients’ knowledge (18.0 vs 20.0, p < 0.001), and systolic blood pressure (139.1 vs 134.7, p < 0.001) after 3 months of follow-up. Random effects least squares regression models showed significant interactions between the intervention group and time period in the change of GP’s communication skills (Parameter Estimated (PE): 0.612, CI:0.310,0.907, p = 0.006), hypertensive patient’s knowledge (PE:0.233, CI: 0.098, 0.514, p < 0.001), satisfaction (PE:0.495, CI: 0.116, 0.706, p = 0.004), SBP (PE:-0.803, CI: -1.327, -0.389, p < 0.001) and DBP (PE:-0.918, CI: -1.694, -0.634, p < 0.001), from baseline to follow-up.ConclusionCommunication training based on the Calgary-Cambridge guide for GPs has shown to be an efficient way in the short term to improve patient-provider communication skills and hypertension outcomes among patients with uncontrolled BPs.Trial registrationThe trial was registered on Chinese Clinical Trials Registry on 2019–04-03. (ChiCTR1900022278).

Are Nurse-Led Patient Consultations and Nurse-Led Dose Adjustments of Permanent Medication Acceptable for Patients with Diabetes Mellitus and Hypertension in General Practice? - Results of a Focus Group Study.

Practice nurse (PN)-led patient consultations and PN-led dosage adjustments of permanent medication are uncommon and not well studied in general practice (GP) in Germany. We investigated the perspectives of patients with common chronic diseases in Germany, diabetes mellitus (DM) type 2 and/or arterial hypertension (AT), on PN-led patient consultations and dosage adjustments of permanent medications in GP. In this exploratory qualitative study, online focus groups were conducted using a semi-structured interview guide. Patients were recruited from collaborating GPs according to a predefined sampling plan. Patients were eligible for this study if they had DM or AT treated by their GP, were on at least one permanent medication and were aged 18 years or older. Focus group transcripts were analyzed using thematic analyses. Analyses of two focus groups, involving a total of 17 patients, revealed four main themes: (1) openness to the PN-led care and perceived benefits, eg because of patients' confidence in PNs' skills, or patients' impression that PN-led care would better meet their needs and increase their compliance. Some patients had (2) reservations and perceived risks, especially for PN-led medication changes eg feeling that medication adjustments were a GP's issue. Patients identified (3) reasons for encounters where they were likely to accept PN-led consultation and medication advice, eg management of DM, AT and thyroid disease. Patients also saw several important general requirements for the implementation of PN-led care in German general practice (4). There is a potential for openness towards PN-led consultation and PN-led medication adjustment for permanent medication in patients with DM or AT. This study is the first qualitative study to investigate PN-led consultations and medication advice in German general practice. If the implementation of PN-led care is planned, our findings add the patients' perspectives of acceptable reasons for encounter for PN-led care and their general requirements.

Nurse-led interventions to manage hypertension in general practice: A systematic review and meta-analysis.

To evaluate the impact of general practice nurse-led interventions for blood pressure control and cardiovascular disease risk factor reduction in patients with hypertension. Systematic review and meta-analysis of randomized control trials. CINAHL, Medline and Scopus databases were searched to identify peer-reviewed studies published between 2000 and 2021. A systematic review of randomized control trials was conducted using a structured search strategy. The Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used to appraise study quality. Meta-analysis and narrative synthesis were performed to determine the effectiveness of the included interventions. Eleven trials comprising of 4454 participants were included in the review. Meta-analysis showed significant reductions in both systolic and diastolic blood pressure in trials with 6months or less follow-up. Improvements were also demonstrated in reducing blood lipids, physical activity, general lifestyle measures and medication adherence. Evidence for dietary improvements and reduction in alcohol and smoking rates was inconclusive. Nurse-led interventions for patients with hypertension are heterogeneous in terms of the nature of the intervention and outcomes measured. However, nurse-led interventions in general practice demonstrate significant potential to improve blood pressure and support cardiovascular disease risk factor reduction. Future research should be directed towards elucidating the successful elements of these interventions, evaluating cost-effectiveness and exploring translation into usual care. This review provides evidence that nurses in general practice could enhance current hypertension management through nurse-led interventions.

