Hypertension control at physicians' offices in the United States

Home blood pressure data visualization for the management of hypertension: using human factors and design principles

BACKGROUND

Home blood pressure measurements have equal or even greater predictive value than clinic blood pressure measurements regarding cardiovascular outcomes. With advances in home blood pressure monitors, we face an imminent flood of home measurements, but current electronic health record systems lack the functionality to allow us to use this data to its fullest. We designed a data visualization display for blood pressure measurements to be used for shared decision making around hypertension.

METHODS

We used an iterative, rapid-prototyping, user-centred design approach to determine the most appropriate designs for this data display. We relied on visual cognition and human factors principles when designing our display. Feedback was provided by expert members of our multidisciplinary research team and through a series of end-user focus groups, comprised of either hypertensive patients or their healthcare providers required from eight academic, community-based practices in the Midwest of the United States.

RESULTS

A total of 40 participants were recruited to participate in patient (N = 16) and provider (N = 24) focus groups. We describe the conceptualization and development of data display for shared decision making around hypertension. We designed and received feedback from both patients and healthcare providers on a number of design elements that were reported to be helpful in understanding blood pressure measurements.

CONCLUSIONS

We developed a data display for substantial amounts of blood pressure measurements that is both simple to understand for patients, but powerful enough to inform clinical decision making. The display used a line graph format for ease of understanding, a LOWESS function for smoothing data to reduce the weight users placed on outlier measurements, colored goal range bands to allow users to quickly determine if measurements were in range, a medication timeline to help link recorded blood pressure measurements with the medications a patient was taking. A data display such as this, specifically designed to encourage shared decision making between hypertensive patients and their healthcare providers, could help us overcome the clinical inertia that often results in a lack of treatment intensification, leading to better care for the 35 million Americans with uncontrolled hypertension.

Plasma Trough Concentrations of Antihypertensive Drugs for the Assessment of Treatment Adherence: A Meta-Analysis

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Biochemical drug screening by liquid chromatography-tandem mass spectrometry in plasma is an accurate method for the quantification of plasma concentrations of antihypertensive medications in patients with hypertension. Trough concentrations could possibly be used as drug-specific cutoff values in the biochemical assessment of (non-)adherence. We performed a literature review and meta-analysis of pharmacokinetic studies to determine plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan. PubMed was searched for pharmacokinetic studies up to September 2020. Eligible studies reported steady-state mean trough concentration and their variance. Pooled trough concentrations were estimated using a three-level random effects meta-analytic model. Moderator analyses were performed to explore sources of heterogeneity. One thousand three hundred eighteen potentially relevant articles were identified of which 45 were eligible for inclusion. The pooled mean trough concentration was 9.2 ng/mL (95% CI, 7.5–10.8) for amlodipine, 41.0 ng/mL (95% CI, 17.4–64.7) for hydrochlorothiazide, and 352.9 ng/mL (95% CI, 243.5–462.3) for valsartan. Substantial heterogeneity was present for all 3 pooled estimates. Moderator analyses identified dosage as a significant moderator for the pooled trough concentration of amlodipine (β₁=0.9; P<0.05), mean age, and mean body weight for the mean trough concentration of hydrochlorothiazide (β₁=2.2, P<0.05, respectively, β₁=−4.0, P<0.05) and no significant moderators for valsartan. Plasma trough concentrations of amlodipine, hydrochlorothiazide, and valsartan, measured with liquid chromatography-tandem mass spectrometry, are highly heterogeneous over the different studies. Use of the pooled trough concentration as a cutoff in the biochemical assessment of adherence can result in inaccurate diagnosis of (non-)adherence, which may seriously harm the patient-physician relationship, and is therefore not recommended.

Characteristics of Non-Spine Musculoskeletal Ambulatory Care Visits in the United States, 2009-2016

BACKGROUND

Despite the enormous economic and societal impact of musculoskeletal disorders, detailed data on the patient demographics and visit characteristics of nonspine musculoskeletal ambulatory care are sparse. Such data are essential to inform policymakers on population health needs and to justify health care resource allocation.

OBJECTIVE

To determine the demographic, patient, and visit characteristics of adult musculoskeletal ambulatory clinic visits, with the exception of spine visits, in the United States.

DESIGN

Survey/registry.

SETTING

National Ambulatory Medical Care Survey (NAMCS), Centers for Disease Control and Prevention (CDC) 2009 to 2016.

