Hypertension in a family practice K.V. RUDNICK, MD; D.L. SACKETT, MD, M SC EPID; S. HIRST, RN; C. HOLMES, RN The performance of an urban Canadian family practice in the detection, evaluation, treatment, control and follow-up of hypertension for the 10-year period 1965-74 was reviewed. Vigorous case-finding and treatment were followed by good control of hypertension in 670/0 of cases and a significant decrease in mortality from stroke and congestive heart failure. It is strongly suggested that the proper location for dealing with hypertension is the primarycare practice and that the general practitioner deserves greater assistance from clinical specialists, health foundations and ministries of health in attacking this problem.
hypertension is to be conducted within the current structure of clinical and health care and is to be integrated with other health services, we must determine the ability of primary-care clinicians to deal with this problem. For this reason we have reviewed the last 10 years' experience of a family practice as it grappled with the detection, evaluation, management and control of hypertension. This review has led to the creation of a series of recommendations and these, along with the data .ipon which they are based, constitute the sLibstance of this report.
Le rendement d'une clinique de medecine familiale en milieu urbain dans Ia detection, l'evaluation, le traitement, le control et Ia surveillance de l'hypertension au cours d'une periode de 10 ans, soit de 1965 a 1974, a ete examine. Un bon control de l'hypertension dans 670/0 des cas et une baisse significative de Ia mortalite par accidents cerebrovasculaires et insuffisance cardiaque ont suivi un depistage et un traitement rigoureux. On suggere fortement que le secteur de premiere ligne est lendroit approprie pour s'occuper du probleme de l'hypertension et que le praticien general merite une plus grande assistance de Ia part des specialistes cliniques et des agences et ministeres de Ia sante en ce sens.
Methods
In the last few years articles on the detection, evaluation and treatment of hypertension have overrun clinical journals. Furthermore, these articles have exhibited three common features: I. They have stressed the relatively high frequency of this disorder, both as an entity and as a cause of disability and untimely death. 2. They have documented a failure of our system of clinical and health care, in the face of efficacious therapy, to identify, evaluate, treat and control even half of our hypertensive citizens. 3. They have tended to focus on either the community at large or the subspecialty hypertension clinic, rather than on the primary-care interface between these settings. If, however, the struggle to control From McMaster University Medical Centre, Hamilton Reprint requests to: Dr. K.V. Rudnick. Department of family medicine. Faculty of health sciences. McMaster University, 1200 Main St w, Hnmilton Ont t 85 4J9
The practice The practice under study has been described in detail elsewhere.' Briefly, it was established in 1955 in a residential section of Hamilton, an industrial city with a population of approximately 300 000. The practice is made up primarily of middle-class, white, AngloSaxon Protestants, almost all of whom had private medical insurance prior to 1969. In 1972 the practice moved to McMaster University Medical Centre and became one of several groups in the family practice unit; although its size subsequently decreased, the characteristics of its patients and their illnesses have remained constant. The head of the practice (K.V.R.) graduated from an Ontario medical school in 1951, completed junior and senior internships, and entered solo family practice in 1955. Prior to its move to the medical centre the team included a nurse (SR.) with considerable previous emergency-room experience, pluis a part-time secretary/receptionist/bookkeeper. At the time of the move the latter was replaced by a fLI 11-time receptionist, a part-time secretary and a part-time clinic aide, and a second nurse (C.H.) joined the practice. Both nurses have subsequently undergone formal training as nurse practitioners. The number of trainees on the team increased from an occasional medical student to a continuous stream of medical and nursing students and uip to four postgraduate trainees in family medicine. For purposes of this study, individuals were considered patients of the practice for the year in question if they appeared in an individual practice record and either had been seen by the
