Prevalence and costs of treating uncomplicated stage 1 hypertension in primary care: a cross-sectional analysis.

BACKGROUND: Treatment for uncomplicated stage 1 hypertension is recommended in most international guidelines but there is little evidence to indicate that therapy is beneficial. AIM: To estimate the prevalence of this condition in an untreated population and the potential costs of initiating therapy in such patients. DESIGN AND SETTING: Cross-sectional study of anonymised patient records in 19 general practices in the West Midlands, UK. METHOD: Data relating to patient demographics, existing cardiovascular disease (CVD), and risk factors (blood pressure and cholesterol) were extracted from patient records. Patients with a blood pressure of 140/90-159/99 mmHg, no CVD, and <20% 10-year cardiovascular risk were classified as having uncomplicated stage 1 hypertension. Missing data were imputed. The prevalence of untreated, uncomplicated stage 1 hypertension was estimated using descriptive statistics and extrapolated using national data. The cost of achieving blood pressure control in this population was examined in a cost-impact analysis using published costs from previous studies. RESULTS: Of the 34 975 patients (aged 40-74 years) in this study, untreated, uncomplicated stage 1 hypertension was present in 2867 individuals (8.2%, 95% confidence interval [CI] = 7.9 to 8.5). This is equivalent to 1 892 519 patients in England and Wales, for whom the additional cost of controlling blood pressure, according to guidelines, was estimated at £106-229 million per annum, depending on the health professional delivering care. CONCLUSION: Untreated, uncomplicated stage 1 hypertension is relatively common, affecting 1 in 12 patients aged 40-74 years in primary care. Current international guidelines and pay-for-performance targets, if followed, will incur significant costs for a patient benefit that is debatable.This work forms part of a larger programme on stroke prevention in primary care supported by the National Institute for Health Research (NIHR) (RP-PG-0606-1153). James P Sheppard holds a Medical Research Council Strategic Skills PostDoctoral Fellowship. Richard J McManus holds an NIHR Professorship. The views and opinions expressed are those of the authors and do not necessarily reflect those of the NHS, NIHR, or the Department of Health

Human Rights and Humanitarian Law in Collision: A Study of the Case of Omar Khadr, a Child Soldier Detained at Guantanamo

Omar Khadr, age 15 and a citizen of Canada, was given emergency medical care for near-fatal gun-shot wounds and taken into custody by U.S. forces in Afghanistan on July 27, 2002. U.S. military forces had been in that country since October of 2001, only a month after the devastating attacks on the United States of September 11. Omar Khadr was, without doubt, a child on the date of his detention and all prior dates of his alleged criminal conduct. He was, however, caught up on that July day in a prolonged military encounter with deaths on both sides including, very nearly, his own. Some would thus first characterize him not as a child but as a combatant – “child soldier” is the term most often applied in such situations, but the more neutral “child in armed conflict” is generally used here

Accuracy of monitors used for blood pressure checks in English retail pharmacies::a cross-sectional observational study

BACKGROUND: Free blood pressure (BP) checks offered by community pharmacies provide a potentially useful opportunity to diagnose and/or manage hypertension, but the accuracy of the sphygmomanometers in use is currently unknown. AIM: To assess the accuracy of validated automatic BP monitors used for BP checks in a UK retail pharmacy chain. DESIGN AND SETTING: Cross-sectional, observational study in 52 pharmacies from one chain in a range of locations (inner city, suburban, and rural) in central England. METHOD: Monitor accuracy was compared with a calibrated reference device (Omron PA-350), at 50 mmHg intervals across the range 0–300 mmHg (static pressure test), with a difference from the reference monitor of +/− 3 mmHg at any interval considered a failure. The results were analysed by usage rates and length of time in service. RESULTS: Of 61 BP monitors tested, eight (13%) monitors failed (that is, were >3 mmHg from reference), all of which underestimated BP. Monitor failure rate from the reference monitor of +/− 3 mmHg at any testing interval varied by length of time in use (2/38, 5% <18 months; 4/14, 29% >18 months, P = 0.038) and to some extent, but non-significantly, by usage rates (4/22, 18% in monitors used more than once daily; 2/33, 6% in those used less frequently, P = 0.204). CONCLUSION: BP monitors within a pharmacy setting fail at similar rates to those in general practice. Annual calibration checks for blood pressure monitors are needed, even for new monitors, as these data indicate declining performance from 18 months onwards

Relationship of self-rated health with fatal and non-fatal outcomes in cardiovascular disease: a systematic review and meta-analysis.