PATIENTS

The NAMCS was designed to capture information regarding the provision and use of ambulatory medical care services in the United States. Nonfederally employed office-based physicians reported data for this survey from 2009 to 2016.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Average annual estimated number (in 100 000s), Average annual estimated rate of ambulatory care musculoskeletal visits per 100 U.S. adults.

RESULTS

During 2009 to 2016, the leading cause of musculoskeletal visits was knee symptoms (15.3 million annually from 2009 to 2010, 14.0 million annually from 2011 to 2012, 12.5 million annually from 2013 to 2014, and 12.4 million annually from 2015 to 2016). Musculoskeletal visits were most frequent in patients that were 45 to 64 years of age (40.4% to 43.6% of visits were for patients 45 to 64 years of age depending on body region). Orthopedic surgeons conducted more musculoskeletal visits than any other physician specialty for all body regions. Among body regions, magnetic resonance imaging (MRI) studies were ordered most commonly for patients with shoulder (total visits in 100 000 ± standard error [SE] 47.00 ± 0.21; 12.5% of total visits for shoulders) and knee symptoms (61.85 ± 0.15; 11.4% of total visits for knees). Opioid and opioid analgesic combinations (9.2% to 14.8% of visits) were most commonly prescribed in visits related to hip complaints.

CONCLUSIONS

Visits were most frequent for knee symptoms and in patients of working age groups, which likely affects work productivity. Orthopedic surgeons were the most common provider specialty. Opioid medications were prescribed most commonly for patients with hip symptoms, which may highlight an area for potential intervention given the ongoing opioid crisis.

Primary care doctors' views on self-monitoring of blood pressure and self-titration among patients with uncontrolled hypertension in Spain. The ADAMPA trial focus group study

Background

Despite the increased use of blood pressure (BP) monitoring devices at home, the hypertension of more than 50% of European patients remains uncontrolled. Nevertheless, the self-management of BP, through the combination of home monitoring of BP with self-titration, could be anaccessible and effective tool for improving hypertension control in the primary care setting. The ADAMPA study is a trial with participants randomised to BP self-management (BPSM) with self-titration of antihypertensive medication or to usual care, in a population of patients with poorly controlled hypertension.

Aim

To explore the views and attitudes of primary care doctors participating in the ADAMPA trial regarding BPSM with self-titration.

Design & setting

A focus group study took place with primary care doctors participating in the ADAMPA trial, which was carried out in one health district of the Valencia Health System in Spain.

Method

Nine primary care doctors participating in the ADAMPA trial were included in the focus group. Three researchers (two using manual methods and one using NVivo software) independently conducted a content analysis, reading the transcripts, identifying, classifying, and coding the contents, and developing a conceptual scheme based on these topics.

Results

Participating doctors clearly support home BP monitoring (HBPM), the setting of individual BP targets, and incorporating patient readings into decision-making. They consider it an investment to educate patients for medication self-adjustment and estimate that an important proportion of their patients are potential candidates for hypertension self-management with medication self-titration. However, they show important divergences regarding the role of nursing in BP control.

Conclusion

Primary care doctors participating in the ADAMPA trial feel comfortable with BPSM with self-titration, and would consider extending its use (or the use of some components, such as BP target setting) to other patients with hypertension outside the trial.

Home blood pressure data visualization for the management of hypertension: designing for patient and physician information needs

Background

Nearly half of US adults with diagnosed hypertension have uncontrolled blood pressure. Clinical inertia may contribute, including patient-physician uncertainty about how variability in blood pressures impacts overall control. Better information display may support clinician-patient hypertension decision making through reduced cognitive load and improved situational awareness.

Methods

A multidisciplinary team employed iterative user-centered design to create a blood pressure visualization EHR prototype that included patient-generated blood pressure data. An attitude and behavior survey and 10 focus groups with patients (N = 16) and physicians (N = 24) guided iterative design and confirmation phases. Thematic analysis of qualitative data yielded insights into patient and physician needs for hypertension management.

Results

Most patients indicated measuring home blood pressure, only half share data with physicians. When receiving home blood pressure data, 88% of physicians indicated entering gestalt averages as text into clinical notes. Qualitative findings suggest that including a data visualization that included home blood pressures brought this valued data into physician workflow and decision-making processes. Data visualization helps both patients and physicians to have a fuller understanding of the blood pressure ‘story’ and ultimately promotes the activated engaged patient and prepared proactive physician central to the Chronic Care Model. Both patients and physicians expressed concerns about workflow for entering and using home blood pressure data for clinical care.

