Treatment of 5413 hypertensive patients: a cross-sectional study.

BACKGROUND: Most hypertensive patients are managed in primary care in Denmark, but previous studies have shown that only 21-43% of hypertensive patients achieve optimal blood pressure (BP) control. Antihypertensive drug treatment, risk factors and cardiovascular disease (CVD) are some of the important factors to consider when optimizing the individual treatment strategy in hypertensive patients. OBJECTIVE: To examine treatment of BP according to Danish guidelines (BP < 140/90 mmHg generally and <130/80 mmHg for diabetics) in a population from general practice in relation to risk factors, CVD and diagnosis of diabetes. METHODS: A cross-sectional study comprising 184 practices and 5413 hypertensive patients was carried out in Denmark. The general practitioners filled in information on each patient's risk factors, CVD and antihypertensive drug treatment. Patients filled in a questionnaire on risk factors. The outcome measures were optimal BP control according to Danish guidelines and antihypertensive drug treatment. RESULTS: Mean patient age was 65.9 years [95% confidence interval (CI): 65.6-66.1]. Optimal BP control was achieved in 29.1% (95% CI: 27.9-30.3) of the study population. Among 842 diabetics with or without CVD, optimal BP control was achieved in 10.9% (95% CI: 8.8-10.3), while 38.7% (35.5-41.9) of patients with CVD achieved optimal BP control. The majority of all patients were treated with 1 (32.5%, 95% CI: 32.5 (31.3-33.8)) or two antihypertensive drugs (39.0%, 95% CI: 38.2-40.8). In hypertensive diabetics, 17.7% were not treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. CONCLUSION: In general practice, the proportion of hypertensive patients achieving optimal BP control is inadequate. The majority of hypertensive patients are treated with only one or two antihypertensive drugs.

Congruence on medication between patients and physicians involved in patient course.

OBJECTIVE: To analyse congruence on medication throughout patient courses, including an acute admission to a medical department. DESIGN: A prospective, observational study. Data were collected from patient records in primary health care, hospital departments, from the Health Insurance database and through patient interviews. SETTING: Departments of internal medicine, general practice and patients' homes. MAIN OUTCOME MEASURES: Number, type and character of discrepancies between paired sources of information on patient medication at predefined time points throughout the complete patient course. Assessment of likelihood and severity of potential untoward effects of discrepancies. RESULTS: Data were obtained for 75 of 99 consecutive patients included. Patients stated use of four drugs (median, range 0-17) at admission, five (0-16) at discharge and four (0-15) 1 month after discharge. At admission, 11 patients used no drugs. A median of one (0-20) to three (0-16) discrepancies per patient were identified in seven paired source comparisons with no improvement along patient course. Full agreement throughout the course was found in six patients (8%; 95% confidence interval: 3-17%). No association was found among source discrepancies and number of drugs and age. Of discrepancies, 4-13% were considered serious and likely to cause untoward effects. Discrepancies due to synonymous and analogous drugs accounted for 2-7% of the discrepancies. CONCLUSION: Congruence between sources of information on medication throughout patient courses cannot be obtained with separate medication charts. Discrepancies among patient, general practitioner and hospital give rise to a definitive risk of serious untoward effects.

[Antibiotic treatment of infections in general practice. Effect of audit assessed by prescriptions data from health insurance registry and physicians' own registration]. / Antibiotikabehandling af infektioner i almen praksis. Effekten af audit bedømt ved ordinationsdata fra Sygesikringens register og laegernes selvregistrering.

The aim was to study whether an audit of treatment of infections in general practice resulted in changed prescribing habits. In 1995-1996 forty-six general practitioners (GP's) from the County of Roskilde participated in an audit regarding infectious diseases (incl. course participation and preparation of treatment guidelines). The effect evaluation was done on the basis of 1) two self-registrations of antibiotic prescriptions carried out with one year's interval, and 2) prescribing data from the National Insurance database collected over two periods, before the first and second self-registration respectively. The number of patients not receiving antibiotics increased significantly from 47.2% to 52.4% after intervention. The self-registration did not show any change in choice of antibiotics, while the registry data showed a shift from broad-spectrum to narrow-spectrum penicillin. This change was, however, also found among the GP's, who did not participate in the audit. The study demonstrated that audit can result in changes in prescribing patterns, but at the same time emphasizes the need for inclusion of external data sources and control groups in the evaluation of intervention effects.

