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

Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Systematic Review

Background

Long-term care for patients with chronic diseases poses a huge challenge in primary care. In particular, there is a deficit regarding monitoring and structured follow-up. Appropriate electronic medical records (EMRs) could help improving this but, so far, there are no evidence-based specifications concerning the indicators that should be monitored at regular intervals.

Objective

The aim was to identify and collect a set of evidence-based indicators that could be used for monitoring chronic conditions at regular intervals in primary care using EMRs.

Methods

We searched MEDLINE (Ovid), Embase (Elsevier), the Cochrane Library (Wiley), the reference lists of included studies and relevant reviews, and the content of clinical guidelines. We included primary studies and guidelines reporting about indicators that allow for the assessment of care and help monitor the status and process of disease for five chronic conditions, including type 2 diabetes mellitus, asthma, arterial hypertension, chronic heart failure, and osteoarthritis.

Results

The use of the term “monitoring” in terms of disease management and long-term care for patients with chronic diseases is not widely used in the literature. Nevertheless, we identified a substantial number of disease-specific indicators that can be used for routine monitoring of chronic diseases in primary care by means of EMRs.

Conclusions

To our knowledge, this is the first systematic review summarizing the existing scientific evidence on the standardized long-term monitoring of chronic diseases using EMRs. In a second step, our extensive set of indicators will serve as a generic template for evaluating their usability by means of an adapted Delphi procedure. In a third step, the indicators will be summarized into a user-friendly EMR layout.

Quality of care in primary health care settings in the Eastern Mediterranean region: a systematic review of the literature

PURPOSE

This systematic review aims at offering a comprehensive synthesis of studies addressing quality of care in the primary healthcare (PHC) sector of the Eastern Mediterranean Region (EMR).

DATA SOURCES

A systematic search was conducted using Medline, Embase and Global Health Library (IMEMR) electronic databases to identify studies related to quality in PHC between years 2000 and 2012.

STUDY SELECTION/DATA EXTRACTION

One hundred and fifty-nine (159) studies fulfilled the eligibility criteria. Each paper was independently reviewed by two reviewers, and the following information was extracted/calculated: dimension of care investigated (structure, processes and outcomes), focus, disease groups, study design, sample size, unit of analysis, response rate, country, setting (public or private) and level of rigor (LOR) score.

RESULTS OF DATA SYNTHESIS

Most of the studies were descriptive/cross-sectional in nature with a relatively modest LOR score. Assessment of quality of care revealed that the process dimension of quality, specifically clinical practice and patient-provider relationship, is an area of major concern. However, interventions targeting enhanced quality in PHC in the EMR countries had favorable and effective outcomes in terms of clinical practice.

CONCLUSION

These findings highlight gaps in evidence on quality in PHC in the EMR; such evidence is key for decision-making. Researchers and policy-makers should address these gaps to generate contextualized information and knowledge that ensures relevance and targeted high-impact interventions.

Overcoming barriers in the management of hypertension: the experience of the cardiovascular health program in chilean primary health care centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

Hypertension and type 2 diabetes: what family physicians can do to improve control of blood pressure--an observational study

BACKGROUND

The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.

METHODS

We conducted a practice-based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient's medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).

RESULTS

Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.

CONCLUSIONS

When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Quality of type 2 diabetes management in the states of the Co-operation Council for the Arab States of the Gulf: a systematic review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.

Treatment and blood pressure control in 47,964 people with diabetes and hypertension: a systematic review of observational studies

BACKGROUND

Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes.

OBJECTIVE

To examine treatment and control of hypertension in people with diabetes.

DATA SOURCES

Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites.

METHOD

Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently.

RESULTS

A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control--160/90 mmHg or less--reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings.

CONCLUSIONS

Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.

Pitfalls in blood pressure measurement in daily practice

BACKGROUND

Accurate blood pressure (BP) readings and correctly interpreting the obtained values are of great importance. However, there is considerable variation in the different BP measuring methods suggested in guidelines and used in hypertension trials.

OBJECTIVE

To compare the different methods used to measure BP; measuring once, the method used for a large study such as the UKPDS, and the methods recommended by various BP guidelines.

METHODS

In 223 patients with type 2 diabetes from five family practices BP was measured according to a protocol to obtain the following data: A = first reading, B = mean of two initial readings, C = at least four readings and the mean of the last three readings with less than 15% coefficient of variation difference, D = mean of the first two consecutive readings with a maximum of 5 mm Hg difference. Mean outcomes measure is the mean difference between different BP measuring methods in mm Hg.

RESULTS

Significant differences in systolic/diastolic BP were found between A and B [mean difference (MD) systolic BP 1.6 mm Hg, P < 0.001], B and C (MD 5.7/2.8 mm Hg, P < 0.001), B and D (MD 6.2/2.8 mm Hg, P < 0.001), A and C (MD 7.3/3.3 mm Hg), and A and D (MD 7.9/3.0 mm Hg, P < 0.001).

CONCLUSION

Different methods to assess BP during one visit in the same patient lead to significantly different BP readings and can lead to overestimation of the mean BP. These differences are clinically relevant and show a gap between different methods in trials, guidelines and daily practice.

Comparison of the quality of diabetes care in primary care diabetic clinics and general practice clinics

OBJECTIVES

To compare the quality of care provided to diabetic hypertensive patients by diabetic clinics versus general practice clinics (GP-clinics) in a primary care setting.

MATERIALS AND METHODS

A retrospective analysis of medical records of patients from six primary care centres in Bahrain.

RESULTS

The recommended target blood pressure <130/85 mmHg was achieved in 6.8 and 10%, and glycated haemoglobin <7% was attained in 14.8 and 11% of patients attending diabetic clinics (n=177) and GP-clinics (n=180), respectively. Although complementary antihypertensive combinations were prescribed at a rate less than that recommended in guidelines, combinations were significantly more often prescribed for patients attending the GP-clinics (46.7% [95% CI 39.4-53.9] versus 33.4% [CI 26.8-40.6]; p=0.01). The prescribing pattern and rank-order of antihypertensive and oral hypoglycaemic agents prescribed, either as monotherapy or in combinations, were similar in both clinics. The majority of diabetic hypertensive patients attending diabetic clinics or GP-clinics were at high cardiovascular risk. Anthropometric characteristics were recorded consistently in patients attending diabetic clinics. Laboratory investigations were extensively utilized for monitoring patients attending diabetic clinics.

CONCLUSIONS

In primary care, in both diabetic clinics and GP-clinics, hypertension and diabetes were inadequately controlled, with no difference between the two settings. An integrated approach involving diabetic clinics managed by primary care physicians and nurses trained in diabetes management, and supported by national guidelines, is needed.