Elderly Patient with Hypertension in General Practice: Clinical Features and Antihypertensive Therapy

The prevalence of arterial hypertension (AH) increases with age: among people over 60 years old this index is more than 2 times higher in the general population, 2/3 of people over 65 years old suffer from hypertension. Among patients 65–89 years old with hypertension, 2/3 patients have isolated systolic hypertension (ISAG). Features of hypertension in the elderly patients are: lability of blood pressure (BP), increasing frequency of pseudohypertension, high frequency of «white coat hypertension», decreased sensitivity of pressor factors for antihypertensive drugs, high frequency of resistant to treatment of hypertension. The new recommendations of the European Society of Cardiology for the diagnosis and treatment of hypertension emphasize 2 groups of elderly patients: 65–79 years old and ≥80 years old, which described the epidemiological features, the prevalence of risk factors for cardiovascular events, blood pressure levels for antihypertensive therapy and target blood pressure, and the recommended principles of drug therapy that are different from young and middle-aged patients. For most patients, fixed combinations are indicated as starting AGT, but monotherapy is recommended for the treatment of hypertension in very elderly patients (over 80 years old) and elderly patients over 65 years old with senile asthenia. The decreasing of blood pressure should be gradual, taking into consideration the increased risk of orthostatic reactions at this age. European and American experts recommend os first-line drugs low doses of thiazide diuretics and calcium channel antagonists (mainly dihydropyridine), which are especially indicated in isolated systolic arterial hypertension to effectively reduce the frequency of cardiovascular complications in the treatment of elderly patients with hypertension.

Nurse-led interventions to manage hypertension in general practice: A systematic review protocol

AimThis systematic review seeks to synthesise randomised controlled trials reporting the impact of interventions delivered by nurses in primary care to enhance blood pressure control and minimise lifestyle risk factors in hypertensive patients. BackgroundGiven the growing demand for chronic care management, there has been a rapid increase in the primary care nursing workforce and emerging diversity in their roles. The primary care nurse’s role has evolved to work in collaboration with general practitioners to manage patients with chronic conditions like hypertension. Despite the nurse’s role in lifestyle modification and behaviour change, there is limited evidence exploring the impact of primary care nurse-initiated interventions for lifestyle modification in those with hypertension. Design/methodsA systematic review of randomised controlled trials will be conducted. Electronic databases will be searched from January 2000 to January 2019, using a structured search strategy. Two reviewers will review title and abstract, screen full-text papers and extract data. The Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) will be used to appraise study quality. Data will be synthesised using either meta-analysis or narrative synthesis depending on the heterogeneity of included studies. DiscussionThis review will assist in understanding the evidence available on the impact of general practice nurse interventions to manage hypertension. The findings will assist in informing effective nurse-directed interventions for controlling hypertension and will identify gaps in the literature for future research to address.

Characteristics and Future Cardiovascular Risk of Patients With Not‐At‐Goal Hypertension in General Practice in France: The AVANT'AGE Study

Although many studies focus on patients with resistant hypertension, general practitioners (GPs) are more likely to face patients in clinical practice with not-at-goal hypertension, whose antihypertensive treatment needs to be modified. However, information regarding such patients is limited. In the present study, 710 GPs in France each included their first 10 not-at-goal hypertensive patients, ie, the patients for whom they decided to modify antihypertensive treatment. The study population was composed of 7032 patients (58% men, mean age 62.4±11.5years). Anthropometric and biologic measurements and clinical data were collected, and vascular age and 10-year cardiovascular risk were estimated by standard formula. Of 7032 participants, cardiovascular risk factors were prevalent, with 15.1% current smokers, 26.1% obese, 22.8% with diabetes mellitus, 35.1% with dyslipidemia, 12.0% with left ventricular hypertrophy, and 4.9% with renal insufficiency. In the subgroup (n=4697) of patients aged between 30 and 74years and undergoing primary cardiovascular prevention, vascular age was superior (13 to 28years) when compared with chronological age in different subgroups. The patients' estimated 10-year cardiovascular global risk was 25.3±13.6%, with 16.0±10.5% for coronary heart disease, 8.7±6.8% for myocardial infarction, 5.8±4.5% for stroke, and 6.8±6.6% for cardiovascular mortality. Patients with not-at-goal hypertension in primary care bear a heavy burden of cardiovascular diseases.