[Benzodiazepine consumption in Hvalsø. Can it be further reduced in a region in which earlier intervention reduced consumption by 38 per cent?]. / Benzodiazepinforbruget i Hvalsø. Kan forbruget reduceres yderligere i et område, hvor det tidligere er nedsat med 38%?

Hvalsø is a country town with six general practitioners in five practices. In 1988, as a result of a campaign influencing both doctors and patients, a 38% reduction in the consumption of benzodiazepines, measured as the number of prescribed doses, was achieved. This reduction still persists. We have now attempted to reduce consumption even further by directly influencing the individual users. We gave them written information, insisted on personal attendance for each prescription renewal, and, for use at these consultations, introduced a new benzodiazepine journal for 60% of the users. Registration of the prescribed amounts of benzodiazepines was performed over two three-month periods, before and after the intervention. The final registration was made six months after the intervention period. The number of prescriptions, number of prescriptions per 1000 patients and the number of users remained unchanged. A 20% reduction in the amount of prescribed sedatives (hypnotics) and a 7% reduction in prescribed minor tranquillizers was achieved because of fewer doses per prescription. We conclude, that we did not manage to change the patients' behaviour, expressed as the number of prescriptions per 1000 patients, but the doctors were influenced to write out fewer doses per prescription. Important reductions in consumption may be achieved in primary interventions.

[Drug utilization in Hvalsö. An attempt to change the attitude of the population and physicians to drug use]. / Medicinforbrug i Hvalsø. Forsøg på holdningsaendring i befolkningen og blandt laeger til brug af laegemidler.

All of the prescriptions, a total of 1,876, issued by the five practitioners in Hvalsø in four chosen weeks in 1987/88 were copied. The prescribed drugs, a total of 3,177, were calculated for the individual groups of drugs and corrected for the age distribution among the population as a whole and in the individual doctor's practice. The main results from the following groups of drugs are presented here: hypnotics, drugs for neurosis, antibiotics, drugs for cardiac and circulatory disease, drugs for asthma, contraceptive pills and female sex hormones. By and large, considerably more medicine was prescribed for women than for men. For example, twice as much medicine for insomnia was prescribed for women. This is enough for every fourth woman over the age for 70 years to receive a daily dose of hypnotics. Women appear to commence using hypnotics at the age of 40 years and men at 60 years. Marked differences were found in the patterns of prescription between the individual practitioners and thei is apparently greatest as regards prescriptions for men while the more liberal prescription of hypnotics to women was observed for all of the practitioners. Two groups of drugs were, however, prescribed mostly for men, viz, asthma medicine for all age groups and cardiac and circulatory medicine for persons greater than 60 years. Where all of the groups of drugs were concerned, comparisons were undertaken between the prescription habits of the individual practitioners. The results of this investigation are employed in local health work among the population, in study circle work among the practitioners and as basic ideas for the county drug committee activities.

A comparison of the properties of renin isolated from pig and rat kidney.

1. On isoelectric focusing, renin from rat kidneys showed three activity peaks with pI values at pH 5.0, 5.2 and 5.4 after a purification procedure involving differential centrifugation, acidification, chromatography on Sephadex G-75 and dialysis. 2. The preparation (purified 140-fold) was compared with a crude kidney extract in the absence and presence of 3 M-urea by isoelectric focusing. The pattern of activity distribution was confirmed by these experiments and the content of isoenzymes in the three groups calculated. 3. Pig renin was prepared and compared with rat renin with regard to molecular weight, acid activation, behaviour on isoelectric focusing, immunogenicity and substrate affinity. 4. Extracts of rat kidney contained multiple forms of renin with mol.wt. between 39000and 42000, whereas active pig renin had an approximate mol.wt. of 40000. Acidification of rat renal extracts did not increase the activity of renin, indicating the absence of an inactive form of renin in rat kidneys, whereas pig renin was activated by this procedure. Pig renin has isoelectric points at pH 4.6, 4.8, 5.05 and 5.2, significantly lower than for rat renin. The isoenzymes from the two species had no antigenicity in common, as shown by crossed immunoelectrophoresis or rocket immunoelectrophoresis. 5. The Michaelis constants for pig and rat renin were in the same range, 1 X 10(-6) M, when rat renin substrate was used. The relative content of rat isoenzyme with pI in the pH ranges 4.9-5.1, 5.1-5.3 and 5.3-5.5 was approx. 20, 27 and 53% respectively. Purified pig renin prepared in two different ways had isoenzymes with pI in the pH regions 4.5-4.7, 4.7-4.9, 4.9-5.05 and 5.05-5.20 in the approximate proportions 14, 24, 28 and 29%.