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Hypertension: Gaps Between Guidelines and Practice

Am Fam Physician. 2005 May 1;71(9):1800-1802.

Hypertension, one of the most common reasons patients visit outpatient medical facilities, affects approximately 50 million Americans. Treatment of hypertension has been shown to reduce the risk for stroke, heart failure, myocardial infarction, end-stage renal disease, and peripheral vascular disease. Multiple studies have shown that reducing blood pressure can have a positive impact on patients’ health. Despite these studies, turning this information into day-to-day clinical practice is challenging. There are multiple steps in treating hypertension, including detection, medical follow-up, medical evaluation and treatment plan, and patient adherence to treatment plans.

In the United States, the majority of patients with uncontrolled hypertension are those who already have been diagnosed and are receiving treatment. A possible barrier to hypertension control is the ineffectiveness of published guidelines. Spranger and associates attempted to identify action items in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) that have been the least well translated into clinical practice.

The study followed, for at least 18 months, patients who received regular medical care for primary hypertension at six urban, community-based, primary care clinics. the authors transformed the major tables from JNC VI into a chart review instrument that included information about the initial evaluation of hypertensive patients, identification of secondary causes, comorbid conditions and target organ damage, and other cardiovascular risk factors. In addition to chart audits, pharmacy records from a system-wide pharmacy database were reviewed. Blood pressures were recorded, and the outcome blood pressure was the reading taken at the last appointment during the study period.

There were 249 patients who were newly diagnosed with hypertension during the study period. Attending physicians deviated from JNC VI guidelines by diagnosing hypertension with only a single reading in 212 patients (85 percent), did not order electrocardiography in 221 patients (89 percent), and did not perform mandatory laboratory tests in about one half of the patients. At the end of the study period, 40 percent of the patients were on monotherapy, and the blood pressure target of less than 140/90 mm Hg was accomplished in 83 of 249 patients (33 percent). All patients with diabetes were given an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker but, at the end of the study, these participants were receiving only 1.7 medications per patient.

The authors conclude that the JNC VI guidelines have not been well translated into clinical practice, including failure to stage blood pressure based on multiple readings, assessing cardiovascular risk, and titration of multiple medications to achieve blood pressure control. They add that multiple innovative interventions are necessary to overcome these practice deficiencies.

Spranger CB, et al. Identifying gaps between guidelines and clinical practice in the evaluation and treatment of patients with hypertension. July 1, 2004;117:14–8.


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