Managing hypertension in general practice: a cross-sectional study of treatment and ethnicity

NICE guidelines are the accepted standard for determining the management of hypertension in UK primary care. To explore adherence and non-adherence to NICE hypertension guidelines, the extent to which this influences blood pressure control, and the role of ethnicity. A cross-sectional study was conducted based on primary care data from Lambeth DataNet, a database of primary care records in one inner-city London borough. NICE guidelines were used to determine adherence to recommended treatment options for four groups of patients with hypertension: aged <55 years on monotherapy; aged ≥55 years on monotherapy; any age on dual therapy; any age and with comorbid diabetes. Blood pressure control was determined for each treatment category and ethnic group. The study controlled for age, sex, social deprivation, and clustering within general practices. A total of 32 183 patients were identified with a current diagnosis of hypertension. Ethnic coding was available for 28 320 (88.0%). Overall, 13 546 patients with ethnicity coding could be allocated to one of the four clinical categories of hypertension; 44% of these patients received non-guideline-adherent treatment; ethnicity was not a significant determinant. Mean arterial pressure did not differ significantly between those receiving 'correct' or 'incorrect' hypotensive therapy. Evidence-based guidelines for the management of hypertension were not followed in a relatively large proportion of patients included in this study. Nevertheless, no evidence was found that failure to follow treatment recommendations resulted in poorer blood pressure control. Further work is needed to determine the reasons for non-implementation of guideline recommendations in primary care.

Does quality of care for hypertension in primary care vary with postcode area deprivation? An observational study

BackgroundHypertension is a common major risk factor for stroke and coronary heart disease. Little is known about how achievement of financially incentivised and non-incentivised indicators of quality of care varies with deprivation, or about the effect of financial incentives on health inequalities in hypertension. General practices in the UK have received financial incentives for high quality care since 2004. This study set out to assess the variations in achievement of incentivised and non-incentivised quality indicators for hypertension by patient area deprivation, before and after the introduction of financial incentives.MethodsAchievement of 14 quality indicators for hypertension in 304 patient participants in 18 general practices in Norfolk, England was assessed one year before (2003) and one year after (2005) the introduction of financial incentives. Four indicators were incentivised and 10 were non-incentivised. Each participant's postcode was linked to an index of multiple deprivation score.ResultsThe range of achievement of incentivised quality indicators was 65-94% in the least deprived third of participants, and 77-94% in the most deprived third in 2003 and 2005 combined. For non-incentivised indicators, the range was 7-85% in the least deprived and 24-93% in the most deprived third.Achievement of incentivised quality indicators in 2003 and 2005 combined did not vary significantly by area deprivation. Achievement of three of 10 non-incentivised indicators was higher in participants from more deprived postcode areas: providing lifestyle advice (odds ratio 1.34, 95% confidence interval 1.00-1.79), assessment of peripheral vascular disease (1.54, 1.02-2.35) and electrocardiography (1.38, 1.04-1.82).ConclusionsParticipants from more deprived areas received at least the same, and sometimes better, quality of care than those from less deprived areas. Quality of care for hypertension in general practice may not follow the inequitable distribution seen with some other conditions.

Chronic kidney disease in patients with diabetes mellitus type 2 or hypertension in general practice

The prevalence and severity of chronic kidney disease (CKD) in primary care patients with diabetes or hypertension is unknown. To assess the prevalence and severity of CKD in patients with diabetes and hypertension; and identify whether age, sex, diabetes, and hypertension are associated with CKD. Cross-sectional survey. Two Dutch primary health care centres (15 954 enlisted patients). Patients, aged ≥ 25 years, with known diabetes type 2 (n = 471) or hypertension (n = 960), were selected on 1 October 2006. Initial screening uptake rates were assessed from the electronic patient records, and patients were invited when blood or urine measurements were missing. The presence of albuminuria was determined, glomerular filtration rate estimated, and clinical characteristics extracted. Initial screening uptake rates were 93% and 69% for diabetes and hypertension, respectively, and increased to 97% (n = 455) and 87% (n = 836) after active invitation. The prevalence of CKD was 28% in diabetes and 21% in hypertension only. The presence of diabetes was independently associated with albuminuria (odds ratio [OR] 4.23; 95% confidence interval [CI] = 2.67 to 6.71), but not with decreased estimated GFR (eGFR) (OR 0.75; 95% CI = 0.54 to 1.04). Age showed the strongest association with decreased eGFR (OR 2.73; 95% CI = 2.02 to 3.70). In primary care, more than one-quarter of patients with diabetes and about one-fifth of patients with hypertension have CKD. The high prevalence justifies longitudinal follow-up in order to evaluate whether intensified cardiovascular risk management is beneficial in this primary care population.