BACKGROUND: People who rate their health as poor experience higher all-cause mortality. Study of disease-specific association with self-rated health might increase understanding of why this association exists. OBJECTIVES: To estimate the strength of association between self-rated health and fatal and non-fatal cardiovascular disease. METHODS: A comprehensive search of PubMed MEDLINE, EMBASE, CINAHL, BIOSIS, PsycINFO, DARE, Cochrane Library, and Web of Science was undertaken during June 2013. Two reviewers independently searched databases and selected studies. Inclusion criteria were prospective cohort studies or cohort analyses of randomised trials with baseline measurement of self-rated health with fatal or non-fatal cardiovascular outcomes. 20 studies were pooled quantitatively in different meta-analyses. Study quality was assessed using Newcastle-Ottawa scales. RESULTS: 'Poor' relative to 'excellent' self-rated health (defined by most extreme categories in each study, most often' poor' or 'very poor' and 'excellent' or 'good') was associated over a follow-up of 2.3-23 years with cardiovascular mortality in studies: where varying degrees of adjustments had been made for cardiovascular disease risk (HR 1.79 (95% CI 1.50 to 2.14); 15 studies, I2 = 71.24%), and in studies reporting outcomes in people with pre-existing cardiovascular disease or ischaemic heart disease symptoms (HR 2.42 (95% CI 1.32 to 4.44); 3 studies; I2 = 71.83%). 'Poor' relative to 'excellent' self rated health was also associated with the combined outcome of fatal and non-fatal cardiovascular events (HR 1.90 (95% CI 1.26 to 2.87); 5 studies; I2 = 68.61%), Self-rated health was not significantly associated with non-fatal cardiovascular disease outcomes (HR 1.66 (95% CI 0.96 to 2.87); 5 studies; I2 = 83.60%). CONCLUSIONS: Poor self rated health is associated with cardiovascular mortality in populations with and without prior cardiovascular disease. Those with current poor self-rated health may warrant additional input from health services to identify and address reasons for their low subjective health.This is the final published version. It is accessible from the PLOS One website at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0103509

Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study

Objective : To compare the characteristics of patients with cerebrovascular disease in primary care with those of the participants in the PROGRESS trial, on which national guidelines for blood pressure lowering are based. Design : Population based cross sectional survey of patients with confirmed stroke or transient ischaemic attack. Setting : Seven general practices in South Birmingham, England. Participants : All patients with a validated history of stroke (n = 413) or transient ischaemic attack (n = 107). Main outcome measures Patient characteristics: age, sex, time since last cerebrovascular event, blood pressure, and whether receiving antihypertensive treatment. Results : Patients were 12 years older than the participants in PROGRESS and twice as likely to be women. The median time that had elapsed since their cerebrovascular event was two and a half years, compared with eight months in PROGRESS. The systolic blood pressure of 315 (61%) patients was over 140 mm Hg, and for 399 (77%) it was over 130 mm Hg. One hundred and forty seven (28%) patients were receiving a thiazide diuretic, and 136 (26%) were receiving an angiotensin converting enzyme inhibitor. Conclusions : Important differences exist between the PROGRESS trial participants and a typical primary care stroke population, which undermine the applicability of the trial’s findings. Research in appropriate populations is urgently needed before the international guidelines are implemented in primary care

Accuracy of blood pressure monitors owned by patients with hypertension (ACCU-RATE study)