492 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117
team during the previous 2 years or had undergone annual health check-ups at work. Definitions Hypertension was considered present if the following systolic (first-phase) and diastolic (fifth-phase) blood pressures (in mm Hg) persisted as the lowest readings obtained after 15 to 20 minutes' rest on each of three separate office visits a few weeks apart: * 16 to 29 years: . 140/ . 90. * 30 to 69 years: . 160/ . 100. * 70 years or older: . 170/ . 100. Hypertension was classified as mild if the fifth-phase diastolic blood pressure was less than 105 mm Hg, moderate if between 105 and 119 mm Hg, and severe if 120 mm Hg or more. Hypertension was considered controlled if all diastolic measurements recorded for the year in question (save those obtained during the first 3 months of therapy in patients with newly diagnosed hypertension) were 90 mm Hg or less. Data All records (including abstracts of hospitalizations and death notes) generated in the practice between Jan. 1, 1965 and Dec. 31, 1974 were reviewed by the senior author (K.V.R.) for blood pressure measurements, reasons for patient encounters, diagnostic tests, diagnoses, treatments and cause-specific mortality, and data concerning the detection, evaluation, treatment, control and outcomes of hypertension were abstracted and analysed. Quality of care The qLlality of care provided to patients with hypertension by the practice was measured both before (1970-71) and after (1973-74) affiliation with the university by an independent research group. The method of this "indicatorcondition" strategy has been described elsewhere.2
Results The prevalence and the incidence of newly detected hypertension in the practice in 1965-74 are shown in Tables I and II, respectively. At the beginning of 1965 hypertension had already been diagnosed in 88 patients, and over the next 10 years the diagnosis was made in an additional 577
Table I Prevalence of hypertension in a family practice, 1965-74 % of patients with hypertensive blood pressure readings* or receiving antihypertensive therapy
Mean no. of patients in this group, 1965-74
Age (yr) and sex 16-19 106 M 109 F 20-29 407 M F 426 30-39 383 M 398 F 40-49 250 M 262 F 50-59 224 M 246 F 60-69 167 M 200 F 70+ 103 M 127 F Entire group *See text for definitions.
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
Mean, 1965-74
0 0
0 0
0 0
0 1.0
0 3.9
0 0
0 0.7
0 0
0 0
0 0
0 0.5
0 0
0 0.2
0.2 0.7
0.2 1.5
0.2 1.8
0.2 1.4
0.3 0.8
0 0
0 0.3
0.4 0.4
0.1 0.8
0.2 0.6
0.4 0.8
3.5 1.4
5.3 3.5
8.5 6.8
6.8 7.0
6.3 6.7
3.9 5.0
6.6 6.4
6.5 7.7
4.7 4.2
0.7 1.8
1.9 3.0
8.5 3.8
11 6.7
13 9.3
11 10
9.8 9.0
11 14
16 14
12 11
2.8 3.4
3.9 4.6
13 8.3
18 13
18 16
15 16
14 14
19 14
18 19
13 18
13 12
5.9 12 12 28 3.0
9.0 13
22 16 16 20 6.3
22 18 27 26 8.2
26 20
19 20 13 25 9.0
18 18 11 24 8.2
21 20
18 17 13 14 8.3
7 17 12 13 8.6
17 17 14 22 7.2
17 27 3.6
15 27 9.8
Table II Incidence of hypertension in the practice, 1965-74 No. of cases of newly detected hypertension per 1000 patients Age (yr) 1965 and sex 16-19 0 M 0 F 20-29 0 M 0 F 30-39 2 M 2 F 40-49 0 M 4 F 50-59 7 M 7 F 60-69 20 M 33 F 70 + M 27 57 F 9 Entire group
1966
1967
1968
1969
1970
1971
1972
1973
1974
0 0
0 0
0 10
0 29
0 0
0 8
0 0
0 0
0 0
0 2
2 6
0 6
0 6
0 2
0 0
0 0
0 3
4 0
2 2
30 4
30 20
34 35
4 8
6 12
13 13
41 27
4 4
13 16
69 13
37 29
30 31
16 15
19 9
32 28
