Clinical and Experimental Hypertension. Part A: Theory and Practice
ISSN: 0730-0077 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iceh19
Impediments to the Control of Hypertension Thomas Strasser & Lars Wilhelmsen To cite this article: Thomas Strasser & Lars Wilhelmsen (1992) Impediments to the Control of Hypertension, Clinical and Experimental Hypertension. Part A: Theory and Practice, 14:1-2, 193-212, DOI: 10.3109/10641969209036182 To link to this article: http://dx.doi.org/10.3109/10641969209036182
Published online: 03 Jul 2009.
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Date: 22 May 2016, At: 19:43
CLIN. AND EXPER. HYPER.-THEORY AND PRACTICE, A14(1&2),
193-212 (1992)
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION Thomas Strasser, Downloaded by [RMIT University Library] at 19:43 22 May 2016
World Hypertension League, 1209 Geneva, Switzerland Lars Wilhelmsen, WHO Collaborating Centre for Health Care Related Research in Hypertension, University of Goteborg, Sweden
*
and the Hypertension Management Audit Group
Keywords :
Clood p r e s s u r e , Hypetension, Therapy
ABSTRACT
Despite the great therapeutic advances, the control of hypertension in populations is far below the achievable level, even in populations with highly developed health
Footnote: The principal contributors to the Hypertension Management Audit are: Accetto, R., Ljubljana, Slovenia, Yugoslavia; Brenner, E., Geneva, Switzerland; Canonico, V., Naples, Italy; Carp, C., Bucharest, Romania; Dolenc, P., Ljubljana, Slovenia, Yugoslavia; Duba, T., Budapest, Hungary; Endrdnyi, F., Budapest, Hungary; Fuller, A., Heidelberg, Germany; Jezersek, P., Ljubljana, Slovenia, Yugoslavia; Keil, U., Bochum-Neuherberg, Germany; Laaser, U., Bielefeld, Germany; Rougemont, A., Geneva, Switzerland; Stanulovic, Novi Sad, Vojvodina, Yugoslavia; Spelsberg, A., Bochum, Germany; Torner i Soler, M., Barcelona, Spain; TClrClk, E., Budapest, Hungary; La Vecchia, L., Vicenza, Italy; Viskoper, R.J., Ashkelon, Israel. The complete list of contributors is given in the full publication (1). 193 Copyright 0 1992 by Marcel Dekker, Inc.
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194
STRASSER AND WILHELMSEN
care. By the end of the 1 9 8 0 ' s , in selected European centres, 1 8 - 3 4 % of case-s of hypertension were undetected, and among those previously known, 2 2 - 3 8 % were untreated. The cooperative WHO/WHL Hypertension Management Audit Project aimed at assessing some of the impediments to better control of hypertension. The concepts and attitudes of 2 , 2 1 5 physicians were surveyed. In various centres and at various patient ages, 2 5 - 4 5 % of physicians would not start drug treatment below 100 mm Hg. When inquiring into the perceived reasons why hypertension had not been detected earlier, among other reasons, physicians tended to incriminate their workload, while patients often felt that there was a lack of interest on the doctor's part t o take a blood pressure reading. I n general, patient satisfaction seemed suboptimal. Physicians' sources of information were varied; neither WHO, nor ISH or WHL seemed to play an important role in informing the physicians. INTRODUCTION Disease control is a complex process that should be considered both in its biomedical and socio-environmental context. The somewhat vague concept of "control" includes prevention, and early detection and treatment. Ideally, prevention should be the mainstay of disease control, but in the case of hypertension primary prevention is still a remote ideal - though not an unrealistic one, at least for an important portion of high blood pressure-related morbidity. Since overweight and alcohol intake are clearly identified risk factors for hypertension, at least in populations in which overnutrition and drinking are common, it is judicious to expect that by combatting these risk factors many cases of hypertension could be prevented. However, from such reasoning to convincing facts there is a long way to go, and intensive research is needed both in the domain of population risk factors and of early iden-
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
tification
of
high-risk
195
individuals,
before
large-scale
primary prevention of hypertension will become a reality. The present insufficiency of practical possibilities in primary prevention of essential hypertension is no doubt the first 3r.d major impediment to hypertension control.
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It
is
therefore
reassuring
that
the bulk of
the present
symposium is devoted to studies into the very problem of primary prevention, and to the advances achieved i n this field. However, pending more concrete possibilities of practical applications of primary prevention, the backbone o f hypertension control remains secondary prevention, i.e. prevention of complications of hypertension by early diagnosis and appropriate treatment and management. How
satisfactory
is
the
present-day
situation
with
respect to the detection and treatment of hypertension in real life, in various populations, o n the international scene? In the early 1 9 7 0 s , in various European countries studied by WHO (1) the proportion of undetected hypertension varied from 2 0 to 65%, and the proportion of untreated hypertensives from 4 0 to 90% of all hypertensives, found on systematical screening of these populations. By the mid 1 9 8 0 s the proportion of untreated hypertensives ranged in various European countries from 5 0 to 8 2 % (average:66%) in men, and from 22 to 7 3 % (average :66%) in women ( 2 ) . In the joint WHO/WHL Hypertension Management Audit Project, now i n press ( 3 ) , among confirmed hypertensive individuals found in 6 populations in 4 different countries, previously undetected cases amounted to 1 8 - 3 4 % , and previously known but untreated patients (in general populations) from 22 to 3 8 % (table 1 ) . Such a situation is unsatisfactory, as is the one found by the Scottish Heart Health Study ( 4 ) , and i n the elderly in Italy (5). Even in the USA where considerable progress has taken place i n the detection and follow-up of hypertension (6), there persists a gap "between the achieved and the achievable" ( 4 ) .