Patients Assessment of Chronic Illness Care (PACIC) in two Australian studies: structure and utility

To validate the Patients Assessment of Chronic Illness Care (PACIC) among patients with chronic disease in the Australian context and to examine the relationship between patient-assessed quality of care and patient and practice characteristics. Cross-sectional analysis of baseline data in two independent health service intervention studies that involved patients with type 2 diabetes, ischaemic heart disease and/or hypertension in general practice. The first study involved 2552 patients from 60 urban and rural general practices. The second involved 989 patients from 26 practices in Sydney. Patients were mailed a questionnaire, which included the PACIC and Short Form Health Survey. Factor analysis was performed and the factor scores and total PACIC were analysed using multi-level regression models against practice and patient characteristics. Factor analysis revealed a two-factor solution with similar loading of PACIC items in both studies: one for shared decision making and self-management and the other for planned care. Practice characteristics were not related to PACIC scores. Scores were related to patient characteristics - education, retirement, type and number and duration of conditions. The two-factor structure of the PACIC found in these Australian studies is different from the five-factor structure found in the US and the European studies. This may be related to differences in the way patients interact with the health system especially the use of Team Care plans. The association of total scores with patient characteristics was consistent with those found in other studies including a lack of association with gender, age and ethnicity. These findings should be taken into consideration when comparing patient-assessed quality of care between countries using this tool.

Oversight: a retrospective study of biochemical monitoring in patients beginning antihypertensive drug treatment in primary care

Guidelines recommend biochemical monitoring of patients treated with antihypertensive agents, although there is little primary evidence for these recommendations. Patients treated for hypertension in general practice often have no biochemical tests before, or in the 6 months after, starting drug treatment. Guidelines on the management of hypertension have recommended baseline testing of serum electrolyte and creatinine concentrations before treatment since the 1990s. We wished to examine the extent of laboratory monitoring in patients with newly diagnosed hypertension and newly treated with antihypertensive drugs. We carried out a retrospective analysis of 74,096 patients in the General Practice Research Database (GPRD) aged 18 years and older with newly diagnosed hypertension and prescribed a single antihypertensive agent. We determined the number of patients with a laboratory test for serum electrolyte and creatinine (or urea) concentrations prior to the first antihypertensive drug prescription and in the 6 months after and patient factors associated with subsequent monitoring. Thirty-four thousand nine hundred and forty-seven patients (47%) had at least one biochemical test in the 12 months prior to beginning antihypertensive treatment, and 26,946 (36%) had at least one biochemical monitoring test in the 6 months after beginning antihypertensive treatment. Thirteen thousand five hundred and four (18%) had both baseline and monitoring tests. Baseline tests were normal in 11,671 patients (86%), of whom 10,213 (88%) had normal tests at first monitoring. Monitoring was significantly more likely in patients treated with ACE inhibitors than thiazides (adjusted OR 1.90; 95% CI 1.80, 2.00), older patients (adjusted OR 1.23; 95% CI 1.11, 1.36) [individuals aged 80-89 years compared with <40 years], and patients with diabetes mellitus (adjusted OR 2.03; 95% CI 1.91, 2.16). Biochemical testing at baseline and monitoring after starting treatment is often omitted in newly diagnosed hypertensive patients. When both are tested, one in eight normal results becomes abnormal.

SOCIAL INEQUALITY IN THE CONTROL OF HYPERTENSION IN A HEALTH CARE SYSTEM WITH EQUAL ACCESS: PP.7.302

Background and Objective: The majority of patients diagnosed with hypertension in Denmark are treated and followed by their general practitioner. Only about 50% achieved controlled blood pressure. The role of socioeconomic status in the control of hypertension is not known and socioeconomic status is not taken into account in the Danish guidelines for treatment of hypertension. Denmark has a tax-funded healthcare system, which includes free access to general practice. The aim of the present study was to analyze the effect of social inequality on the control of hypertension. Design and Method: 179 general practices participated in an audit about hypertension. Data included blood pressure, information about risk factors, medication and duration of hypertension for 7111 patients with known hypertension. The population analyzed comprised 5413 patients who had filled out a questionnaire about their treatment of hypertension. Information about income, education, employment status, marital status and degree of urbanization were retrieved from national registers. Data will be analyzed using logistic regression adjusted for age, gender, diabetes and other possible confounder effect. Results: Preliminary results from the present study indicate that only 49% of patients treated for hypertension in general practice have controlled blood pressure. Living alone (divorced/widowed) as opposed to living with a partner was associated with uncontrolled hypertension. Having children, lack of education other than basic school or having vocational training all increases the odds of being uncontrolled. Conclusions: Social inequality plays a prominent role for the control of hypertension in Denmark despite equal access to health care.