101 42
6 10
22 26
94 40 136 45 45 0 31
81 44 87 26 30 7 27
38 34 53 26 26 27 25
15 10 5 13 0 7 7
20 27 18 5 23 9 10
28 15 21 23 0 0 11
64 71
13 6 9 7 14 8 6
37 18 43 15 11
16 7 0 10 28
13 16 7.8
9.0 7.6
Table V-Proportion of patients with hypertension receiving antihypertensive medication Laboratory test and findings
% with abnormal result 6.2 2.7 1.0 0 0.3
3.3 1.6 5.6 11 4.0 2.4 4.5 2.5 1.7 7.0 4.5 1.8 0.9 0.2 0.2 6.3 4.7 1.9 2.5 0.9 0.3 0.3 0.3 0.2 0.2
Table IV-Causes for hypertension in this practice and elsewhere
Cause Pheochromocytoma Cushing's syndrome Primary aldosteronism Coarctation of aorta Renovascular Renal parenchymal Oral contraceptives Post-poliomyelitis Hyperparathyroidism Essential hypertension
Among 665 patients in this practice 0 0.2 0 0.2 0.2 4.7 0.2 0.2 94.3
Frequency (%) Among 4939 patients referred to Cleveland Clinic3 0.2 0.3 0.4 0.6 4.4 5.2 0 0 88.9
Among random sample of 689 Swedish men4 0 0 0.1 0.1 0.6 4.6
0 0.3 94.3
Year 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974
No. with hypertension (and % receiving antihypertensive medication) 116 (78) 145 (97) 263 (96) 330 (99) 386 (94) 367 (95) 258 (98) 163 (96) 224 (98) 200 (100)
Table VI-Proportion of patients with hypertension in whom diastolic blood pressure (DOP) was maintained at or below 90 mm Hg throughouttheyear*
% of patients with blood pressure under good control Initial DBP (mm Hg) All patients with Year 105 hypertension 1965 56 61 57 1966 82 70 79 1967 66 72 67 1968 64 77 66 1969 66 73 67 1970 70 63 68 1971 70 75 72 1972 59 80 65 1973 59 72 63 1974 66 74 68 Overall 66 72 67 *Except for the first 3 months of therapy in patients with newly diagnosed hypertension.
Table VII Effort expended by the practice in caring for patients with hypertension 1965 No. of encounters* with patients more than 16 years old 8403 % of these encounters' devoted to care of hypertension 3.3 Mean no. of encounters' per year by patients with hypertension for care of hypertension 2.4 Rank of hypertension as cause of patient encounters* 12 *lncluding office or hospital visits plus house calls.
1966
1967
1968
1969
1970
1971
1972
1973
1974
8621
8734
8339
8274
8109
7425
5939
6584
6031
11
11
11
11
4.5
7.2
2.7
2.4
2.7
2.3
2.4
3.1
11
8
6
6
6
5
6.9
9.4
2.5
2.8
3.4
4
4
11
11
j..Des¶rurnxs* GEL .NtRA UTaouElEtACNE
U
quamuX
.j1AcweTREAtMwNTsffL".1,rIfl
PHARMACCUTiCALS BELLEVILLE,ONTARIOK8N5E9
for patient encounters (Table VII). Despite this shift in emphasis the quality of care provided for all patients in the practice was maintained throughout the period (Table VIII). Patients move and change physicians, and this can result in the interruption or even discontinuation of therapy. One quarter of the patients with hypertension detected in this practice moved away or otherwise changed physicians, and we took pains to achieve continuity of their antihypertensive therapy through contact with their new clinicians. We are convinced that the results obtained are worth the effort. Not only has it been possible to achieve good control of blood pressure in a high proportion of patients, but also the gratifying decline in the mortality attributed to stroke and heart failure (Fig. 1) suggests that the benefits to our patients have been real. Recommendations The review of this decade of effort has convinced us of the value of attacking hypertension in family and general practice. However, the primarycare clinician could do with more practical help from tertiary-care experts in hypertension, from interested lay groups and from government. We suggest the following: 1. Case-finding for hypertension should become a component of every patient encounter in primary care, and the encouragement of this approach to detection should take precedence over all others. * Citizens should be encouraged to have periodic checks of their blood pressure by their primary-care clinicians, and this information should become part of a lifetime health record. * Detection of hypertension should not be attempted in other settings and circumstances unless linkage to a source of work-up, therapy and longterm care is guaranteed. 