Topics

Cardiovascular diseases

Cardiovascular diseases Letters 16 May 2022 Free

Uncontrolled blood pressure in Australia: a call to action

To the Editor: We congratulate Schutte and colleagues1 for their call to action for improved management of blood pressure in Australia, highlighting that 68% of people have uncontrolled high blood pressure. The burden of high blood pressure is unevenly distributed, with Aboriginal and Torres Strait Islander (hereafter referred to respectfully as Indigenous) people reportedly having a higher rate of high blood pressure than non‐Indigenous Australians in every age group.2 Reducing the prevalence of high blood pressure is one of the most important means of reducing serious circulatory diseases, which are among the leading causes of death for Indigenous Australians.3 Hence, we want to extend the call to action and report on what is happening in primary health care settings with the control of blood pressure for Indigenous people. During 2012–13, we analysed blood pressure screening and follow‐up for patients diagnosed with hypertension (n = 6523) from 123 primary health care centres across Australia using continuous quality improvement data from audits of adherence to best practice chronic illness care.4 Given there are no recently available data on follow‐up actions after an abnormal blood pressure reading at this geographic scale, and as blood pressure continues to be relatively uncontrolled, these data continue to provide unique insight. The data, aggregated at primary health care centre level (Box), tells a story of clinical inertia. Regular blood pressure screening was done well — centres on average completed blood pressure screening for about 90% of patients within the past 6 and 12 months. In this cohort, about 65% of patients recorded abnormal blood pressure (n = 4240). Most primary health care centres had documentation of a follow‐up plan for more than 70% of patients, but there was wide variation (range, 0–100%; Box). Dealing with the low levels of medication reviews and adjustments (mean, ~15%; range, 0–100%) is a vital early step in limiting the contribution of uncontrolled blood pressure to adverse health outcomes for Indigenous people. These data support the need for training on strategies to overcome clinical inertia, which was identified as a top priority by over 200 Indigenous primary health care practitioners, managers and policymakers.5 We add to the call for more attention on prevention of cardiovascular disease and suggest additional investment in evidence‐based interventions appropriate to Indigenous Australian culture and needs. The time for system‐wide action has come. Box – Boxplots showing a record of scheduled services received by patients with hypertension and follow‐up of abnormal findings within the last 12 months of audit (unless otherwise indicated) at primary health centres during 2012–13 x = mean value. More information on how to interpret box plots is available in Matthews et al.4

Jodie Bailie · Veronica Matthews · Ross S Bailie

Mja2 51503
Cardiovascular diseases Letters 15 November 2021 Free

Absolute risk assessment for guiding cardiovascular risk management in a chest pain clinic

To the Editor: We read with interest the study by Black and colleagues1 on the effectiveness of a pro‐active risk factor management strategy based on absolute cardiovascular disease risk score compared with usual care, in a rapid access chest pain clinic setting. The study suggested that such a strategy significantly improved 5‐year cardiovascular risk scores; however, we would consider some caution before reaching such a conclusion. Although the authors point out several potential sources for bias in their study, there is an additional one that has not been highlighted. In the results, the authors state that “the increase in use of guideline‐based therapies was similar in the two groups,” yet do not go on to explain the differential effect as to why the blood pressure and lipid profiles decreased in the interventional group only. We suggest that the reason for this lies in a fundamental difference between the groups selected. The interventional group at baseline was receiving proportionately greater amounts of lipid‐lowering and anti‐hypertensive therapy: 56% and 30% higher, respectively, than in the control arm. These higher treatment rates may explain the lower blood pressure, the lipid profiles observed and, consequently, the improved final risk scores in the interventional arm. Also, as the authors pointed out, almost a third of eligible patients approached declined to participate and is therefore an important source of potential selection bias. We also note that the offer of referral to a public smoking cessation service was limited to those in the intervention group. National guidelines recommend this strategy as part of standard care,2 and hence we question whether this intervention should truly be considered to deviate from best practice or usual care.

Penni L Blazak · Kim Greaves

Cardiovascular diseases Letters 16 August 2021 Free

Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

To the Editor: The research letter by Hespe and colleagues1 on cardiovascular disease prevention is itself a missed opportunity to illuminate the complexities of person‐focused management of patients in general practice. While it provides a snapshot on cardiovascular disease prevention, it does not offer any exploration of the veracity or otherwise of these findings. Aggregate decontextualised and — as acknowledged — limited data ultimately fail to identify the true nature of the problem. Simply focusing on easily extractable data from computerised medical record systems, without linkage to the unique features and context of the person to whom these data belong, necessarily results in a distorted picture. Big data has the potential to inform only if it is appropriately interpreted and may be useful in process monitoring. Such data have a limited role in assessing general practitioner performance and outcomes of care.2 One must always remember that guidelines are nothing more than guides, which must be appropriately adapted to the unique circumstances of each patient. A more relevant research question would be: how appropriately or inappropriately are preventive treatments applied? This question addresses both overtreatment and undertreatment.3 As a binary question, however, it fails to ask more important contextual questions such as whether the patient can cope with the demands of the treatment, whether the treatment decision is a truly informed one, and whether it fits the needs and expectations of the patient given other health concerns. It ignores entirely the impact of a therapeutic alliance on actual health outcomes.4 Finally, the implied need for a hawkish attitude to prevention must take account of the fact that no intervention is risk‐free. Our obligation clearly states: primum non nocere. Research aiming to improve understanding of the interdependencies inherent in each and every consultation is urgently needed. The health and wellbeing outcomes of medical care are far less determined by biomedical interventions than by the contextual stressors in a person’s life.5 Providing general practice with the tools and resources to truly address the complexities of our patients’ needs is of utmost urgency.

Joachim P Sturmberg · Carmel M Martin

Mja2 51193

Subscribe to MJA email alerts

No spam, you can unsubscribe anytime you want.

By providing your information, you agree to our Terms of Use and our Privacy Policy.

Thanks for Subscribing! Tell us more

Your email updates will use your name.

Good one! Your updates are coming

Thank you for subscribing to the MJA email alerts. Receive the latest content in your inbox.