*
m+f 18-34
22-38*
22-73(%:44)
f
3
2
2
1
Re fer enc e
P r o p o r t i o n of p r e v i o u s l y k n o w n but u n t r e a t e d
End 1 9 8 0 s
50-82(%:66)
40-90*
Untreated
m
20-65
m+f
Early 1970s
Hid 1 9 8 0 s
Undetected
Sex
Period
TABLE 1 Hypertension detection and treatment levels in selected European countries; X of confirmed hypertensives found in population survey
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P z tl
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
197
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Clearly, hypertension control has several facets o r levels. At the top of the pyramid - o r iceberg - basic research and drug development are achieving miraculous advances. At the hospital level, treatment is (let us hope) exemplary. In the population, ~t the grassroots level, the basis of the pyramid, o r the bulk of the iceberg, management seems to be deficient. RECENT FINDINGS FROM THE AUDIT PROJECT The Hypertension Management Audit Project ( 3 ) has tried to identify some of the factors that may impede o r slow down improvements of hypertension control, by analyzing its health care components. Obstacles may be ( a ) with the doctors (or health professions); (b) with the patients; o r (c) with drug utilization (for medicamentous treatment). The three components are obviously strongly interacting, and special instruments should still be developed to assess o r measure these interactions. Instead, the Audit Project has used intentionally simple, descriptive methods to assess these components. Here are some o f the findings. Table 2 presents the numbers of surveyed physicians. Table 3 presents the opinion of the majority of the physicians, as to what is considered hypertension, and at which values drug treatment should be started. The majority opinion corresponds to international consensus. However, there is a considerable scatter in physicians' opinions and attitudes, even within a same, limited area. As an example, the replies of the 1 3 5 physicians from Vicenza were distributed as shown in Table 4 and 5 ( 8 ) . The perceptions of 3 8 1 Hungarian general practitioners showed a similar distribution (Table 6) ( 9 ) . In a survey of 1 , 4 2 4 Spanish general practitioners ( l o ) , 3 8 % o f the respondents started drug treatment above 95 mm H g , another 3 8 % above 100 mm Hg, and further 18% only above 105 mm Hg diastolic blood pressure (Table 7). Hypertension thus seems to start,
Hungary Romania Ljubljana Catalonia Bochum-Dortmund Stuttgart Munich Vicenza Siano
1900 115 950 2359 442 361 1251 248 175
physicians in region
No. of
381 115 950 427 442 36 1 1251 248 175
164 98 413 226 314 245 500 135 126
Replies physicians received in sample
No. of
43 85 43 53 71 68 40 54 72
x
Response rate
Hypertension Audit Project: Physician survey
TABLE 2
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m P
v1
z
*Both e q u a l l y f r e q u e n t
D i a s t o l i c Below 35 y e a r s 35-59 y e a r s 6 0 y e a r s and o v e r
Majority c o n s i d e r drug treatment n e c e s s a r y S y s t o l i c B e l o w 35 y e a r s 35-59 y e a r s 6 0 y e a r s and over
0
0
0
0
...
0
0
0
0
0
..*
0
0
0
90 95 95
B e l o w 35 y e a r s 120 35-59 y e a r s 150/160* 6 0 y e a r s and o v e r 170
D i a s t o l i c B e l o w 35 y e a r s 35-59 y e a r s 6 0 y e a r s and over
Systolic
0
0
0
95 100
160 180
140
90 95 95
150 160 160 0
0
0
0
0
0
0
0
0
0
0
0
9
.
95
0
0
160
0
0
0
0
0
0
0
0
.
0
0
0
0
0 0
0
0
0
0
0
0
0
90
0
0
0
0
0
0
0
0
0
100
0
0
160
0
0
0
0
150
0
0
0
0
0
0
0
.
0
0
0
0
90 95 95
0
0
0
95 100
0
0
0
0
0
0
0
0
0
95 95
0
150 160 180
90 90 90
140 150 160
Hungary Romania Ljublana C a t a l o n i a Vicenza S i a n o
TABLE 3 Blood p r e s s u r e c o n s i d e r e d by m a j o r i t y a s h y p e r t e n s i o n (mm H g )
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2
1
18 -
8
-
No answer
2 32 47
35-59
9 57 24
-
90
8S
Below 35
95 100 105 110
above above above above above above
DBP rnHg
Age of patient
1
-
1
1 17 44 52
60 and above
TABLE 4 What diastolic blood pressure levels do you consider abnormal, when systolic blood pressure is 140-159 amHg? Replies by physicians from Vicenza ( X of respondents)
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U
z
'p
above 85 above 9 0 above 9 5 above 100 above 105 above 1 1 0 N o answer
DBP mmHg
40 4
1 5
20 39 32 1
7
-
13
1
36
1
1 6 25 47 10 7 4
Age of p a t i e n t Below 35 35-59 6 0 and above
TABLE 5 A t what d i a s t o l i c blood p r e s s u r e v a l u e s d o you c o n s i d e r drug treatment n e c e s s a r y when s y s t o l i c blood p r e s s u r e i s 1 4 0 - 1 5 9 mm Hg? R e p l i e s by p h y s i c i a n s from Vicenza ( X of r e s p o n d e n t s ) .