A role for single-pill triple therapy in hypertension

Hypertension remains the most prevalent chronic disease in the world, and its adequate treatment results in predictable reductions in cardiovascular morbidity and mortality. However, most hypertensive subjects do not achieve goal blood pressure despite availability of multiple antihypertensive agents with various pharmacological mechanisms of action and relatively few side effects. We review the reasons for low hypertension control rates, including factors that affect patients' adherence to therapy, number of agents required to achieve goal blood pressure, pathophysiology-based selection of therapy and diagnosis of resistant hypertension. Within this framework, we discuss the possible impact of a single-pill, triple-therapy combination with an antagonist of the renin-angiotensin system, a calcium-channel blocker and a diuretic. We focus on possible differential diagnostic implications in terms of refractoriness to treatment, and therapeutic implications in terms of successful blood pressure control. We conclude that a single-pill, triple-therapy combination may improve control of hypertension by enhancing compliance, by achieving blood pressure goal rapidly and by reducing physician inertia in prescribing adequate antihypertensive therapy. We also suggest that such a combination may lead to improved accuracy in diagnosing resistant hypertension in general practice, avoiding unnecessary further workup and referrals to hypertension specialists.

Self-reported prescribing for hypertension in general practice

To describe the self-reported management of hypertension in general practice and how this compares to national guidelines for hypertension. Analysis of self-reported cross-sectional clinical audit data. Australian general practice for the years 1999, 2001, 2003 and 2004. A total of 5247 general practitioners who voluntarily participated in one of four hypertension clinical audits and provided data for 105,086 adult patients with a previous diagnosis of hypertension. Selection of blood pressure targets consistent with recommendation of hypertension guidelines, percentage of patients achieving target blood pressure and percentage of patients with selected co-morbidities treated with the preferred class of antihypertensive medications. In 2001, target blood pressures of 140/90 mmHg and 130/85 mmHg were being used for 38% and 55% of patients, respectively. In 2004, target blood pressures were 140/90 mmHg (39%), 130/85 mmHg (49%) and 125/75 mmHg (0.5%). In 2003 and 2004, 58% and 70% of patients were reported to have achieved a target blood pressure that was consistent with guidelines according to patient age and co-morbidities. However, only 54-62% of hypertensive patients with heart failure were prescribed an ACE inhibitor and 52% of patients with a history of myocardial infarction were receiving a beta-blocker or ACE inhibitor. The self-reported data from general practitioners participating in clinical audits show that these general practitioners are using blood pressures targets consistent with guideline recommendations for most patients and that more patients are reaching their target blood pressure. However, drug selection based on co-morbidities could improve.

CRISTOPH – A cluster-randomised intervention study to optimise the treatment of patients with hypertension in General Practice

BackgroundRecent guidelines for the management of hypertension focus on treating patients according to their global cardiovascular risk (CVR), rather than strictly keeping blood pressure, or other risk factors, below set limit values. The objective of this study is to compare the effect of a simple versus a complex educational intervention implementing this new concept among General Practitioners (GPs).Methods/designA prospective longitudinal cluster-randomised intervention trial with 94 German GPs consecutively enroling 40 patients each with known hypertension. All GPs then received a written manual specifically developed to transfer the global concept of CVR into daily General Practice. After cluster-randomisation, half of the GPs additionally received a clinical outreach visit, with a trained peer discussing with them the concept of global CVR referring to example study patients from the respective GP. Main outcome measure is the improvement of calculated CVR six months after intervention in the subgroup of patients with high CVR (but no history of cardiovascular disease), defined as 10-year-mortality ≥ 5% employing the European SCORE formula. Secondary outcome measures include the intervention's effect on single risk factors, and on prescription rates of drugs targeting CVR. All outcome measures are separately studied in the three subgroups of patients with 1. high CVR (defined as above), 2. low CVR (SCORE < 5%), and 3. a history of cardiovascular disease. The influence of age, sex, social status, and the perceived quality of the respective doctor-patient-relation on the effects will be examined.DiscussionTo our knowledge, no other published intervention study has yet evaluated the impact of educating GPs with the goal to treat patients with hypertension according to their global cardiovascular risk.Trial registrationISRCTN44478543

Nurse-Led Blood Pressure Treatment in Primary Health Care: An Intervention Study Comparing Two Regimens