Conclusions

Our user-centered design process with physicians and patients produced a well-received blood pressure visualization prototype that includes home blood pressures and addresses patient-physician information needs. Next steps include evaluating a recent EHR visualization implementation, designing annotation functions aligned with users’ needs, and addressing additional stakeholders’ needs (nurses, care managers, caregivers). This significant innovation has potential to improve quality of care for hypertension through better patient-physician understanding of control and goals. It also has the potential to enable remote monitoring of patient blood pressure, a newly reimbursed activity, and is a strong addition to telehealth efforts.

On the transition from a nurse-led hypertension clinic to hypertension control in primary care: identifying barriers to and factors acting against continuous hypertension control

Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner's office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.

Hypertension-associated hospitalizations and costs in the United States, 1979-2006

BACKGROUND AND OBJECTIVE

In the USA, the prevalence of hypertension has been high and increasing in recent decades. Even so, little is known about the changes over time in hospitalizations and the economic burden associated with this epidemic. We examined hypertension-associated hospitalizations and costs from 1979 to 2006.

METHODS

Using the National Hospital Discharge Survey and the costs of community hospitals in the USA, we analyzed the changes in hypertension-associated hospitalizations and costs over time. We included those hospitalizations with a primary or secondary diagnosis of hypertension among patients aged 25 years and above. We examined changes in costs by adjusting them into year 2008 dollars. The costs included hospital expenses of payroll, employee benefits, professional fees and supplies.

RESULTS

From 1979-1982 to 2003-2006, the proportion of hospitalizations that were associated with hypertension (primary or secondary diagnosis) increased from 1.9% to 5.4%. Among all hypertension-associated hospitalizations, the proportion with a secondary diagnosis of hypertension increased from 81.8% to 95.1%. In 2008 dollars, annual costs for hypertension-related hospitalizations increased from US$40 billion (5.1% of total hospital costs) during 1979-1982 to US$113 billion (15.1% of total hospital costs) during 2003-2006.

CONCLUSIONS

Both the proportions of hospitalizations that were associated with hypertension and the adjusted annual costs of such hospitalizations nearly tripled over the past 28 years. The increases were in substantial measure due to the greatly increasing proportion of hospitalizations in which hypertension was listed as a secondary diagnosis. Interventions for the management of hypertension as a secondary diagnosis might be potentially cost-effective.

Receipt of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers among Medicare Beneficiaries with Diabetes and Hypertension

OBJECTIVES

The proportion of patients with diabetes and hypertension receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARB), is one of the quality measures for medication management employed by the Centers for Medicare and Medicaid Services to rate Medicare Part D plans. The objectives of this study were to determine the rate and predictors of receiving ACE/ARB in physician office and outpatient visits made by Medicare beneficiaries with diabetes and hypertension.

METHODS

The study population was Medicare beneficiaries with diabetes and hypertension from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department, from 2007 to 2009. Predictors of receiving ACE/ARB were determined using bivariate and multivariate logistic regression analysis.

KEY FINDINGS

Of the 6,311 Medicare outpatient and physician office visits with hypertension and diabetes, 40.70% patient visits were associated with receiving ACE/ARB. Bivariate analysis found that higher proportions of ACE/ARB were received during visits made to primary care physicians compared to visits to non-primary care physicians (48.39% vs. 32.56%; p<0.05). Adjusted multivariate analyses indicated that ACE/ARB were more likely to be received during visits to primary care physicians than visits to non-primary care physicians (odds ratio [OR]: 1.96; 95% confidence interval [CI]: 1.59-2.43), and ACE/ARB were more likely to be received during visits by patients residing in zip codes with median household income within Quartile 2 ($32,794-$40,626), compared to visits by patients residing in zip codes with median household income within Quartile 1 (< $32,793, OR: 1.45; 95% CI: 1.13-1.87).

CONCLUSIONS

Fewer than half of the patient visits were associated with receiving ACE/ARB. Promoting evidence-based medicine and increasing access to primary care may have the potential to increase the rates of receiving ACE/ARB in this population.