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z
0
H
vl
z
M
1
‘d
z
.e
X
-¶
0
r
1
0 0 2
m
X
4
0
4
z
2
Y
180
160 170
120 140 150
above 80 above 85 above 90 above 95 above 100 above 105 above 110
DBP mmHG
above above above above above above
SBP mmHg
13 6
40
39 4
22 10 -
39 35
37
22 2
45 20
15 -
2
1 5
1 19 3
34
-
-
9 11
53
17
56
-
5 23
-
12
-
A g e of p a t i e n t Below 35 35-59 6 0 and above
TABLE 6 D e f i n i n g h y p e r t e n s i o n : p e r c e n t a g e s of p e r c e p t i o n s o f c u t - o f f l e v e l s i n sample o f Hungarian g e n e r a l p r a c t i t i o n e r s ( % of r e s p o n d e n t s )
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h)
0
H
I
U
2
>
P
m
0)
rn
>
P
rn
H
N
203
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
TABLE 7
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Diastolic blood pressure at which Spanish general practitioners start drug treatment Percentage of replies of 1 4 2 4 physicians (10) DBP mmHg
Percent
Above Above Above Above
7 (7) 37 ( 4 4 ) 38 (82) 1 8 (100)
90 95 100 105
in middle age, above 100 mm Hg diastolic for 18 to 22% of practising physicians, and drug treatment is considered necessary by 40 to 55% of physicians only above 100 mm Hg. When inquiring, in cases that were newly diagncsed on population screening, about the reasons why the condicion had not been detected earlier, the interpretations of doctors and patients were often quite different, as shown on the example of Ljubljana, Yugoslavia (11) in Table 8. While doctors were rather blaming their own workload, one out of four patients thought the doctor was not interested to take their blood pressure. Of course, both parties may be right. Data from Budapest, Hungary (9) look at the same question from a different angle (Table 9 ) , by describing the actual actions taken. Both approaches point to certain impediments which, in theory, should not be difficult to overcome. an adequate long term follow-up, an indispensable component of hypertension control, cooperation of the patient is needed. Patient satisfaction is a precondition of continuing cooperation. Information available from the For
22 20
Lack of patient's interest to check blood pressure
Patients do not see a doctor when feeling well
5
25
Lack of doctor's interest for blood pressure when patient seen for other reasons
Patients' fears
28
Patient
Overload of health services
Reason
7
20
27
1
45
Examiner
Interpretations of patients and examiners, why hypertension had not been detected earlier ( % of replies): Ljubljana (n=332)
TABLE 8
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m a
v)
Cn
r3
cn
205
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
TABLE 9 A s s e s s m e n t of r e a s o n s why h y p e r t e n s i o n had n o t b e e n d i a g n o s e d e a r l i e r ( X of c a s e s ) : Budapest (n=94)
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Interpretation S u b j e c t w a s n o t s e e n by d o c t o r f o r the past 2 years
16
S u b j e c t was s e e n by d o c t o r , b u t b l o o d pressure w a s not taken
15
Blood p r e s s u r e w a s t a k e n w i t h i n t h e l a s t 2 y e a r s and w a s f o u n d normal
26*
Blood p r e s s u r e was f o u n d e l e v a t e d b u t no f u r t h e r a c t i o n was t a k e n
36
Blood p r e s s u r e w a s m e a s u r e d b u t i t s v a l u e was n o t t o l d t o p a t i e n t
7
* G e n u i n e l y new c a s e s
Audit
project
(3)
suggests mixed feelings in this regard,
as shown in the following tables. Attachment of patients to "their" doctor (Table 1 0 ) is one indicator, showing various degrees of satisfaction. Replies to a more direct question are given in Table 11. (The inquiry was anonymous.) There seems to be plenty of leeway for improving doctorpatient relationships, as described in the methodology of educating hypertensive patients ( 1 2 ) . Which
are
the
usual
sources
of
information
about
hypertension, used by the general practitioners? Table 1 2
0
1 0
0
2
*Romania
N o opinion
0
10 0
15
1
Not at a l l
3
11 6
21
11
Not especially
15
41
13
33
34
Rather
82
37
81
31
52
Absolutely
Siano
Vicenza
Sibiu*
Budapest
Ljubljana
TABLE 10 P a t i e n t i n q u i r y : " I s i t important f o r you t o m e e t t h e same d o c t o r a t r e p e a t e d v i s i t s ? ( X of r e s p o n s e s )
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a
m
v)
%
a
4
v)
*Romania
5
7
No opinion
5
4
5
1
0
1
Very dissatisfied
10
10
4
Not satisfied
69
12
Vicenza
20
63
54
70
Satisfied
Ljubljana
11
Sibiu* 31
18
Very satisfied
Budapest
15
21
Siano
TABLE 1 1 m* Patient inquiry: How satisfied are you with the care given?" ( X of responses)
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U
0
N
crj
0
r
3
0
n
m
T
r-3
0
r-3
cn
z r-3
E M
H
Congresses
I SH National programs
Hedical journals Continuing education Textbooks Pharna-information TV/radio / newspapers Antihypertens,ion Leagues WHO 37 95 82 37 33 24 44
-
90 68 76
13
-
-
78
-
22
95
97
10
-
-
61 23 74
87 0
.
