Why is my hypertensive patient still not controlled?

UNLABELLED: Despite the well-known obstacles to blood pressure (BP) control, significant improvement can be obtained. Unfortunately more than a third of hypertensive patients remain non-controlled even after improving initiatives. We asked a group of General Practitioners (GPs) why their patients failed to reach the target despite their efforts. METHODS: After an audit the control rate increased from 50.8 % to 64.1 %. The 18 participating GPs analyzed the 2,674 patients who remained non controlled (no available BP recording in the last year or last available recorded value ≥140/90 mmHg -office BP-, ≥135/85 mmHg -home BP-, ≥130/80 mmHg -ambulatory BP-) and filled a questionnaire about the reasons for patients' non-attendance and for lack of BP control. RESULTS: BP values were missing in 1,769 (66.1 %) patients; reasons: contact impossible (19 %), contacted, but did not attend (29 %), forgot to check BP (19 %), BP checked at home, but not recorded (10 %), patients cared for by specialists (12 %), the patient is a doctor or a doctor's relative (4 %), other (12 %). Among the other 905 (33.9 %) non-controlled subjects (with recorded BP) 23 % were prescribed with ≥3, and 10 % with ≥4 drugs. Reasons not to increase therapy were: patient choice (29 %), wait and see strategy/patient not stable yet (26 %), increase inappropriate (20 %), others caring for hypertension (9 %), secondary hypertension (5 %), reached maximum possible therapy (4 %), "resistant hypertension" (4 %), forgot to increase therapy (3 %), other (5 %). CONCLUSIONS: The priorities for further improvement are the patients who do not see their doctors (regularly), followed by those unwilling to increase their therapy.

How many hypertensive patients can be controlled in "real life": an improvement strategy in primary care.

BACKGROUND: It is well known that hypertension control is non-satisfactory, but it is not clear how many hypertensive patients can be controlled in real life. We addressed this question implementing a simple, multifaceted improvement strategy in family practice. METHODS: Eighteen General Practitioner (GPs) agreed upon a simple improvement strategy including: 1) the use of occasional direct/indirect contacts (prescription refilling) to decrease missing blood pressure (BP) recording, and to increase therapeutic adherence, 2) the use of home BP measurements in non-controlled patients, 3) the addition of a new drug in non-controlled, but adequately adherent patients. Results were assessed after one year by automatic data extraction from the clinical records of all hypertensive subjects. RESULTS: The patients with a diagnosis of hypertension increased from 6.309 (age 58.5 +/- 12.4; M 45.5%) to 6.717 (age 58.6 +/- 12.9; M 45.7%): prevalence 25.3% to 27.0%. The BP recording increased: 4,305 patients (68.2%) vs 4,948 patients (78.4%) (+ 10.2%, ci 9.4%-10.9%; p < 0.001), as well as the BP control: 3,203 (50.8% of all the diagnosed hypertensive patients and 74.4% of the subjects with recorded BP value) vs 4,043 (64.1% of all the diagnosed hypertensive patients and 81.7% of the subjects with recorded BP value) (+ 13.3%, ci 12.5%-14.2%; p < 0.001 and + 7.3%, ci 6.7%-8.0%; p < 0.001). CONCLUSIONS: Almost 82% of hypertensive subjects who contact their doctors can be easily controlled. Most non-controlled patients simply don't see their GPs; in almost all the remaining non-controlled patients GPs fail to increase drug therapy. A further improvement is therefore possible.

Obstructive sleep apnoea in patients with obesity and hypertension.

BACKGROUND: The links between obstructive sleep apnoea and hypertension are well established; obstructive sleep apnoea is reported in up to 30% of patients with hypertension, although it is frequently underdiagnosed. Physicians can assess the degree of sleepiness by administering the Epworth Sleepiness Scale, but the large number of patients with hypertension makes this strategy difficult for busy physicians to implement. Obese patients form a subgroup at higher risk for obstructive sleep apnoea, which can be targeted for screening. AIM: The study carried out a preliminary exploration of the effectiveness of screening patients with hypertension and obesity for obstructive sleep apnoea in general practice using the Epworth Sleepiness Scale. SETTING: One group practice in Italy. DESIGN OF STUDY: 'Good clinical practice' was systematically applied: identification of patients with hypertension and obesity; qualitative interview to identify obstructive sleep apnea; and consequent work-up and therapy. METHOD: Three family physicians, caring for 769 pharmacologically-treated patients with hypertension, identified 220 obese patients without relevant pulmonary or neurological diseases or insomnia; 31 of these 220 patients scored >11 on the Epworth Sleepiness Scale. RESULTS: Polysomnography confirmed obstructive sleep apnoea in 10% of the obese, hypertensive population (95% confidence interval [CI] = 7.03% to 13.63%), and in 3.9% of the whole hypertensive population (95% CI = 2.74% to 5.51%). At baseline, 24-hour blood pressure monitoring showed uncontrolled blood pressure in all these patients. Under continuous positive airway pressure (CPAP), the blood pressure value normalised (P<0.05), and the mean Epworth Sleepiness Scale score decreased significantly: mean 13.68 versus 7.84 (P<0.001). CONCLUSION: In obese patients with hypertension examined in this study, the prevalence of obstructive sleep apnoea prevalence is about 10%. CPAP significantly ameliorates the blood pressure control. This simple screening and treatment strategy may be easily adopted in primary care.