Trends in antihypertensive drug prescription patterns among ambulatory stroke patients in the United States, 2000-2009

BACKGROUND

Although the ambulatory setting is recognized as the best arena for optimizing antihypertensive drug treatment after a stroke, little is known about recent office-based antihypertensive drug treatment patterns in the United States. We assessed national trends in antihypertensive treatment for stroke patients in office-based medical practice.

METHODS

Data from the 2000-2009 National Ambulatory Medical Care Surveys were analyzed comprising outpatient visits to physicians in office-based practice by patients aged 40 years or older with a diagnosis of stroke (weighted estimate=46,317,269). The main outcome measure was visits with a prescription of antihypertensive medication(s).

RESULTS

The proportion of total visits that included a prescription of antihypertensive medication was 35.6% in 2000-2002, 29.5% in 2003-2005, and 49.3% in 2006-2009 (P=.002); 50.9% were primary care physician (PCP) visits versus 26.2% neurologist visits (P<.0001). Age-adjusted logistic regression analyses confirmed a higher prescription rate in 2006-2009 versus 2000-2002 (1.81; 95% confidence interval [CI], 1.10-2.96) and PCP versus neurologists (2.82; 95% CI, 1.86-4.27). Use of 2 or more agent classes was 31.6% in 2000-2002, 44.2% in 2003-2005, and 56.7% in 2006-2009 (P=.014). Age-adjusted logistic regression analyses confirmed a higher prescription rate of 2 or more agent classes in 2006-2009 versus 2000-2002 (2.96; 95% CI, 1.40-6.24). There were no significant differences in agent class type or number between neurologists versus PCPs.

CONCLUSIONS

Over the last decade, there was a significant rise in the use of antihypertensive drugs and combination of agent classes for patients aged 40 years or older seen in an ambulatory setting with a diagnosis of stroke. PCPs were more likely than neurologists to prescribe these agents.

Rationale for establishing a mechanism to increase reimbursement to hypertension specialists

Hypertension is an important public health problem both in the United States and worldwide, contributing to many forms of cardiovascular and renal diseases. Although great strides have been made in the proportion of the US population that achieves recommended blood pressure targets, many Americans still have undertreated and uncontrolled blood pressure that increases the risk of expensive strokes, heart attacks, heart failure, and dialysis. Because hypertension is a common but heterogeneous and sometimes complex condition, the American Society of Hypertension (ASH) has, since 1999, designated physicians as "ASH Hypertension Specialists." Such Hypertension Specialists (as defined by ASH's Specialist Program) are fully licensed physicians with a primary board certification who are competent in all aspects of the diagnosis and treatment of hypertension, as evidenced by passing a specific examination on these topics offered by ASH's Specialist Program. These physicians have a proven track record of controlling blood pressure in "resistant hypertensive" patients, the general population whom they serve, and educating other physicians to help them achieve higher blood pressure control rates among their patient populations. This report sets out a rationale for increased reimbursement for care of hypertensive patients by ASH-Designated Hypertension Specialists.

Blood pressure control in Italian essential hypertensives treated by general practitioners

BACKGROUND

Adequate control of blood pressure (BP) is limited worldwide. This has serious consequences for public health because in hypertensive patients, uncontrolled BP is associated with a higher incidence of cardiovascular events, particularly stroke. The aim of this study was to investigate BP control in a cohort of treated patients with diagnosed hypertension, who were under general practitioner care in Italy.

METHODS

Data were collected by 2,643 physicians on 8,572 individual Italian patients. Office BP was measured 5 min after seating each patient and then 3-5 min later. For each patient, data such as medical history of patients, physical examination data, antihypertensive drug usage, and self-BP measurement frequency were obtained.

RESULTS

Male prevalence was 48.4%, and mean age was 64.3 ± 10.5 years. Based on the second measurement, BP control (<140/90 mm Hg) was observed in 33.5% of all patients (34.2% in men and 33.4% in women). BP control was much lower for systolic BP than for diastolic BP (35.9 vs. 61.3%, P < 0.0001); moreover, BP control was much more common in patients who were engaged in self-BP measurement (61.2 vs. 38.8%, P < 0.0001). A stricter BP control recommended by the guidelines of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) (<130/80 mm Hg) was observed in only 5.5% of diabetic patients.

CONCLUSIONS

In treated Italian hypertensives effective BP control remains uncommon largely due to the failure to appropriately reduce the systolic BP. The stricter values recommended by the ESH/ESC guidelines for diabetic patients are achieved only by a small fraction of hypertensive diabetic population.