2. Initial evaluation of the symptomless patient with hypertension should be limited to history-taking and physical examination, measurements of serum potassium and creatinine concentrations and urinalysis. An exhaustive search for secondary forms of hypertension should be carried out only if indicated by the initial evaluation or if the patient responds paradoxically or not at all to therapy. 3. Primary-care clinicians should commit themselves to the lifelong treatment, care and follow-up of patients with hypertension. 4. Under appropriate sponsorship from interested lay groups and ministries of health a working party of experts in the practical aspects of hypertension should summarize and dissem-
References
mate up-to-date information on the following: * Levels of blood pressure beyond which treatment does more good than harm (according to solid evidence from randomized clinical trials). * "Tried and true" treatment regimens of well established efficacy and safety, along with information on potential drug reactions, side effects and drug-drug interactions. * Strategies for detecting and improving low compliance (based on solid evidence from randomized clinical trials). * Validated systems, including clinical record systems and programs for the sharing of responsibility among team members, for the detection, evaluation, treatment and follow-up of hypertension. There should be an up-to-date central repository for this information so that it can be immediately available to the clinician. 5. Because of the mobility of patients with hypertension, research priority should be given to determining the value of a hypertension registry that would summarize pertinent baseline, diagnostic, treatment, compliance and side effects information on individual patients and (with consent) forward this information to other clinicians billing for the care of these patients.
1. RUON ICK KV, SPITZER WO, PIERCE J: Coniparison of a private family practice and university teaching practice. J Med Educ 51: 395. 1976 2. SleLE.' JC, SPITZER WO RUDNICK KV, et al: Quality-of-care appraisaf in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 3. Gin.oito RW: Evaluation of the hypertensive patient with emphasis on detecting curable causes. Mi/bank Men, Fund Q 47: 170, 1969 4. BERGLAND G, ANDER55ON 0, WILHELM5EN L: Prevalence of primary and secondary hypertension: studies in a random population sample. Br Med J 2: 554, 1976 5. TAYLOR JO: The Hypertension Detection and Follow-up Program (NHLBI), Cleveland,
Council for High Blood Pressure Research, Oct 1976 6. FRY J: The natural history of hypertension.
Lancet 2: 431, 1974 7. COOPE J: A screening clinic for hypertension in general practice. J R Coil Gen Pract 24:
161, 1974 J: Psychosocial consequences of blood pressure intervention: results after 6 months of treatment. Paper presented to the Society for Epidemiologic Research, June 15-18, 1976
8. MossEY
9. SACKETT DL, TAYLOR DW, HAYNES RB, et al: The short term disadvantage of being diagnosed hypertensive (abstr). J C/in Res 25:
266A, 1977
10. SACKETT DL:
Screening
for cardiovascular
disease. Lancet 2: 357, 1974 11. GIFFORD RW: Evaluation of the hypertensive patient. Chest 64: 336, 1973 12. LAIDLAW JC: Hypertension:
a challenge in
preventive medicine. I R Co// Physicians Lond 9: 41, 1974 13. STAMLER R, GoscH FC, STAMLER J, et al: Adherence and blood pressure response to hypertension treatment. Lancet 2: 1227, 1975 14. SACKETT DL, HAYNES RB: Comp/tance with Therapeutic Regimens, Baltimore, Johns Hopkins U Pr, 1976, p xi 15. HAYNES RB, SACKETr DL, GIBsON ES, et al: Improvement of medication compliance in uncontrolled hypertension. Lancet 1: 1265, 1976 16. SACKETIT DL, HAYNES RB, GIBSON ES, et al: A primer on compliance with antihyperten-
sive medications. Pract Cardiol 35: May 1976
*
THERAPrUTIC.