Background Home blood pressure (BP) monitoring is recommended in guidelines and increasingly popular with patients and health care professionals, but the accuracy of patients’ own monitors in real world use is not known. Aim To assess the accuracy of home BP monitors used by people with hypertension, and investigate factors affecting accuracy. Design and Setting Patients on the hypertension register at seven practices in central England were surveyed to ascertain if they owned a monitor and wanted it tested. Method Monitor accuracy was compared to a calibrated reference device, at 50 mmHg intervals between 0-280/300 mmHg (static pressure test), with a difference from the reference monitor of +/-3 mmHg at any interval considered a failure. Cuff performance was also assessed. Results were analysed by usage rates, length of time in service, make and model, monitor validation status, cost, and any previous testing. Results 251 (76%, 95% CI 71-80%) of 331 tested devices passed all tests (monitors and cuffs) and 86% passed the static pressure test, deficiencies primarily due to overestimation. 40% of testable monitors were unvalidated. Pass rate on the static pressure test was greater in validated monitors (96% [95% CI 94-98%] vs 64% [95% CI 58-69%]), those retailing for over £10, and those in use for less than four years.12% of cuffs failed. Conclusion Patients’ own BP monitor failure rate was similar to that in studies performed in professional settings, though cuff failure was more frequent. Clinicians can be confident of the accuracy of patients’ own BP monitors, if validated and less than five years old.This work represents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-1209-10051). The views expressed in this study are those of the authors and not necessarily of the NHS, the NIHR or the Department of Health. RJM was supported by an NIHR Professorship (NIHR-RP-02-12-015) and by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford at Oxford Health NHS Foundation Trust. FDRH is part funded as Director of the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), Theme Leader of the NIHR Oxford Biomedical Research Centre (BRC), and Director of the NIHR CLAHRC Oxford. JM is an NIHR Senior Investigator. No funding for this study was received from any monitor manufacturer

Accuracy of blood-pressure monitors owned by patients with hypertension (ACCU-RATE study): a cross-sectional, observational study in central England.

BACKGROUND: Home blood-pressure (BP) monitoring is recommended in guidelines and is increasingly popular with patients and health professionals, but the accuracy of patients' own monitors in real-world use is not known. AIM: To assess the accuracy of home BP monitors used by people with hypertension, and to investigate factors affecting accuracy. DESIGN AND SETTING: Cross-sectional, observational study in urban and suburban settings in central England. METHOD: Patients (n = 6891) on the hypertension register at seven practices in the West Midlands, England, were surveyed to ascertain whether they owned a BP monitor and wanted it tested. Monitor accuracy was compared with a calibrated reference device at 50 mmHg intervals between 0-280/300 mmHg (static pressure test); a difference from the reference monitor of +/-3 mmHg at any interval was considered a failure. Cuff performance was also assessed. Results were analysed by frequency of use, length of time in service, make and model, monitor validation status, purchase price, and any previous testing. RESULTS: In total, 251 (76%, 95% confidence interval [95% CI] = 71 to 80%) of 331 tested devices passed all tests (monitors and cuffs), and 86% (CI] = 82 to 90%) passed the static pressure test; deficiencies were, primarily, because of monitors overestimating BP. A total of 40% of testable monitors were not validated. The pass rate on the static pressure test was greater in validated monitors (96%, 95% CI = 94 to 98%) versus unvalidated monitors (64%, 95% CI = 58 to 69%), those retailing for >£10 (90%, 95% CI = 86 to 94%), those retailing for ≤£10 (66%, 95% CI = 51 to 80%), those in use for ≤4 years (95%, 95% CI = 91 to 98%), and those in use for >4 years (74%, 95% CI = 67 to 82%). All in all, 12% of cuffs failed. CONCLUSION: Patients' own BP monitor failure rate was similar to that demonstrated in studies performed in professional settings, although cuff failure was more frequent. Clinicians can be confident of the accuracy of patients' own BP monitors if the devices are validated and ≤4 years old

Impact of Changes to National Hypertension Guidelines on Hypertension Management and Outcomes in the United Kingdom.