0
.
.
0
0
. o o
0
0
. o o
48
0
59 60
0
94 0
0
.
0
0
0
-
0
.
.
0
.
.
.
.
0
0
33
0
55 69
0
93
0
0
0
0
0
0
.
0
0
.
38
..o
53 58
0
93
.
.
.
.
4
-
-
1 13
3
64 60 58
84
-
21
-
-
32
92
20 18
90
Hungary Romania Ljubljana Bochum Stuttgart Munich Vicenza Siano Dortmund
TABLE 12 Physicians' usual sour,ces of information ( X of respondents)
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IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
209
sums up the results of an inquiry from 8 populations of physicians in Europe. More than one reply was possible. Medical journals, somewhat surprisingly, rated highest; as expected, pharma-information rated high in all groups. Textbooks seemed to be in common use. Continuing education was prominent in some countries, absent in some others. In Germany, the League against Hypertension was definitely present as a source of information for physicians; in Hungary and Romania national information programmes seemed to play an iiiipurtant role. WHO, I S H and congresses rated in this respect disappointingly (though understandably) low: a reminder that the horizons of practising physicians necessarily differ from those of academia. A s a matter of fact, information derived from the mass media - TV, radio, newspapers - seems to play a greater role than scientific information.
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(3)
Drug utilization, the third pillar o f hypertension control, has been studied as well; there are some intercountry differences in the choice of drugs, depending on price, sometimes on availability, but mostly on tradition and prescribing habits. However, the problem has been approached until now only from the European and North American perspective. When leaving the terrain of developed countries, the problems of drug supply and affordability are becoming towering obstacles to the control of hypertension. An analysis of the socio-economical relativity of drug treament of hypertension is at present in preparation.*
*T. Strasser, A . Griffiths: The socio-economic relativity of the treatment hypertension. Y e be presented at the WHL Workshop on The Economics of Hypertension Control, Barcelona, September 2 7 / 2 8 , 1991.
210
STRASSER AND WILHELMSEN
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DISCUSSION The control of hypertension is still far from being satisfactory, even in socio-economically and medically well developed parts of the world. The first impediment to more efficient control is the absence of practical possibilities of primary prevention of essential hypertension; further research in this direction is very much needed. However, on the other hand, despite all the brilliant therapeutic advances, treatment and management of hypertension 9 populations is still far below the achievable level. There seem to be several identifiable obstacles which impede the improvement of hypertension control in general practice. The concepts of physicans greatly vary as regards the definition of hypertension and the requirements of drug treatment at various levels of blood pressure. There are some identifiable (and remediable 1 reasons for the fact that a portion of hypertensive patients still remains undiagnosed or, if diagnosed, untreated. Doctor-patient relationships, indispensable for long-term follow-up and partnership in disease control call for improvement. Finally, information transfer to general practitioners seems to be suboptimal. In the developing world, drug prices and the availability of health services - are staggering problems. The present paper is a first attempt to analyze the above impediments to hypertension control; however, more data and systematical analyses of the problematique are needed. Nevertheless, the existing information should be considered for the basis for elaborating more advanced policies for the control of hypertension. References 1. World Health Organization: Report of the meeting of investigators on community control of arterial hypertension, Geneva,l-3 December 1980. WHO document CVD/88.3.
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
211
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2. WHO MONICA Project: Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years, World Health Statistics Quarterly, 1988, 41:115-140. 3. Strasser T, Wilhelmsen L (editors): Assessment of levels of hypertension control and management - The Audit Project. Report of a collaborative WHO/WHL study in Europe. World Health Organization, Regional Office for Europe (in press). Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe H: Control of blood pressure in Scotland: the rule of the halves. British med.J., 1990, 300:981-983. 4.
5. Avanzini F, Alli C, Bettelli G , et al: Awareness, treatment and control of hypertension in the elderly in general practice experience. Clinical Cardiology, 1989, 12:283-288. Subcommittee on Definition and Prevalence of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure: Hypertension prevalence and the status of awareness, treatment, and control in the United States. National High Blood Pressure Education Program,l985. 6.
7. Winickoff RN, Murphy PK: The persistent problem of poor blood pressure control. Archives of Internal Medicine, 1987, 147:1393-1396.
La Vecchia L, Vincenzi M: Assessment of levels hypertension control and management: Italy - Vincenza, ref .3. 8.
9.
Torok
ref .3.
E, Duba
J:
The
Hungarian
Audit
Project,
of
in: 2:
STRASSER AND WILHELMSEN
2 12
10.
P a r d e l l H, T r e s s e r a s
R: S p a n i s h d o c t o r s a n d h y p e r t e n -
sion. S p a n i s h L e a g u e against H y p e r t e n s i o n , M a d r i d , 1988.
11.
J e z e r s e k P, A c c e t t o
R,
Cibic
hypertension control in Ljubljana,
12.
Grueninger
Downloaded by [RMIT University Library] at 19:43 22 May 2016
hypertensive Hypertension
U,
patient
4,
Strasser
-
T
teaching
suppl.1, 1990.
B et al:
&I:
ref.3.
(editors): the
T h e s t a t u s of
Educating
teacher.