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FOR * *
SKIN CARE UR..A EAU SEC
A
.
I
£ 0
I 0
*; S :0
I U
0 S
*; 6
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PHARMACCUT1CAL. BELLEVILLE,ONTARIOK8N5E9 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117 497
hypertension is to be conducted within the current structure of clinical and health care and is to be integrated with other health services, we must determine the ability of primary-care clinicians to deal with this problem. For this reason we have reviewed the last 10 years' experience of a family practice as it grappled with the detection, evaluation, management and control of hypertension. This review has led to the creation of a series of recommendations and these, along with the data .ipon which they are based, constitute the sLibstance of this report.
Le rendement d'une clinique de medecine familiale en milieu urbain dans Ia detection, l'evaluation, le traitement, le control et Ia surveillance de l'hypertension au cours d'une periode de 10 ans, soit de 1965 a 1974, a ete examine. Un bon control de l'hypertension dans 670/0 des cas et une baisse significative de Ia mortalite par accidents cerebrovasculaires et insuffisance cardiaque ont suivi un depistage et un traitement rigoureux. On suggere fortement que le secteur de premiere ligne est lendroit approprie pour s'occuper du probleme de l'hypertension et que le praticien general merite une plus grande assistance de Ia part des specialistes cliniques et des agences et ministeres de Ia sante en ce sens.
Methods
In the last few years articles on the detection, evaluation and treatment of hypertension have overrun clinical journals. Furthermore, these articles have exhibited three common features: I. They have stressed the relatively high frequency of this disorder, both as an entity and as a cause of disability and untimely death. 2. They have documented a failure of our system of clinical and health care, in the face of efficacious therapy, to identify, evaluate, treat and control even half of our hypertensive citizens. 3. They have tended to focus on either the community at large or the subspecialty hypertension clinic, rather than on the primary-care interface between these settings. If, however, the struggle to control From McMaster University Medical Centre, Hamilton Reprint requests to: Dr. K.V. Rudnick. Department of family medicine. Faculty of health sciences. McMaster University, 1200 Main St w, Hnmilton Ont t 85 4J9
The practice The practice under study has been described in detail elsewhere.' Briefly, it was established in 1955 in a residential section of Hamilton, an industrial city with a population of approximately 300 000. The practice is made up primarily of middle-class, white, AngloSaxon Protestants, almost all of whom had private medical insurance prior to 1969. In 1972 the practice moved to McMaster University Medical Centre and became one of several groups in the family practice unit; although its size subsequently decreased, the characteristics of its patients and their illnesses have remained constant. The head of the practice (K.V.R.) graduated from an Ontario medical school in 1951, completed junior and senior internships, and entered solo family practice in 1955. Prior to its move to the medical centre the team included a nurse (SR.) with considerable previous emergency-room experience, pluis a part-time secretary/receptionist/bookkeeper. At the time of the move the latter was replaced by a fLI 11-time receptionist, a part-time secretary and a part-time clinic aide, and a second nurse (C.H.) joined the practice. Both nurses have subsequently undergone formal training as nurse practitioners. The number of trainees on the team increased from an occasional medical student to a continuous stream of medical and nursing students and uip to four postgraduate trainees in family medicine. For purposes of this study, individuals were considered patients of the practice for the year in question if they appeared in an individual practice record and either had been seen by the