In recent years, national and international guidelines have recommended the use of out-of-office blood pressure monitoring for diagnosing hypertension. Despite evidence of cost-effectiveness, critics expressed concerns this would increase cardiovascular morbidity. We assessed the impact of these changes on the incidence of hypertension, out-of-office monitoring and cardiovascular morbidity using routine clinical data from English general practices, linked to inpatient hospital, mortality, and socio-economic status data. We studied 3 937 191 adults with median follow-up of 4.2 years (49% men, mean age=39.7 years) between April 1, 2006 and March 31, 2017. Interrupted time series analysis was used to examine the impact of changes to English hypertension guidelines in 2011 on incidence of hypertension (primary outcome). Secondary outcomes included rate of out-of-office monitoring and cardiovascular events. Across the study period, incidence of hypertension fell from 2.1 to 1.4 per 100 person-years. The change in guidance in 2011 was not associated with an immediate change in incidence (change in rate=0.01 [95% CI, -0.18-0.20]) but did result in a leveling out of the downward trend (change in yearly trend =0.09 [95% CI, 0.04-0.15]). Ambulatory monitoring increased significantly in 2011/2012 (change in rate =0.52 [95% CI, 0.43-0.60]). The rate of cardiovascular events remained unchanged (change in rate =-0.02 [95% CI, -0.05-0.02]). In summary, changes to hypertension guidelines in 2011 were associated with a stabilisation in incidence and no increase in cardiovascular events. Guidelines should continue to recommend out-of-office monitoring for diagnosis of hypertension

Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke--Blood Pressure) randomised controlled trial.

OBJECTIVE: To assess whether using intensive blood pressure targets leads to lower blood pressure in a community population of people with prevalent cerebrovascular disease. DESIGN: Open label randomised controlled trial. SETTING: 99 general practices in England, with participants recruited in 2009-11. PARTICIPANTS: People with a history of stroke or transient ischaemic attack whose systolic blood pressure was 125 mm Hg or above. INTERVENTIONS: Intensive systolic blood pressure target (<130 mm Hg or 10 mm Hg reduction from baseline if this was <140 mm Hg) or standard target (<140 mm Hg). Apart from the different target, patients in both arms were actively managed in the same way with regular reviews by the primary care team. MAIN OUTCOME MEASURE: Change in systolic blood pressure between baseline and 12 months. RESULTS: 529 patients (mean age 72) were enrolled, 266 to the intensive target arm and 263 to the standard target arm, of whom 379 were included in the primary analysis (182 (68%) intensive arm; 197 (75%) standard arm). 84 patients withdrew from the study during the follow-up period (52 intensive arm; 32 standard arm). Mean systolic blood pressure dropped by 16.1 mm Hg to 127.4 mm Hg in the intensive target arm and by 12.8 mm Hg to 129.4 mm Hg in the standard arm (difference between groups 2.9 (95% confidence interval 0.2 to 5.7) mm Hg; P=0.03). CONCLUSIONS: Aiming for target below 130 mm Hg rather than 140 mm Hg for systolic blood pressure in people with cerebrovascular disease in primary care led to a small additional reduction in blood pressure. Active management of systolic blood pressure in this population using a <140 mm Hg target led to a clinically important reduction in blood pressure.Trial registration Current Controlled Trials ISRCTN29062286.This report is independent research funded by the National Institute for Health Research (Stroke Prevention in Primary Care, Programme Grant for Applied Research, RP-PG-0606-1153), and by an NIHR Professorship (Prof McManus). FDRH is part funded as Director of the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), Theme Leader of the NIHR Oxford Biomedical Research Centre (BRC), and Director of the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS. The study sponsor was the University of Birmingham. The study funder and sponsor had no role in the study design, collection, analysis or interpretation of data, in the writing of the report, or in the decision to submit to publication. The researchers are independent of the funders.This is the final version of the article. It first appeared from the BMJ Publishing Group via http://dx.doi.org/10.1136/bmj.i70