J.
the Human
ISSN: 0730-0077 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iceh19
Impediments to the Control of Hypertension Thomas Strasser & Lars Wilhelmsen To cite this article: Thomas Strasser & Lars Wilhelmsen (1992) Impediments to the Control of Hypertension, Clinical and Experimental Hypertension. Part A: Theory and Practice, 14:1-2, 193-212, DOI: 10.3109/10641969209036182 To link to this article: http://dx.doi.org/10.3109/10641969209036182
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 5
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iceh19 Download by: [RMIT University Library]
Date: 22 May 2016, At: 19:43
CLIN. AND EXPER. HYPER.-THEORY AND PRACTICE, A14(1&2),
193-212 (1992)
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION Thomas Strasser, Downloaded by [RMIT University Library] at 19:43 22 May 2016
World Hypertension League, 1209 Geneva, Switzerland Lars Wilhelmsen, WHO Collaborating Centre for Health Care Related Research in Hypertension, University of Goteborg, Sweden
*
and the Hypertension Management Audit Group
Keywords :
Clood p r e s s u r e , Hypetension, Therapy
ABSTRACT
Despite the great therapeutic advances, the control of hypertension in populations is far below the achievable level, even in populations with highly developed health
Footnote: The principal contributors to the Hypertension Management Audit are: Accetto, R., Ljubljana, Slovenia, Yugoslavia; Brenner, E., Geneva, Switzerland; Canonico, V., Naples, Italy; Carp, C., Bucharest, Romania; Dolenc, P., Ljubljana, Slovenia, Yugoslavia; Duba, T., Budapest, Hungary; Endrdnyi, F., Budapest, Hungary; Fuller, A., Heidelberg, Germany; Jezersek, P., Ljubljana, Slovenia, Yugoslavia; Keil, U., Bochum-Neuherberg, Germany; Laaser, U., Bielefeld, Germany; Rougemont, A., Geneva, Switzerland; Stanulovic, Novi Sad, Vojvodina, Yugoslavia; Spelsberg, A., Bochum, Germany; Torner i Soler, M., Barcelona, Spain; TClrClk, E., Budapest, Hungary; La Vecchia, L., Vicenza, Italy; Viskoper, R.J., Ashkelon, Israel. The complete list of contributors is given in the full publication (1). 193 Copyright 0 1992 by Marcel Dekker, Inc.
Downloaded by [RMIT University Library] at 19:43 22 May 2016
194
STRASSER AND WILHELMSEN
care. By the end of the 1 9 8 0 ' s , in selected European centres, 1 8 - 3 4 % of case-s of hypertension were undetected, and among those previously known, 2 2 - 3 8 % were untreated. The cooperative WHO/WHL Hypertension Management Audit Project aimed at assessing some of the impediments to better control of hypertension. The concepts and attitudes of 2 , 2 1 5 physicians were surveyed. In various centres and at various patient ages, 2 5 - 4 5 % of physicians would not start drug treatment below 100 mm Hg. When inquiring into the perceived reasons why hypertension had not been detected earlier, among other reasons, physicians tended to incriminate their workload, while patients often felt that there was a lack of interest on the doctor's part t o take a blood pressure reading. I n general, patient satisfaction seemed suboptimal. Physicians' sources of information were varied; neither WHO, nor ISH or WHL seemed to play an important role in informing the physicians. INTRODUCTION Disease control is a complex process that should be considered both in its biomedical and socio-environmental context. The somewhat vague concept of "control" includes prevention, and early detection and treatment. Ideally, prevention should be the mainstay of disease control, but in the case of hypertension primary prevention is still a remote ideal - though not an unrealistic one, at least for an important portion of high blood pressure-related morbidity. Since overweight and alcohol intake are clearly identified risk factors for hypertension, at least in populations in which overnutrition and drinking are common, it is judicious to expect that by combatting these risk factors many cases of hypertension could be prevented. However, from such reasoning to convincing facts there is a long way to go, and intensive research is needed both in the domain of population risk factors and of early iden-
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
tification
of
high-risk
195
individuals,
before
large-scale
primary prevention of hypertension will become a reality. The present insufficiency of practical possibilities in primary prevention of essential hypertension is no doubt the first 3r.d major impediment to hypertension control.
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It
is
therefore
reassuring
that
the bulk of
the present
symposium is devoted to studies into the very problem of primary prevention, and to the advances achieved i n this field. However, pending more concrete possibilities of practical applications of primary prevention, the backbone o f hypertension control remains secondary prevention, i.e. prevention of complications of hypertension by early diagnosis and appropriate treatment and management. How
satisfactory
is
the
present-day
situation
with
respect to the detection and treatment of hypertension in real life, in various populations, o n the international scene? In the early 1 9 7 0 s , in various European countries studied by WHO (1) the proportion of undetected hypertension varied from 2 0 to 65%, and the proportion of untreated hypertensives from 4 0 to 90% of all hypertensives, found on systematical screening of these populations. By the mid 1 9 8 0 s the proportion of untreated hypertensives ranged in various European countries from 5 0 to 8 2 % (average:66%) in men, and from 22 to 7 3 % (average :66%) in women ( 2 ) . In the joint WHO/WHL Hypertension Management Audit Project, now i n press ( 3 ) , among confirmed hypertensive individuals found in 6 populations in 4 different countries, previously undetected cases amounted to 1 8 - 3 4 % , and previously known but untreated patients (in general populations) from 22 to 3 8 % (table 1 ) . Such a situation is unsatisfactory, as is the one found by the Scottish Heart Health Study ( 4 ) , and i n the elderly in Italy (5). Even in the USA where considerable progress has taken place i n the detection and follow-up of hypertension (6), there persists a gap "between the achieved and the achievable" ( 4 ) .
