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Am Fam Physician. 2002;66(10):1979-1980

Blood pressure control among hypertensive patients has proved elusive. Currently, only about 25 percent of hypertensive patients achieve blood pressure levels less than 140/90 mm Hg. Although commonly cited obstacles to good blood pressure control include lack of awareness of hypertension, suboptimal medical management, and poor patient adherence to medication regimens, a key factor associated with successful blood pressure control is the physician;'s knowledge about and attitude toward the importance of achieving targeted blood pressure levels. Maue and associates tested a coordinated approach to blood pressure control among patients enrolled in a specific managed care program.

The approach, designed by the managed care program, consisted of disseminating guidelines (from the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure), offering continuing medication education programs, and providing a newsletter containing findings about the patient population identified during the random baseline evaluation. Suggested physician activities included (1) promoting routine blood pressure monitoring by patients, (2) promoting patient medication adherence, (3) encouraging consideration and documentation of risk factors to plan antihypertensive treatment, (4) increasing the use of medication combination preparations to improve compliance, (5) avoiding high-dose calcium channel blockers to minimize side effects, and (6) maintaining a registry to monitor patients and track the percentage achieving target goals. Education sessions were held between clinical pharmacists and individual physicians to review and reassess current pharmacotherapeutic decisions. Post-intervention assessment was performed approximately six months after completion of the intervention.

Select a condition with measurable outcomes for which evidence-based guidelines are available.
Identify all patients within the total population who have the condition.
Identify desirable and measurable evidence-based outcomes.
Measure outcomes continuously to identify improvement or lack of improvement.

Blood pressure control increased significantly, with 52 percent of hypertensive patients achieving blood pressure levels less than 140/90 mm Hg, compared with 41 percent at baseline. The percentage of hypertensive patients with diabetes appropriately receiving an angiotensin-converting enzyme inhibitor increased significantly. The appropriate use of beta blockers in hypertensive patients with a history of myocar-dial infarction also increased significantly. Calcium channel blockers were the most commonly prescribed antihypertensive medication before and after the intervention.

The authors conclude that an educational intervention that includes physician feedback can improve physicians;' prescribing habits and patients;' blood pressure control. Low-dose combination therapies have strong advantages in terms of added blood pressure-lowering effects and improved patient adherence. Systems to help physicians monitor and care for patients proactively can improve health outcomes in patients with chronic illnesses. A four-step process to implement a population-based health care system in practice is described in the accompanying table.

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