A novel approach to quality improvement in a safety-net practice: concurrent peer review visits

OBJECTIVE

Concurrent peer review visits are structured office visits conducted by clinician peers of the primary care clinician that are specifically designed to reduce competing demands, clinical inertia, and bias. We assessed whether a single concurrent peer review visit reduced clinical inertia and improved control of hypertension, hyperlipidemia, and diabetes control among underserved patients.

METHODS

We conducted a randomized encouragement trial to evaluate concurrent peer review visits with a community health center. Seven hundred twenty-seven patients with hypertension, hyperlipidemia, and/or diabetes who were not at goal for systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and/or glycated hemoglobin (A1c) were randomly assigned to an invitation to participate in a concurrent peer review visit or to usual care. We compared change in these measures using mixed models and rates of therapeutic intensification during concurrent peer review visits with control visits.

RESULTS

One hundred seventy-one patients completed a concurrent peer review visit. SBP improved significantly (p < .01) more among those completing concurrent peer review visits than among those who failed to respond to a concurrent peer review invitation or those randomized to usual care. There were no differences seen for changes in LDL-C or A1c. Concurrent peer review visits were associated with statistically significant greater clinician intensification of blood pressure (p < .001), lipid (p < .001), and diabetes (p < .005) treatment than either for control visits for patients in either the nonresponse group or usual care group.

CONCLUSIONS

Concurrent peer review visits represent a promising strategy for improving blood pressure control and improving therapeutic intensification in community health centers.

Physician characteristics as predictors of blood pressure control in patients enrolled in the hypertension improvement project (HIP)

The authors sought to examine the relationship between physician characteristics and patient blood pressure (BP) in participants enrolled in the Hypertension Improvement Project (HIP). In this cross-sectional study using baseline data of HIP participants, the authors used multiple linear regression to examine how patient BP was related to physician characteristics, including experience, practice patterns, and clinic load. Patients had significantly lower systolic BP (SBP) (-0.2 mm Hg for every 1% increase, P=.008) and diastolic BP (DBP) (-0.1 mm Hg for every 1% increase, P=.0007) when seen by physicians with a higher percentage of patients with hypertension. Patients had significantly higher SBP (0.8 mm Hg for every 1% increase, P=.002) when seen by physicians with a higher number of total clinic visits per day. Patients had significantly lower DBP (-4.4 mm Hg decrease, P=.0002) when seen by physicians with inpatient duties. Physician's volume of patients with hypertension was related to better BP control. However, two indicators of a busy practice had conflicting relationships with BP control. Given the increasing time demands on physicians, future research should examine how physicians with a busy practice are able to successfully address BP in their patients.

Fruits and vegetables intake and physical activity among hypertensive adults in the United States: behavioral risk factor surveillance system, 2003 and 2007

BACKGROUND

Consuming enough fruits and vegetables and engaging in regular physical activity are believed to be two important components of several lifestyle modifications for people with hypertension. The purpose of this study was to measure the degree to which US adults with hypertension achieved recommended intakes of fruits and vegetables and engaged in recommended levels of physical activity in 2003 and 2007.

METHODS

Using the Behavioral Risk Factor Surveillance System (BRFSS) data conducted in 2003 (N = 264,178) and 2007 (N = 430,082), we determined the changes in the prevalence of eating > or =5 servings of fruits and vegetables and of obtaining Healthy People 2010 recommended level of physical activity among adults with hypertension during the period.

RESULTS

In 2003 and 2007, among individuals with hypertension, age-adjusted prevalences of eating > or =5 servings of fruits and vegetables were 23.8 and 24.4% (P = 0.394) and meeting a recommended physical activity level were 38.2 and 40.3% (P < 0.001). With 2003 as the reference, odds ratios (95% confidence interval) of eating > or =5 servings of fruits and vegetables and meeting a recommended physical activity for 2007 were 1.02 (0.97-1.08) and 1.06 (1.01-1.10), respectively, after adjusting for relevant factors.

CONCLUSIONS

Among hypertensives, less than a quarter are eating five or more servings of fruits and vegetables per day, and less than half are meeting recommended physical activity. In 4 years, there was no statistically significant improvement in intake of fruits and vegetables and just a slight, albeit statistically significant, improvement in physical activity among US adults.