*
m+f 18-34
22-38*
22-73(%:44)
f
3
2
2
1
Re fer enc e
P r o p o r t i o n of p r e v i o u s l y k n o w n but u n t r e a t e d
End 1 9 8 0 s
50-82(%:66)
40-90*
Untreated
m
20-65
m+f
Early 1970s
Hid 1 9 8 0 s
Undetected
Sex
Period
TABLE 1 Hypertension detection and treatment levels in selected European countries; X of confirmed hypertensives found in population survey
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P z tl
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
197
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Clearly, hypertension control has several facets o r levels. At the top of the pyramid - o r iceberg - basic research and drug development are achieving miraculous advances. At the hospital level, treatment is (let us hope) exemplary. In the population, ~t the grassroots level, the basis of the pyramid, o r the bulk of the iceberg, management seems to be deficient. RECENT FINDINGS FROM THE AUDIT PROJECT The Hypertension Management Audit Project ( 3 ) has tried to identify some of the factors that may impede o r slow down improvements of hypertension control, by analyzing its health care components. Obstacles may be ( a ) with the doctors (or health professions); (b) with the patients; o r (c) with drug utilization (for medicamentous treatment). The three components are obviously strongly interacting, and special instruments should still be developed to assess o r measure these interactions. Instead, the Audit Project has used intentionally simple, descriptive methods to assess these components. Here are some o f the findings. Table 2 presents the numbers of surveyed physicians. Table 3 presents the opinion of the majority of the physicians, as to what is considered hypertension, and at which values drug treatment should be started. The majority opinion corresponds to international consensus. However, there is a considerable scatter in physicians' opinions and attitudes, even within a same, limited area. As an example, the replies of the 1 3 5 physicians from Vicenza were distributed as shown in Table 4 and 5 ( 8 ) . The perceptions of 3 8 1 Hungarian general practitioners showed a similar distribution (Table 6) ( 9 ) . In a survey of 1 , 4 2 4 Spanish general practitioners ( l o ) , 3 8 % o f the respondents started drug treatment above 95 mm H g , another 3 8 % above 100 mm Hg, and further 18% only above 105 mm Hg diastolic blood pressure (Table 7). Hypertension thus seems to start,
Hungary Romania Ljubljana Catalonia Bochum-Dortmund Stuttgart Munich Vicenza Siano
1900 115 950 2359 442 361 1251 248 175
physicians in region
No. of
381 115 950 427 442 36 1 1251 248 175
164 98 413 226 314 245 500 135 126
Replies physicians received in sample
No. of
43 85 43 53 71 68 40 54 72
x
Response rate
Hypertension Audit Project: Physician survey
TABLE 2
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m P
v1
z
*Both e q u a l l y f r e q u e n t
D i a s t o l i c Below 35 y e a r s 35-59 y e a r s 6 0 y e a r s and o v e r
Majority c o n s i d e r drug treatment n e c e s s a r y S y s t o l i c B e l o w 35 y e a r s 35-59 y e a r s 6 0 y e a r s and over
0
0
0
0
...
0
0
0
0
0
..*
0
0
0
90 95 95
B e l o w 35 y e a r s 120 35-59 y e a r s 150/160* 6 0 y e a r s and o v e r 170
D i a s t o l i c B e l o w 35 y e a r s 35-59 y e a r s 6 0 y e a r s and over
Systolic
0
0
0
95 100
160 180
140
90 95 95
150 160 160 0
0
0
0
0
0
0
0
0
0
0
0
9
.
95
0
0
160
0
0
0
0
0
0
0
0
.
0
0
0
0
0 0
0
0
0
0
0
0
0
90
0
0
0
0
0
0
0
0
0
100
0
0
160
0
0
0
0
150
0
0
0
0
0
0
0
.
0
0
0
0
90 95 95
0
0
0
95 100
0
0
0
0
0
0
0
0
0
95 95
0
150 160 180
90 90 90
140 150 160
Hungary Romania Ljublana C a t a l o n i a Vicenza S i a n o
TABLE 3 Blood p r e s s u r e c o n s i d e r e d by m a j o r i t y a s h y p e r t e n s i o n (mm H g )
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2
1
18 -
8
-
No answer
2 32 47
35-59
9 57 24
-
90
8S
Below 35
95 100 105 110
above above above above above above
DBP rnHg
Age of patient
1
-
1
1 17 44 52
60 and above
TABLE 4 What diastolic blood pressure levels do you consider abnormal, when systolic blood pressure is 140-159 amHg? Replies by physicians from Vicenza ( X of respondents)
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U
z
'p
above 85 above 9 0 above 9 5 above 100 above 105 above 1 1 0 N o answer
DBP mmHg
40 4
1 5
20 39 32 1
7
-
13
1
36
1
1 6 25 47 10 7 4
Age of p a t i e n t Below 35 35-59 6 0 and above
TABLE 5 A t what d i a s t o l i c blood p r e s s u r e v a l u e s d o you c o n s i d e r drug treatment n e c e s s a r y when s y s t o l i c blood p r e s s u r e i s 1 4 0 - 1 5 9 mm Hg? R e p l i e s by p h y s i c i a n s from Vicenza ( X of r e s p o n d e n t s ) .