492 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117
team during the previous 2 years or had undergone annual health check-ups at work. Definitions Hypertension was considered present if the following systolic (first-phase) and diastolic (fifth-phase) blood pressures (in mm Hg) persisted as the lowest readings obtained after 15 to 20 minutes' rest on each of three separate office visits a few weeks apart: * 16 to 29 years: . 140/ . 90. * 30 to 69 years: . 160/ . 100. * 70 years or older: . 170/ . 100. Hypertension was classified as mild if the fifth-phase diastolic blood pressure was less than 105 mm Hg, moderate if between 105 and 119 mm Hg, and severe if 120 mm Hg or more. Hypertension was considered controlled if all diastolic measurements recorded for the year in question (save those obtained during the first 3 months of therapy in patients with newly diagnosed hypertension) were 90 mm Hg or less. Data All records (including abstracts of hospitalizations and death notes) generated in the practice between Jan. 1, 1965 and Dec. 31, 1974 were reviewed by the senior author (K.V.R.) for blood pressure measurements, reasons for patient encounters, diagnostic tests, diagnoses, treatments and cause-specific mortality, and data concerning the detection, evaluation, treatment, control and outcomes of hypertension were abstracted and analysed. Quality of care The qLlality of care provided to patients with hypertension by the practice was measured both before (1970-71) and after (1973-74) affiliation with the university by an independent research group. The method of this "indicatorcondition" strategy has been described elsewhere.2
Results The prevalence and the incidence of newly detected hypertension in the practice in 1965-74 are shown in Tables I and II, respectively. At the beginning of 1965 hypertension had already been diagnosed in 88 patients, and over the next 10 years the diagnosis was made in an additional 577
Table I Prevalence of hypertension in a family practice, 1965-74 % of patients with hypertensive blood pressure readings* or receiving antihypertensive therapy
Mean no. of patients in this group, 1965-74
Age (yr) and sex 16-19 106 M 109 F 20-29 407 M F 426 30-39 383 M 398 F 40-49 250 M 262 F 50-59 224 M 246 F 60-69 167 M 200 F 70+ 103 M 127 F Entire group *See text for definitions.
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
Mean, 1965-74
0 0
0 0
0 0
0 1.0
0 3.9
0 0
0 0.7
0 0
0 0
0 0
0 0.5
0 0
0 0.2
0.2 0.7
0.2 1.5
0.2 1.8
0.2 1.4
0.3 0.8
0 0
0 0.3
0.4 0.4
0.1 0.8
0.2 0.6
0.4 0.8
3.5 1.4
5.3 3.5
8.5 6.8
6.8 7.0
6.3 6.7
3.9 5.0
6.6 6.4
6.5 7.7
4.7 4.2
0.7 1.8
1.9 3.0
8.5 3.8
11 6.7
13 9.3
11 10
9.8 9.0
11 14
16 14
12 11
2.8 3.4
3.9 4.6
13 8.3
18 13
18 16
15 16
14 14
19 14
18 19
13 18
13 12
5.9 12 12 28 3.0
9.0 13
22 16 16 20 6.3
22 18 27 26 8.2
26 20
19 20 13 25 9.0
18 18 11 24 8.2
21 20
18 17 13 14 8.3
7 17 12 13 8.6
17 17 14 22 7.2
17 27 3.6
15 27 9.8
Table II Incidence of hypertension in the practice, 1965-74 No. of cases of newly detected hypertension per 1000 patients Age (yr) 1965 and sex 16-19 0 M 0 F 20-29 0 M 0 F 30-39 2 M 2 F 40-49 0 M 4 F 50-59 7 M 7 F 60-69 20 M 33 F 70 + M 27 57 F 9 Entire group
1966
1967
1968
1969
1970
1971
1972
1973
1974
0 0
0 0
0 10
0 29
0 0
0 8
0 0
0 0
0 0
0 2
2 6
0 6
0 6
0 2
0 0
0 0
0 3
4 0
2 2
30 4
30 20
34 35
4 8
6 12
13 13
41 27
4 4
13 16
69 13
37 29
30 31
16 15
19 9
32 28
101 42
6 10
22 26
94 40 136 45 45 0 31
81 44 87 26 30 7 27
38 34 53 26 26 27 25
15 10 5 13 0 7 7
20 27 18 5 23 9 10
28 15 21 23 0 0 11
64 71
13 6 9 7 14 8 6
37 18 43 15 11
16 7 0 10 28
13 16 7.8
9.0 7.6
Table V-Proportion of patients with hypertension receiving antihypertensive medication Laboratory test and findings
