Original ArticlesCardiovascular Morbidity and Mortality Among Hypertensive Patients in General Practice: The Evaluation of Long-Term Systematic Management
Introduction
Hypertension is one of the principal risk factors associated with cardiovascular disease 1, 2. The success of short-term interventions with drug treatment in hypertensive patients has already been shown convincingly [3]. Interestingly, the most spectacular results of these studies were obtained among elderly [4]. However, the outcome of systematic management of hypertensive patients in general practice has been studied much less, and long-term studies in this field in particular are rare.
General practitioners (GPs) in The Netherlands are in a good position to implement prevention of cardiovascular disease, as are those in the United Kingdom 5, 6. The continuity of care, the fixed practice list of Dutch GPs, and the low threshold on the part of patients to consult GPs give them the opportunity to detect, treat, and follow patients who have a high risk for cardiovascular diseases. Systematic management involves surveillance and treatment of several risk factors, as well as of established cardiovascular disease.
In 1978, four general practitioners in Eindhoven (The Netherlands) started a systematic hypertension management program, including detection, treatment, and long-term management of hypertension. Systematic registration of patient data was an essential element of this program. As a substantial number of patients were employees of a local major electronic company with periodic occupational health examinations, also independent and standardized data on these patients are available. Because this company is the major employer in the region, it was also possible to identify a large reference group of hypertensive patients who were not registered in these four practices. This unique situation has led us to examine the following questions: (i) Are there differences in cardiovascular morbidity and mortality between hypertensive patients under systematic management and hypertensive patients under usual general practice care? (ii) What are the differences in time course of cardiovascular risk factors between both groups?
Section snippets
Design
This article reports on a follow-up study among two subcohorts: an index and a reference group of hypertensive patients. The index group was characterized by participation in a systematic management program for hypertensive patients. The reference group receiving “usual care” for hypertension was established by matching. The number of cardiovascular events and the time course of cardiovascular risk factors was compared between these two groups. Cardiovascular events were measured over the
Comparability of the Index and the Reference Group
Table 1 shows the baseline characteristics of the two groups. The mean duration of hypertension was 4.5 years for the index group, and 3.4 years for the reference group. Substantial differences between the two groups were found for SES, family history of hypertension, baseline blood pressure, and GFR. The baseline blood pressure was clearly higher in the index group (164/103 SBP/DBP mmHg) than in the reference group (148/95 SBP/DBP mmHg). The reference group consisted of more patients of high
Discussion
This cohort study demonstrates that more than 10 years of systematic management of hypertensive patients, i.e., systematic treatment and follow-up in general practice, is associated with lower cardiovascular morbidity rates as compared with usual care, as well as with a larger decrease in systolic and diastolic blood pressure in patients aged 50 to 65 years. Unlike blood pressure, the differences between the index and the reference groups with regard to other risk factors such as increased
Acknowledgements
The authors thank Mrs. D. Kriegsman, M.D., Ph.D. for her help in carrying out the survival analysis.
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