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z
0
H
vl
z
M
1
‘d
z
.e
X
-¶
0
r
1
0 0 2
m
X
4
0
4
z
2
Y
180
160 170
120 140 150
above 80 above 85 above 90 above 95 above 100 above 105 above 110
DBP mmHG
above above above above above above
SBP mmHg
13 6
40
39 4
22 10 -
39 35
37
22 2
45 20
15 -
2
1 5
1 19 3
34
-
-
9 11
53
17
56
-
5 23
-
12
-
A g e of p a t i e n t Below 35 35-59 6 0 and above
TABLE 6 D e f i n i n g h y p e r t e n s i o n : p e r c e n t a g e s of p e r c e p t i o n s o f c u t - o f f l e v e l s i n sample o f Hungarian g e n e r a l p r a c t i t i o n e r s ( % of r e s p o n d e n t s )
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h)
0
H
I
U
2
>
P
m
0)
rn
>
P
rn
H
N
203
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
TABLE 7
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Diastolic blood pressure at which Spanish general practitioners start drug treatment Percentage of replies of 1 4 2 4 physicians (10) DBP mmHg
Percent
Above Above Above Above
7 (7) 37 ( 4 4 ) 38 (82) 1 8 (100)
90 95 100 105
in middle age, above 100 mm Hg diastolic for 18 to 22% of practising physicians, and drug treatment is considered necessary by 40 to 55% of physicians only above 100 mm Hg. When inquiring, in cases that were newly diagncsed on population screening, about the reasons why the condicion had not been detected earlier, the interpretations of doctors and patients were often quite different, as shown on the example of Ljubljana, Yugoslavia (11) in Table 8. While doctors were rather blaming their own workload, one out of four patients thought the doctor was not interested to take their blood pressure. Of course, both parties may be right. Data from Budapest, Hungary (9) look at the same question from a different angle (Table 9 ) , by describing the actual actions taken. Both approaches point to certain impediments which, in theory, should not be difficult to overcome. an adequate long term follow-up, an indispensable component of hypertension control, cooperation of the patient is needed. Patient satisfaction is a precondition of continuing cooperation. Information available from the For
22 20
Lack of patient's interest to check blood pressure
Patients do not see a doctor when feeling well
5
25
Lack of doctor's interest for blood pressure when patient seen for other reasons
Patients' fears
28
Patient
Overload of health services
Reason
7
20
27
1
45
Examiner
Interpretations of patients and examiners, why hypertension had not been detected earlier ( % of replies): Ljubljana (n=332)
TABLE 8
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m a
v)
Cn
r3
cn
205
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
TABLE 9 A s s e s s m e n t of r e a s o n s why h y p e r t e n s i o n had n o t b e e n d i a g n o s e d e a r l i e r ( X of c a s e s ) : Budapest (n=94)
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Interpretation S u b j e c t w a s n o t s e e n by d o c t o r f o r the past 2 years
16
S u b j e c t was s e e n by d o c t o r , b u t b l o o d pressure w a s not taken
15
Blood p r e s s u r e w a s t a k e n w i t h i n t h e l a s t 2 y e a r s and w a s f o u n d normal
26*
Blood p r e s s u r e was f o u n d e l e v a t e d b u t no f u r t h e r a c t i o n was t a k e n
36
Blood p r e s s u r e w a s m e a s u r e d b u t i t s v a l u e was n o t t o l d t o p a t i e n t
7
* G e n u i n e l y new c a s e s
Audit
project
(3)
suggests mixed feelings in this regard,
as shown in the following tables. Attachment of patients to "their" doctor (Table 1 0 ) is one indicator, showing various degrees of satisfaction. Replies to a more direct question are given in Table 11. (The inquiry was anonymous.) There seems to be plenty of leeway for improving doctorpatient relationships, as described in the methodology of educating hypertensive patients ( 1 2 ) . Which
are
the
usual
sources
of
information
about
hypertension, used by the general practitioners? Table 1 2
0
1 0
0
2
*Romania
N o opinion
0
10 0
15
1
Not at a l l
3
11 6
21
11
Not especially
15
41
13
33
34
Rather
82
37
81
31
52
Absolutely
Siano
Vicenza
Sibiu*
Budapest
Ljubljana
TABLE 10 P a t i e n t i n q u i r y : " I s i t important f o r you t o m e e t t h e same d o c t o r a t r e p e a t e d v i s i t s ? ( X of r e s p o n s e s )
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a
m
v)
%
a
4
v)
*Romania
5
7
No opinion
5
4
5
1
0
1
Very dissatisfied
10
10
4
Not satisfied
69
12
Vicenza
20
63
54
70
Satisfied
Ljubljana
11
Sibiu* 31
18
Very satisfied
Budapest
15
21
Siano
TABLE 1 1 m* Patient inquiry: How satisfied are you with the care given?" ( X of responses)
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U
0
N
crj
0
r
3
0
n
m
T
r-3
0
r-3
cn
z r-3
E M
H
Congresses
I SH National programs
Hedical journals Continuing education Textbooks Pharna-information TV/radio / newspapers Antihypertens,ion Leagues WHO 37 95 82 37 33 24 44
-
90 68 76
13
-
-
78
-
22
95
97
10
-
-
61 23 74
87 0
.