BackgroundCurrent treatment of hypertension in general practice is often inadequate, despite clinical guidelines.ObjectiveThe aim of this study was to describe and evaluate a district nurse-led extended health-care regimen to improve blood measure treatment. This included scheduled appointments with the district nurse and physician, a documentation of risk factors, an offer of assistance with supportive health measures, an established individual blood pressure goal and the provision of a personal blood pressure card as means of informing and motivating the patients.MethodThis was a pretest-post-test control group study comprised 200 patients with systolic and/or diastolic blood pressure over 140/90 divided into an intervention group and a control group. Blood pressure, weight, waistline measurement, nicotine and drug use were registered before and after a six month period of intervention.ResultsA significant reduction of blood pressure, both systolic and diastolic, was observed in both groups after the in...

‘Under pressure’: how Ghanaian, African-Surinamese and Dutch patients explain hypertension

The aim of this study was to explore and compare explanatory models (EMs) of hypertension in native-Dutch, first-generation Ghanaian and African-Surinamese (Surinamese) hypertensives in Amsterdam, the Netherlands. Through semi-structured interviews, we elicited accounts of the nature, causes and consequences of hypertension in a purposive sample of 46 patients (aged 35-65 years, treated for hypertension in general practice >1 year). All three groups had difficulty in describing hypertension. All groups mentioned culturally specific nutritional habits as possible causes of hypertension (Dutch liquorice; Ghanaians fufu; Surinamese salty diet). Most respondents, particularly those of Ghanaian and Surinamese background, perceived stress as the main cause of hypertension and experienced symptoms of hypertension. Many Ghanaian and Surinamese respondents attributed hypertension to migration-related factors: changes in diet or climate, stress owing to adaptation to the Dutch society or obligations towards family in their homelands. Many immigrants felt a return to their homeland could cure hypertension and were concerned about the consequences of hypertension. Half of the Dutch and almost all Ghanaian and Surinamese respondents believed uncontrolled hypertension could cause immediate damage. Some Ghanaians expressed reservations sharing their concerns with community members because it might cause social stigma. Few respondents associated hypertension with obesity, even though many were overweight. Confirming findings from UK and US studies, this study reveals that EMs of hypertension in patients from three ethnic groups differ from the common medical perspective. These differences are greater for patients from migrant groups. Our findings can be useful in developing patient-centred hypertension interventions, particularly in new migrant populations.

A clinical audit of the quality of care of hypertension in general practice

Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from "best practice" can then be examined, and causes can be determined and acted upon. The Ministry of Health (MOH), Jamaica, has recently published standards of care for hypertension. The medical records of a convenience sample of 125 hypertensive patients being managed by five current family medicine residents in their respective primary care practices were audited Initial results showed limited adherence to the MOH recommended hypertension management guidelines. The same practices were re-audited after an interval of six months, during which time the physicians were sensitized to the results of the preliminary audit. Marked improvements were noted in the second audit. Assessment for co-risk factors for hypertension-related diseases improved: nutritional advice (33% to 74%), smoking and alcohol intake history (40% to 65%) and history taking of physical activity (30% to 47%). Assessment for target organ damage also improved: fundoscopy done (11% to 54%), foot examination done (30% to 58%) and yearly electrolytes done (28% to 62%). There are clear gaps between current practice and standards that exist internationally and locally for management of hypertension. The MOH needs to disseminate and educate general practitioners about the standards of care guidelines.

An Empirical Model for the Development of Disease Management Programs in General Practice

Objective: The aim of this research was to develop an empirically derived methodological model for the development of disease management programs in general practice. The model was developed applying the example of hypertension. Methods: Using a rapid appraisal framework, empirical investigations, which included structured panel discussions, face-to-face structured interviews and formal presentations, were conducted to design, test and confirm the disease management model. A broad range of stakeholders were consulted from general practice, other health providers, industry, federal government and consumers. Results: The outcome of the research was a testable definition of disease management for hypertension, and the Australian Disease Management Approach to Hypertension in General Practice (ADAGE) for patients at low to high risk of major cardiovascular events. The central platform of this program is an information, communication technology package for risk assessment and management, plus access to a dietician commissioned by the program and a tailored suite of audiovisual and written material. Conclusion: This study used hypertension to demonstrate a model for the development of theoretically sound disease management models for application in general practice. The ADAGE program is currently under evaluation in a cluster randomized trial of 76 general practices in South Australia and Victoria in both metropolitan and rural settings. It is anticipated that this model will contribute to the development of other disease management programs for addressing chronic disease.