Lifestyle behaviors and receipt of preventive health care services among hypertensive Americans aged 45 years or older in 2007

OBJECTIVE.: The aim of the study was to explore opportunities for more effective interventions on lifestyle modifications among hypertensives. METHODS.: Using 2007 data from the Behavioral Risk Factor Surveillance System from the United States, we assessed the prevalence of various lifestyle behaviors and receipt of preventive health care services among US adults aged 45 years or older based on hypertension and treatment status (n=218,228). RESULTS.: Compared with nonhypertensives, hypertensives were significantly less likely to engage in recommended levels of physical activity and to be more obese regardless of treatment status. Compared to nonhypertensives, hypertensives on medical treatment were less likely to consume five or more servings of fruit and vegetables per day, be current smokers, and binge drinkers. Hypertensives not on medical treatment were more likely to be current smokers, binge and heavy drinkers. Hypertensives on medical treatment were more likely to have routine health checkup, have blood cholesterol checkup within previous 5 years and have a flu shot within the previous year than hypertensives not on treatment. CONCLUSION.: Different patterns of lifestyle behaviors and use of preventive health care services were found based on treatment status among hypertensives. Intervention programs should be tailored accordingly to achieve optimal outcome on lifestyle modification.

Competence of Polish primary-care doctors in the pharmacological treatment of hypertension

RATIONALE, AIMS AND OBJECTIVES

Compliance with treatment guidelines for hypertension is variable. This study assessed the competence of Polish general practitioners in compliance with hypertension treatment guidelines, and doctor and patient characteristics associated with compliance.

METHODS

The study was conducted on a random sample of Polish primary-care doctors working in clinics contracted by the national health insurance funds. Doctors completed a questionnaire consisting of eight case vignettes describing patients with elevated blood pressure. The cases differed on three variables relating to the level of blood pressure, the presence or absence of diabetes mellitus, and the presence or absence of other risk factors. Doctors were asked to give their treatment decision for each case. Demographic data and details of the doctor's practice were also collected. Treatment decisions were tabulated, and associations between doctor and patient characteristics and treatments were assessed.

RESULTS

One hundred twenty-five doctors (65% response rate) completed the questionnaire. Compliance with treatment guidelines was judged to be 51%. Poor compliance with guidelines was noted for patients with diabetes mellitus. The level of blood pressure was the strongest predictor of drug treatment. Angiotensin-converting enzyme inhibitors were the most frequently prescribed medications. Appropriate decisions were associated with practice in large cities.

CONCLUSIONS

Compliance with hypertension treatment guidelines was judged to be poor in this study of a sample of Polish primary-care doctors using case vignettes to test competence. Additional emphasis on hypertension guidelines in training doctors is needed, especially for diabetic patients and for doctors outside urban centres.

Improving outcomes in hypertensive patients: focus on adherence and persistence with antihypertensive therapy

Although effective control of blood pressure (BP) reduces the risk of cardiovascular events in patients with hypertension, BP control rates among treated patients in actual clinical practice are less than optimal. Although the costs of medicines and medical care (which are difficult to estimate both in clinical trials and general clinical practice) are important, medication-taking behavior--adherence and persistence with antihypertensive regimens--influences BP control rates. Many factors affect adherence and persistence with medications, including efficacy and tolerability of drugs prescribed, such that rates vary greatly among antihypertensive classes. In general, medications with fewer adverse effects (in registration trials or large outcomes studies) are associated with increased adherence and lower discontinuation rates. More widespread use of such agents, particularly those available in generic formulations or in low-cost formularies, may lead to better long-term BP control and fewer cardiovascular events.

Hypertensive crises

The key points of this article are: (1) A hypertensive crisis is present when markedly elevated blood pressure is accompanied by progressive or impending acute target organ damage. (2) Most instances of very elevated blood pressure encountered in the office setting will not be crises and will not require acute reduction of blood pressure. (3) Hypertensive crises are largely preventable and often result from inadequate management of hypertension or poor adherence to therapy. (4) Effective triage of patients into categories of severe hypertension, hypertensive urgency, and hypertensive emergency through an expeditious history, examination, and testing should guide therapy. (5) Hypertensive urgency is managed with oral medications and usually on an outpatient basis; a hypertensive emergency warrants intensive care unit admission and parenteral therapy. (6) Ensuring adequate follow-up after treatment of very elevated blood pressure is a critical step that is often mishandled.