Current European guidelines for management of arterial hypertension: are they adequate for use in primary care? Modelling study based on the Norwegian HUNT 2 population

Applying current European periodontitis clinical practice guidelines is not feasible even for the richest countries in the world

Clinical practice guidelines aim to enhance the quality, equality and consistency of care but often demand more time than is available, rendering adherence impractical and exceeding feasible resources. The 2017 introduction of a new periodontal classification system by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) sought to refine clinical and epidemiological practices by serving as the basis for clinical practice guidelines and epidemiological investigations around the world. Following this classification, the EFP recommends supportive periodontal care visits every 3-12 months for all periodontitis cases. Given that in Norway, approximately 72% of the adult population are identified as periodontitis cases under the current AAP/EFP case definition, this poses a significant demand on healthcare resources. We calculated that between 60% and 70% of all estimated available working hours available for adult dental care provided by dentists and dental hygienists in Norway in 2017 would be spent on supportive periodontal care visits alone if the recommendations were to be met. This situation calls for a reevaluation of disease definitions and clinical practice guidelines to ensure they are practical, financially feasible and patient-outcome relevant.

Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence

Background

Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice.

Methods

The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases.

Result

All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity.

Conclusions

Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.

Stroke follow-up in primary care: a prospective cohort study on guideline adherence

Background

After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines.

Methods

The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ (GPs’) medical records for these patients in the first year of follow-up; in total 381 consultations.

Results

Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded.

Conclusions

The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0872-9) contains supplementary material, which is available to authorized users.

Applying clinical guidelines in general practice: a qualitative study of potential complications

Background

Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines.

Methods

Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.

Results

The GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.

Conclusions

The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Is the quality of primary healthcare services influenced by the healthcare centre's type of ownership?-An observational study of patient perceived quality, prescription rates and follow-up routines in privately and publicly owned primary care centres

Background

Primary healthcare in Sweden has undergone comprehensive reforms, including freedom of choice regarding provider, freedom of establishment and increased privatisation aiming to meet demands for quality and availability. In this system privately and publicly owned primary care centres with different business models (for-profit vs non-profit) coexist and compete for patients, which makes it important to study whether or not the type of ownership influences the quality of the primary healthcare services.

Methods

In this retrospective observational study (April 2011 to January 2014) the patient perceived quality, the use of antibiotics and benzodiazepine derivatives, and the follow-up routines of certain chronic diseases were analysed for all primary care centres in Region Västra Götaland. The outcome measures were compared on a group level between privately owned (n = 86) and publicly owned (n = 114) primary care centres (PCC).

Results

In comparison with the group of publicly owned PCCs, the group of privately owned PCCs were characterized by: a smaller, but continuously growing share of the population served (from 32 to 36 %); smaller PCC population sizes (avg. 5932 vs. 9432 individuals); a higher fraction of PCCs located in urban areas (57 % vs 35 %); a higher fraction of listed citizens in working age (62 % vs. 56 %) and belonging to the second most affluent socioeconomic quintile (26 % vs. 14 %); higher perceived patient quality (82.4 vs. 79.6 points); higher use of antibiotics (6.0 vs. 5.1 prescriptions per 100 individuals in a quarter); lower use of benzodiazepines (DDD per 100 patients/month) for 20–74 year olds (278 vs. 306) and >74 year olds (1744 vs.1791); lower rates for follow-ups of chronic diseases (71.2 % vs 74.6 %). While antibiotic use decreased, the use of benzodiazepines increased for both groups over time.

Conclusions

The findings of this study cannot unambiguously answer the question of whether or not the quality is influenced by the healthcare centre’s type of ownership. It can be questioned whether the reform created conditions that encouraged quality improvements. Tendencies of an (unintended) unequal distribution of the population between the two groups with disparities in age, socio-economy and geography might lead to unpredictable effects. Further studies are necessary for evidence-informed policy-making.

Is there an association between disease ignorance and self-rated health? The HUNT Study, a cross-sectional survey

OBJECTIVE

To explore whether awareness versus unawareness of thyroid dysfunction, diabetes mellitus or hypertension is associated with self-rated health.

DESIGN

Large-scale, cross-sectional population-based study. The association between thyroid function, diabetes mellitus and blood pressure and self-rated health was explored by multiple logistic regression analysis.

SETTING

The second survey of the Nord-Trøndelag Health Study, HUNT2, 1995-1997.