0
.
.
0
0
. o o
0
0
. o o
48
0
59 60
0
94 0
0
.
0
0
0
-
0
.
.
0
.
.
.
.
0
0
33
0
55 69
0
93
0
0
0
0
0
0
.
0
0
.
38
..o
53 58
0
93
.
.
.
.
4
-
-
1 13
3
64 60 58
84
-
21
-
-
32
92
20 18
90
Hungary Romania Ljubljana Bochum Stuttgart Munich Vicenza Siano Dortmund
TABLE 12 Physicians' usual sour,ces of information ( X of respondents)
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IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
209
sums up the results of an inquiry from 8 populations of physicians in Europe. More than one reply was possible. Medical journals, somewhat surprisingly, rated highest; as expected, pharma-information rated high in all groups. Textbooks seemed to be in common use. Continuing education was prominent in some countries, absent in some others. In Germany, the League against Hypertension was definitely present as a source of information for physicians; in Hungary and Romania national information programmes seemed to play an iiiipurtant role. WHO, I S H and congresses rated in this respect disappointingly (though understandably) low: a reminder that the horizons of practising physicians necessarily differ from those of academia. A s a matter of fact, information derived from the mass media - TV, radio, newspapers - seems to play a greater role than scientific information.
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(3)
Drug utilization, the third pillar o f hypertension control, has been studied as well; there are some intercountry differences in the choice of drugs, depending on price, sometimes on availability, but mostly on tradition and prescribing habits. However, the problem has been approached until now only from the European and North American perspective. When leaving the terrain of developed countries, the problems of drug supply and affordability are becoming towering obstacles to the control of hypertension. An analysis of the socio-economical relativity of drug treament of hypertension is at present in preparation.*
*T. Strasser, A . Griffiths: The socio-economic relativity of the treatment hypertension. Y e be presented at the WHL Workshop on The Economics of Hypertension Control, Barcelona, September 2 7 / 2 8 , 1991.
210
STRASSER AND WILHELMSEN
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DISCUSSION The control of hypertension is still far from being satisfactory, even in socio-economically and medically well developed parts of the world. The first impediment to more efficient control is the absence of practical possibilities of primary prevention of essential hypertension; further research in this direction is very much needed. However, on the other hand, despite all the brilliant therapeutic advances, treatment and management of hypertension 9 populations is still far below the achievable level. There seem to be several identifiable obstacles which impede the improvement of hypertension control in general practice. The concepts of physicans greatly vary as regards the definition of hypertension and the requirements of drug treatment at various levels of blood pressure. There are some identifiable (and remediable 1 reasons for the fact that a portion of hypertensive patients still remains undiagnosed or, if diagnosed, untreated. Doctor-patient relationships, indispensable for long-term follow-up and partnership in disease control call for improvement. Finally, information transfer to general practitioners seems to be suboptimal. In the developing world, drug prices and the availability of health services - are staggering problems. The present paper is a first attempt to analyze the above impediments to hypertension control; however, more data and systematical analyses of the problematique are needed. Nevertheless, the existing information should be considered for the basis for elaborating more advanced policies for the control of hypertension. References 1. World Health Organization: Report of the meeting of investigators on community control of arterial hypertension, Geneva,l-3 December 1980. WHO document CVD/88.3.
IMPEDIMENTS TO THE CONTROL OF HYPERTENSION
211
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2. WHO MONICA Project: Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years, World Health Statistics Quarterly, 1988, 41:115-140. 3. Strasser T, Wilhelmsen L (editors): Assessment of levels of hypertension control and management - The Audit Project. Report of a collaborative WHO/WHL study in Europe. World Health Organization, Regional Office for Europe (in press). Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe H: Control of blood pressure in Scotland: the rule of the halves. British med.J., 1990, 300:981-983. 4.
5. Avanzini F, Alli C, Bettelli G , et al: Awareness, treatment and control of hypertension in the elderly in general practice experience. Clinical Cardiology, 1989, 12:283-288. Subcommittee on Definition and Prevalence of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure: Hypertension prevalence and the status of awareness, treatment, and control in the United States. National High Blood Pressure Education Program,l985. 6.
7. Winickoff RN, Murphy PK: The persistent problem of poor blood pressure control. Archives of Internal Medicine, 1987, 147:1393-1396.
La Vecchia L, Vincenzi M: Assessment of levels hypertension control and management: Italy - Vincenza, ref .3. 8.
9.
Torok
ref .3.
E, Duba
J:
The
Hungarian
Audit
Project,
of
in: 2:
STRASSER AND WILHELMSEN
2 12
10.
P a r d e l l H, T r e s s e r a s
R: S p a n i s h d o c t o r s a n d h y p e r t e n -
sion. S p a n i s h L e a g u e against H y p e r t e n s i o n , M a d r i d , 1988.
11.
J e z e r s e k P, A c c e t t o
R,
Cibic
hypertension control in Ljubljana,
12.
Grueninger
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hypertensive Hypertension
U,
patient
4,
Strasser
-
T
teaching
suppl.1, 1990.
B et al:
&I:
ref.3.
(editors): the
T h e s t a t u s of
Educating
teacher.
J.
the Human
