In November, the National Heart, Lung, and Blood Institute (NHLBI) released the latest in its series of documents from the Joint National Committee on Hypertension (JNC). JNC VI, as this one is known, is the first to aim specifically at being an evidence-based clinical policy statement for primary care physicians. The need for a clinical policy is readily apparent: only one half of hypertensive patients have been diagnosed and, of those diagnosed, only one half are adequately treated. Hypertension is a major cause of stroke, myocardial infarction and renal failure, and it is probably the major cause of congestive heart failure.
The JNC VI document was published in the November 25, 1997, issue of the Archives of Internal Medicine. It can also be accessed on the World Wide Web at http://www.nhlbi.nih.gov/nhlbi/cardio/hbp/prof/jncintro.htm.
NHLBI clinical policies have traditionally been consensus statements, developed largely by content-area experts. With JNC VI, the Institute has taken a new and welcome direction. JNC VI is an evidence-based clinical policy statement, developed with explicit concern for usefulness to primary care physicians. A full-scale explicit-methodology policy on hypertension would have to be narrower in scope and much costlier than the JNC's mandate required. However, the JNC process applied as much of the rigor of the explicit methodology as could be applied within its constraints. The evidence used was graded, negative papers were sought as well as positive ones, recommendations focused on interventions supported by the most reliable evidence, and interventions were evaluated in terms of their proven absolute risk reductions wherever available. The result is a clinical policy statement that is realistic, scientifically sound, outcome-oriented and well documented.
The NHLBI took pains to ensure that it was not creating a document of, by and for hypertension experts. In addition to placing a family physician (myself) on the writing team, the NHLBI presented early drafts to focus groups of family physicians and general internists who were active, community-based primary clinicians. The feedback from these physicians was used to guide the content and, more importantly, the form and focus of the JNC VI document toward usefulness and applicability in community practice. The result is a comprehensive document that is useful in teaching, as a JNC statement must be, but also contains the “news you can use” in patient care.
The AAFP and family physicians can do three positive things as a follow-up to the JNC VI report. The first and most important is to implement the guidelines to improve the somewhat dismal state of hypertension treatment in the United States. The second is to support the NHLBI's move away from expert opinion to evidence-based policies. Further, we should urge that the shift be extended beyond the NHLBI to the other institutes at the National Institutes of Health (NIH). The NIH might do well to make use of the new Evidence-Based Practice Centers of the Agency for Health Care Policy and Research to develop and grade evidence for panels to use in constructing clinical policies. The third is to urge the NIH to continue and extend the practice of listening to primary care physicians early in the process of preparing clinical policies. The focus group method should be applauded and extended, and panels should include formal expertise in medical decision making and dissemination and adoption of guidelines.
Most of the treatment decisions are made in the primary care physician's office, and it is there that the full spectrum of patients is seen. With the JNC VI report, the NHLBI has aimed a practice policy there, too. Let us support this shift in method and focus, with the goal of improving outcomes for the broadest possible range of patients.