PARTICIPANTS

33 734 persons aged 40-70 years.

PRIMARY OUTCOME MEASURES

Logistic regression was used to estimate ORs for good self-rated health as a function of thyroid status, diabetes mellitus status and blood pressure status.

RESULTS

Persons aware of their hypothyroidism, diabetes mellitus or hypertension reported poorer self-rated health than individuals without such conditions. Women with unknown and subclinical hypothyroidism reported better self-rated health than women with normal thyroid status. In women and men, unknown and probable diabetes as well as unknown mild/moderate hypertension was not associated with poorer health. Furthermore, persons with unknown severe hypertension reported better health than normotensive persons.

CONCLUSIONS

People with undiagnosed but prevalent hypothyroidism, diabetes mellitus and hypertension often have good self-rated health, while when aware of their diagnoses, they report reduced self-rated health. Use of screening, more sensitive tests and widened diagnostic criteria might have a negative effect on perceived health in the population.

Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study

BACKGROUND

Guidelines indicate eligibility for lipid lowering drugs, but it is not known to what extent GPs' follow guidelines in routine clinical practice or whether additional clinical factors systematically influence their prescribing decisions.

METHODS

A retrospective cohort analysis was undertaken using electronic primary care records from 421 UK general practices. At baseline (May 2008) patients were aged 30 to 74 years, free from cardiovascular disease and not taking lipid lowering drugs. The outcome was prescription of a lipid lowering drug within the next two years. The proportions of eligible and ineligible patients prescribed lipid lowering drugs were reported and multivariable logistic regression models were used to investigate associations between age, sex, cardiovascular risk factors and prescribing.

RESULTS

Of 365,718 patients with complete data, 13.8% (50,558) were prescribed lipid lowering drugs: 28.5% (21,101/74,137) of those eligible and 10.1% (29,457/291,581) of those ineligible. Only 41.7% (21,101/50,558) of those prescribed lipid lowering drugs were eligible. In multivariable analysis prescribing was most strongly associated with increasing age (OR for age ≥ 65 years 4.21; 95% CI 4.05-4.39); diabetes (OR 4.49; 95% CI 4.35-4.64); total cholesterol level ≥ 7 mmol/L (OR 2.20; 95% CI 2.12-2.29); and ≥ 4 blood pressure measurements in the past year (OR 4.24; 95% CI 4.06-4.42). The predictors were similar in eligible and ineligible patients.

CONCLUSIONS

Most lipid lowering drugs for primary prevention are prescribed to ineligible patients. There is underuse of lipid lowering drugs in eligible patients.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners

Background

Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks.

Methods

In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs’ preferences for time spent on preventive health care activities and age, gender and practice characteristics.

Results

Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs’ preferences for time spent on preventive health care services.

Conclusions

The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.

General medical practitioners' knowledge and beliefs about osteoporosis and its investigation and management

This qualitative study explored beliefs and attitudes regarding osteoporosis and its management. General medical practitioners (GPs) were ambivalent about osteoporosis due to concern about financial barriers for patients and their own beliefs about the salience of osteoporosis. GPs considered investigation and treatment in the context of patients' whole lives.

PURPOSE

We aimed to investigate barriers, enablers, and other factors influencing the investigation and management of osteoporosis using a qualitative approach. This paper analyses data from discussions with general medical practitioners (GPs) about their beliefs and attitudes regarding osteoporosis and its management.

METHODS

Fourteen GPs and two practice nurses aged 27-89 years participated in four focus groups, from June 2010 to March 2011. Each group comprised 3-5 participants, and discussions were semi-structured, according to the protocol developed for the main study. Discussion points ranged from the circumstances under which GPs would initiate investigation for osteoporosis and their subsequent actions to their views about treatment efficacy and patient adherence to prescribed treatment. Audio recordings were transcribed and coded for analysis using analytic comparison to identify the major themes.

RESULTS

The GPs were not particularly concerned about osteoporosis in their patients or the general population, ranking diabetes, osteoarthritis, cardiovascular disease, and hypertension higher than concern about osteoporosis. They expressed confidence in the efficacy of anti-fracture medications but were concerned about the potential financial burden on patients with limited incomes. The GPs were unsure about guidelines for investigation and management of osteoporosis in men and the appropriate duration of treatment, particularly for the bisphosphonates in all patients.

