Treatment of hypertension in Spanish primary care centres: is it evidence based?

Unit of Public Health, Hygiene and Environmental Health, Valencia University, Spain.
Public Health (Impact Factor: 1.35). 01/2005; 118(8):594-8. DOI: 10.1016/j.puhe.2003.12.010
Source: PubMed
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    ABSTRACT: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure placed increased emphasis on lifestyle modification for the prevention and management of hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet, rich in fruits, vegetables, nuts, and low-fat dairy foods, with reduced saturated and total fats, was found in clinical trials to lower blood pressure substantially and significantly. The DASH diet appears appropriate for use in the primary care setting, although it is unknown whether results will mirror those found in clinical trial. A review of the literature of successful physician-based dietary interventions and of the Stages of Change model as it applies to dietary behavior was completed. Some changes needed to adapt the DASH diet to the outpatient family practice setting were identified and implemented among a predominantly non-Caucasian (56%), female (61%) population. The most common concerns and diagnoses among this population are essential hypertension, diabetes, and general medical examination. Under study conditions, DASH reported that patients experienced an average reduction of 6 mmHg systolic and 3 mmHg diastolic blood pressure. Results were better in those with high blood pressure--systolic dropped by 11 mmHg and diastolic dropped by 6 mmHg. This reduction occurred within 2 weeks of starting the plan. Our clinical experience matches these published results.
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    ABSTRACT: Context Despite condition-specific and managed care–specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries.Objective To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.Design, Setting, and Participants National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state.Main Outcome Measures Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so.Results Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low.Conclusions It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. Figures in this Article As concern grows that attempts to control the cost of health care will crowd out quality, evidence has also emerged that quality of care is and has been far more uneven than previously recognized. The public health report entitled Healthy People 20101 showed wide gaps between public health performance goals and actual achievements on many measures, including some delivered by the fee-for-service (FFS) health care system. Reviews, most notably by Schuster et al,2 showed that there were major gaps in acute, chronic, and preventive care almost everywhere that studies have been done. More recently, a report from the Institute of Medicine showed serious problems of harm to patients from medical errors.3 This kind of evidence was reflected in the recommendation of a recent presidential commission that quality of health care should become a major national priority.4 Despite condition-specific and managed care–specific reports, there has been no systematic program for monitoring the quality of medical care provided to FFS Medicare beneficiaries. Except for the clinical measures of the Health Plan Employer Data and Information Set (HEDIS)5 and the Diabetes Quality Improvement Project (DQIP)6 there is no clinical quality measure set in general national use. About 4 years ago, the Health Care Financing Administration (HCFA) began to implement a program to measure and track the quality of the care for which Medicare pays. Simultaneously, HCFA committed to using its peer review organization (PRO) contractors to systematically promote improved performance on the quality measures tracked under this program using a voluntary, collaborative, and nonpunitive educational strategy.7 This article describes the 24 initial measures used in this program and reports the baseline values measured in 1997-1999. The Medicare measurement system we developed includes most of the HEDIS clinical measures, but it addresses more conditions, measures more elements of care, and measures the care delivered to the 85% of Medicare beneficiaries who are covered under FFS. The sampling frame provides state-level results to target PRO activities, evaluate PRO and HCFA effectiveness in improving care, and create a national picture of care under Medicare FFS. Even though purchasers and beneficiaries are primarily interested in outcomes, we focused on measuring processes of care critical to outcomes rather than on measuring outcomes themselves. Five reasons drove this choice: (1) in comparison to outcomes of care, there is more consensus on appropriate processes of care and the target rates (nearly 100%); (2) measuring processes of care generally does not require the risk adjustment that has been so controversial in comparisons of outcomes; (3) it is easier for providers, practitioners, and plans to identify and fix the reasons why critical processes of care were not carried out than to determine why outcomes are not optimal; (4) many important outcomes take years; and (5) because significant, achievable improvements in outcomes are generally much smaller in relative terms than improvements in processes, unrealistic sample sizes are necessary to measure significant improvements in outcomes. While we report only process measures here, HCFA intends to track outcomes, risk-adjusted when possible, at the national level for the targeted conditions.
    JAMA The Journal of the American Medical Association 01/2000; 284(13):1670-1676. · 29.98 Impact Factor