% with abnormal result 6.2 2.7 1.0 0 0.3
3.3 1.6 5.6 11 4.0 2.4 4.5 2.5 1.7 7.0 4.5 1.8 0.9 0.2 0.2 6.3 4.7 1.9 2.5 0.9 0.3 0.3 0.3 0.2 0.2
Table IV-Causes for hypertension in this practice and elsewhere
Cause Pheochromocytoma Cushing's syndrome Primary aldosteronism Coarctation of aorta Renovascular Renal parenchymal Oral contraceptives Post-poliomyelitis Hyperparathyroidism Essential hypertension
Among 665 patients in this practice 0 0.2 0 0.2 0.2 4.7 0.2 0.2 94.3
Frequency (%) Among 4939 patients referred to Cleveland Clinic3 0.2 0.3 0.4 0.6 4.4 5.2 0 0 88.9
Among random sample of 689 Swedish men4 0 0 0.1 0.1 0.6 4.6
0 0.3 94.3
Year 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974
No. with hypertension (and % receiving antihypertensive medication) 116 (78) 145 (97) 263 (96) 330 (99) 386 (94) 367 (95) 258 (98) 163 (96) 224 (98) 200 (100)
Table VI-Proportion of patients with hypertension in whom diastolic blood pressure (DOP) was maintained at or below 90 mm Hg throughouttheyear*
% of patients with blood pressure under good control Initial DBP (mm Hg) All patients with Year 105 hypertension 1965 56 61 57 1966 82 70 79 1967 66 72 67 1968 64 77 66 1969 66 73 67 1970 70 63 68 1971 70 75 72 1972 59 80 65 1973 59 72 63 1974 66 74 68 Overall 66 72 67 *Except for the first 3 months of therapy in patients with newly diagnosed hypertension.
Table VII Effort expended by the practice in caring for patients with hypertension 1965 No. of encounters* with patients more than 16 years old 8403 % of these encounters' devoted to care of hypertension 3.3 Mean no. of encounters' per year by patients with hypertension for care of hypertension 2.4 Rank of hypertension as cause of patient encounters* 12 *lncluding office or hospital visits plus house calls.
1966
1967
1968
1969
1970
1971
1972
1973
1974
8621
8734
8339
8274
8109
7425
5939
6584
6031
11
11
11
11
4.5
7.2
2.7
2.4
2.7
2.3
2.4
3.1
11
8
6
6
6
5
6.9
9.4
2.5
2.8
3.4
4
4
11
11
j..Des¶rurnxs* GEL .NtRA UTaouElEtACNE
U
quamuX
.j1AcweTREAtMwNTsffL".1,rIfl
PHARMACCUTiCALS BELLEVILLE,ONTARIOK8N5E9
for patient encounters (Table VII). Despite this shift in emphasis the quality of care provided for all patients in the practice was maintained throughout the period (Table VIII). Patients move and change physicians, and this can result in the interruption or even discontinuation of therapy. One quarter of the patients with hypertension detected in this practice moved away or otherwise changed physicians, and we took pains to achieve continuity of their antihypertensive therapy through contact with their new clinicians. We are convinced that the results obtained are worth the effort. Not only has it been possible to achieve good control of blood pressure in a high proportion of patients, but also the gratifying decline in the mortality attributed to stroke and heart failure (Fig. 1) suggests that the benefits to our patients have been real. Recommendations The review of this decade of effort has convinced us of the value of attacking hypertension in family and general practice. However, the primarycare clinician could do with more practical help from tertiary-care experts in hypertension, from interested lay groups and from government. We suggest the following: 1. Case-finding for hypertension should become a component of every patient encounter in primary care, and the encouragement of this approach to detection should take precedence over all others. * Citizens should be encouraged to have periodic checks of their blood pressure by their primary-care clinicians, and this information should become part of a lifetime health record. * Detection of hypertension should not be attempted in other settings and circumstances unless linkage to a source of work-up, therapy and longterm care is guaranteed. 