CONCLUSIONS

The GPs' ambivalence about osteoporosis appeared to stem from structural factors such as financial barriers for patients and their own beliefs about the salience of osteoporosis. GPs considered the impact of investigating and prescribing treatment in the context of patients' whole lives.

Patient and other factors influencing the prescribing of cardiovascular prevention therapy in the general practice setting with and without nurse assessment

BACKGROUND

Although guidelines indicate when patients are eligible for antihypertensives and statins, little is known about whether general practitioners (GPs) follow this guidance.

OBJECTIVE

To determine the factors influencing GPs decisions to prescribe cardiovascular prevention drugs.

DESIGN OF STUDY

Secondary analysis of data collected on patients whose cardiovascular risk factors were measured as part of a controlled study comparing nurse-led risk assessment (four practices) with GP-led risk assessment (two practices).

SETTING

Six general practices in the West Midlands, England.

PATIENTS

Five hundred patients: 297 assessed by the project nurse, 203 assessed by their GP.

MEASUREMENTS

Cardiovascular risk factor data and whether statins or antihypertensives were prescribed. Multivariable logistic regression models investigated the relationship between prescription of preventive treatments and cardiovascular risk factors.

RESULTS

Among patients assessed by their GP, statin prescribing was significantly associated only with a total cholesterol concentration ≥ 7 mmol/L and antihypertensive prescribing only with blood pressure ≥ 160/100 mm Hg. Patients prescribed an antihypertensive by their GP were five times more likely to be prescribed a statin. Among patients assessed by the project nurse, statin prescribing was significantly associated with age, sex, and all major cardiovascular risk factors. Antihypertensive prescribing was associated with blood pressures ≥ 140/90 mm Hg and with 10-year cardiovascular risk.

LIMITATIONS

Generalizability is limited, as this is a small analysis in the context of a specific cardiovascular prevention program.

CONCLUSIONS

GP prescribing of preventive treatments appears to be largely determined by elevation of a single risk factor. When patients were assessed by the project nurse, prescribing was much more consistent with established guidelines.

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

RATIONALE, AIMS AND OBJECTIVES

Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline.

METHODS

We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total).

RESULTS

Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern.

CONCLUSION

Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.

Hypertension 2010: what was new for the cardiologist?

IMPORTANCE OF THE FIELD

Despite extensive clinical research, still there is some uncertainty regarding management of hypertension, in particular initial and goal blood pressure levels and selection of optimal pharmacotherapy, as well as concomitant medications, to reduce other risk factors.

AREAS COVERED IN THIS REVIEW

An overview of recent findings from major clinical trials in hypertension (until July 2010), along with a reappraisal of the European Society of Hypertension 2009 guidelines.

WHAT THE READER WILL GAIN

Practical overview of the management of hypertension, including threshold and goal blood pressure in specific situations, choice of antihypertensive medications and indications for treatment of concomitant risk factors.

TAKE HOME MESSAGE

Primary benefits of antihypertensive therapy are mediated by blood pressure reduction and the majority of patients will require at least two drugs, with the preference of fixed-dose combinations for effective blood pressure control.

Who receives anticoagulant treatment with warfarin and why? A population-based study in Finland

OBJECTIVE

To ascertain the age and gender distribution of patients receiving anticoagulant (AC) treatment with warfarin, and to establish the prevalence of AC treatment and its indications among the Finnish population.

DESIGN

A cross-sectional study in which the patients were identified from the patient records of health centres.

SETTING

Primary health care in the Hospital District of South Ostrobothnia in Finland.

PATIENTS

Those inhabitants of 15 municipalities in the study area who received AC treatment with warfarin on 1 April 2004. The total number of inhabitants was 132 621 at the end of 2003.

MAIN OUTCOME MEASURES

Patient age and gender distributions, the prevalence of AC treatment in the study area, and indications for AC treatment.

RESULTS

Altogether 2389 patients were identified, 51.4% of them men. The mean age of the patients was 72.4 years. The prevalence of AC treatment was 1.8%; when age-adjusted to match the Finnish population it was 1.64%. The proportion of men receiving AC treatment was higher than that of women in all age groups. Atrial fibrillation (AF) was the most common main (60.2%) and second (7.2%) indication for AC treatment.

CONCLUSION

Compared with Finnish figures 12 years earlier the prevalence of AC treatment has more than doubled, and the proportion of AF among indications has increased from 47% to 67%. New current care guidelines on AF and the increasing proportion of the elderly among the population are probable explanations.