Improving the Quality of Care for Patients with Hypertension

The Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services has published a technical review on improving the quality of care for patients with hypertension. “Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Volume 3 – Hypertension Care” (AHRQ Publication no. 04–0051–3) was released in January 2005 and is available online at http://www.ahrq.gov/clinic/evrptpdfs.htm#qualgap2.

The authors searched MEDLINE, the Cochrane Effective Practice and Organisation of Care Review Group registry, and other databases, and hand searched bibliographies and articles for experimental evaluation of quality-improvement interventions in the care of non-pregnant patients with primary hypertension.

Quality improvement targets included measures of blood pressure screening (i.e., strategies to increase the awareness of hypertension in undiagnosed patients) and control (i.e., the percentage of diagnosed patients whose blood pressure is within the range recommended by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure [less than 120/80 mm Hg]). Sixty-three articles met the inclusion criteria. The strategies assessed in the studies were organizational change, education of patients and health care professionals, facilitated relay of clinical data, audit and feedback, promotion of self-management, reminders for physicians and patients, and financial incentives.

The authors’ findings suggest that quality improvement strategies are associated with improved detection and control of hypertension, but they could not discern which strategies have the greatest effect. Studies that involved organizational change appeared to have the largest positive effect; however, there were some methodologic concerns about confounding because of study size, and the authors note that organizational change may be only an indication of high levels of administrative support or funding. Patient education also appeared to have a large positive effect, but the results were confounded by study size. Studies that focused on improving physician adherence to recommendations for hypertension management had less effect. The authors noted that there may be several reasons for this, including rapidly changing recommendations and time and resource constraints.

The authors concluded that the most noticeable finding was the need for more high-quality research to clarify the best strategies with which to improve the care of patients with hypertension.

Use of Antiretrovirals to Prevent HIV Infection from a Nonoccupational Source

The Centers for Disease Control and Prevention has published a recommendation report on the use of antiretroviral drugs to prevent human immunodeficiency virus (HIV) infection after injection-drug use, sexual, and accidental exposure. “Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States” was released January 21, 2005, and is available online at http://www.cdc.gov/mmwr/mmwr_rr.html. The report summarizes information about the use of nonoccupational postexposure prophylaxis and lists guidelines for its use.

Recent data from human and animal studies, case reports, and documentation of the use of nonoccupational postexposure prophylaxis prompted the U.S. Department of Health and Human Services to update its recommendation for the use of nonoccupational postexposure prophylaxis in patients who seek treatment within 72 hours of high-risk exposure to a person known to be HIV positive.

According to the authors, when highly active antiretroviral therapy (HAART) is prescribed within 48 to 72 hours of nonoccupational exposure to HIV and continued for 28 days, the likelihood of transmission may be reduced. The earlier the nonoccupational postexposure prophylaxis is administered, the higher the chance that it will interrupt transmission.

The authors state that no specific antiretroviral medication or combination is optimal for nonoccupational postexposure prophylaxis. However, preferred regimens include efavirenz and lamivudine or emtricitabine with zidovudine or tenofovir (as a nonnucleoside-based regimen) and lopinavir and ritonavir (co-formulated in one tablet) and zidovudine with either lamivudine or emtricitabine. No evidence suggests that a three-drug HAART regimen is more effective than a two-drug regimen. When the source person is available for interview, his or her medication history and most recent viral load measurement should be considered when choosing medications for nonoccupational postexposure prophylaxis. This could help prevent prescription of medications to which the virus is already resistant.

According to the report, all patients seeking treatment after HIV exposure should be tested for antibodies at baseline, four to six weeks, three months, and six months. Patients should be informed about the signs and symptoms of acute retroviral infection and should be asked to return for evaluation if these occur. Physicians who provide nonoccupational postexposure prophylaxis also should monitor patients’ liver function, renal function, and hematologic parameters.

When a patient’s risk of transmission from contact is small or when more than 72 hours have passed since exposure, nonoccupational postexposure prophyl axis is not recommended. However, when a patient seeks treatment more than 72 hours after exposure, but the risk of virus transmission is severe, physicians may decide that the potential benefit of nonoccupational postexposure prophylaxis is greater than the potential risk of complications from antiretroviral therapy.