2. Initial evaluation of the symptomless patient with hypertension should be limited to history-taking and physical examination, measurements of serum potassium and creatinine concentrations and urinalysis. An exhaustive search for secondary forms of hypertension should be carried out only if indicated by the initial evaluation or if the patient responds paradoxically or not at all to therapy. 3. Primary-care clinicians should commit themselves to the lifelong treatment, care and follow-up of patients with hypertension. 4. Under appropriate sponsorship from interested lay groups and ministries of health a working party of experts in the practical aspects of hypertension should summarize and dissem-
References
mate up-to-date information on the following: * Levels of blood pressure beyond which treatment does more good than harm (according to solid evidence from randomized clinical trials). * "Tried and true" treatment regimens of well established efficacy and safety, along with information on potential drug reactions, side effects and drug-drug interactions. * Strategies for detecting and improving low compliance (based on solid evidence from randomized clinical trials). * Validated systems, including clinical record systems and programs for the sharing of responsibility among team members, for the detection, evaluation, treatment and follow-up of hypertension. There should be an up-to-date central repository for this information so that it can be immediately available to the clinician. 5. Because of the mobility of patients with hypertension, research priority should be given to determining the value of a hypertension registry that would summarize pertinent baseline, diagnostic, treatment, compliance and side effects information on individual patients and (with consent) forward this information to other clinicians billing for the care of these patients.
1. RUON ICK KV, SPITZER WO, PIERCE J: Coniparison of a private family practice and university teaching practice. J Med Educ 51: 395. 1976 2. SleLE.' JC, SPITZER WO RUDNICK KV, et al: Quality-of-care appraisaf in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 3. Gin.oito RW: Evaluation of the hypertensive patient with emphasis on detecting curable causes. Mi/bank Men, Fund Q 47: 170, 1969 4. BERGLAND G, ANDER55ON 0, WILHELM5EN L: Prevalence of primary and secondary hypertension: studies in a random population sample. Br Med J 2: 554, 1976 5. TAYLOR JO: The Hypertension Detection and Follow-up Program (NHLBI), Cleveland,
Council for High Blood Pressure Research, Oct 1976 6. FRY J: The natural history of hypertension.
Lancet 2: 431, 1974 7. COOPE J: A screening clinic for hypertension in general practice. J R Coil Gen Pract 24:
161, 1974 J: Psychosocial consequences of blood pressure intervention: results after 6 months of treatment. Paper presented to the Society for Epidemiologic Research, June 15-18, 1976
8. MossEY
9. SACKETT DL, TAYLOR DW, HAYNES RB, et al: The short term disadvantage of being diagnosed hypertensive (abstr). J C/in Res 25:
266A, 1977
10. SACKETT DL:
Screening
for cardiovascular
disease. Lancet 2: 357, 1974 11. GIFFORD RW: Evaluation of the hypertensive patient. Chest 64: 336, 1973 12. LAIDLAW JC: Hypertension:
a challenge in
preventive medicine. I R Co// Physicians Lond 9: 41, 1974 13. STAMLER R, GoscH FC, STAMLER J, et al: Adherence and blood pressure response to hypertension treatment. Lancet 2: 1227, 1975 14. SACKETT DL, HAYNES RB: Comp/tance with Therapeutic Regimens, Baltimore, Johns Hopkins U Pr, 1976, p xi 15. HAYNES RB, SACKETr DL, GIBsON ES, et al: Improvement of medication compliance in uncontrolled hypertension. Lancet 1: 1265, 1976 16. SACKETIT DL, HAYNES RB, GIBSON ES, et al: A primer on compliance with antihyperten-
sive medications. Pract Cardiol 35: May 1976
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PHARMACCUT1CAL. BELLEVILLE,ONTARIOK8N5E9 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117 497
