Fs Howes

Guideline for the diagnosis and management of hypertension in adults - 2016

The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010).

Ankle-Brachial Index determination and peripheral arterial disease diagnosis by an oscillometric blood pressure device in primary care: validation and diagnostic accuracy study

Objectives To determine the level of agreement between a ‘conventional’ Ankle-Brachial Index (ABI) measurement (using Doppler and mercury sphygmomanometer taken by a research nurse) and a ‘pragmatic’ ABI measure (using an oscillometric device taken by a practice nurse) in primary care. To ascertain the utility of a pragmatic ABI measure for the diagnosis of peripheral arterial disease (PAD) in primary care. Design Cross-sectional validation and diagnostic accuracy study. Descriptive analyses were used to investigate the agreement between the two procedures using the Bland and Altman method to determine whether the correlation between ABI readings varied systematically. Diagnostic accuracy was assessed via sensitivity, specificity, accuracy, likelihood ratios, positive and negative predictive values, with ABI readings dichotomised and Receiver Operating Curve analysis using both univariable and multivariable logistic regression. Setting Primary care in metropolitan and rural Victoria, Australia between October 2009 and November 2010. Participants 250 persons with cardiovascular disease (CVD) or at high risk (three or more risk factors) of CVD. Results Despite a strong association between the two methods measurements of ABI there was poor agreement with 95% of readings within ±0.4 of the 0.9 ABI cut point. The multivariable C statistic of diagnosis of PAD was 0.89. Other diagnostic measures were sensitivity 62%, specificity 92%, positive predictive value 67%, negative predictive value 90%, accuracy 85%, positive likelihood ratio 7.3 and the negative likelihood ratio 0.42. Conclusions Oscillometric ABI measures by primary care nurses on a population with a 22% prevalence of PAD lacked sufficient agreement with conventional measures to be recommended for routine diagnosis of PAD. This pragmatic method may however be used as a screening tool high-risk and overt CVD patients in primary care as it can reliably exclude the condition.

Home blood pressure monitoring: Australian Expert Consensus Statement

Measurement of blood pressure (BP) by a doctor in the clinic has limitations that may result in an unrepresentative measure of underlying BP which can impact on the appropriate assessment and management of high BP. Home BP monitoring is the self-measurement of BP in the home setting (usually in the morning and evening) over a defined period (e.g. 7 days) under the direction of a healthcare provider. When it may not be feasible to measure 24-h ambulatory BP, home BP may be offered as a method to diagnose and manage patients with high BP. Home BP has good reproducibility, is well tolerated, is relatively inexpensive and is superior to clinic BP for prognosis of cardiovascular morbidity and mortality. Home BP can be used in combination with clinic BP to identify ‘white coat’ and ‘masked’ hypertension. An average home BP of at least 135/85 mmHg is an appropriate threshold for the diagnosis of hypertension. Home BP may also offer the advantage of empowering patients with their BP management, with benefits including increased adherence to therapy and lower achieved BP levels. It is recommended that, when feasible, home BP should be considered for routine use in the clinical management of hypertension.

Barriers to lifestyle risk factor assessment and management in hypertension: a qualitative study of Australian general practitioners

Hypertension is a leading cause of mortality and disease burden worldwide, yet its management remains suboptimal. Identification and management of lifestyle risk factors should be a clinical priority in all patients because of the beneficial effects of lifestyle intervention on blood pressure. The objective of this qualitative focus group study was to identify barriers to lifestyle management in hypertension in Australian general practice. Purposeful sampling was used to select large group practices. Six focus groups (n=30) were audio recorded and transcribed. An iterative thematic analysis was conducted. Overall participants felt they had the required knowledge to provide broad lifestyle advice. However, cynicism dominated due to an overwhelming lack of success in practice. Patient reluctance and ambivalence were identified as major barriers but participants were willing to share the responsibility. Other barriers included time, reduced access to allied health and broader determinants of health. General practitioners need to be empowered to allow continuation of valuable lifestyle advice and counselling. The results emphasise the importance of ongoing lifestyle assessment and tailoring of management to the complex interplay of factors that impact on a patient’s ability to adopt and maintain lifestyle change. System issues need to be addressed to provide better streamlined care.

Whole person care, patient-centred care and clinical practice guidelines in general practice

ABSTRACT Clinical practice guidelines (CPGs) are a central technique within the evidence-based medicine (EBM) movement. General practice is an area of medicine that seems to be particularly resistant to the use of CPGs. This article contributes to the debates about GPs and CPGs by reflecting on three different Australian studies conducted by the authors in an attempt to better understand variations between GPs’ practices and the recommendations found in relevant CPGs. These projects focused on dementia, chronic obstructive pulmonary disease and hypertension (high blood pressure). A common finding across the three studies was that GPs described how their focus on the whole person and their patients’ priorities and needs meant that the recommendations found in CPGs were not always appropriate or easy to apply. In doing this, our study participants were describing tensions between the holistic/whole person and patient-centred approach of GPs and the narrow disease-specific focus of guidelines. Our work provides insight into the rationality of GPs and illustrates some of the ways that whole person care and patient-centred care create operational challenges to the application of EBM in the form of CPGs.

Research: Why aren’t more medical students doing it?

Background: Many medical schools in Australia and Internationally struggle to engage medical students along a research pathway. Aims: The aim of this study was to identify medical student’s confidence, attitudes and perceived obstacles to participating in research during medical school. Methods: A cross-sectional survey was carried out of undergraduate medical students in years 1–5 attending the University of Tasmania. Results: Of the 237 students who responded to the survey (response rate of 41.9 per cent) the majority (70.3 per cent) agreed that research was a useful experience and expressed a desire to be involved in research (60.1 per cent). Women were generally less confident than men in their ability to conduct research while research experience was significantly associated with an increase in confidence in conducting research. Frequently endorsed reasons by students for not undertaking an Honours year were a desire to not delay graduation by a year for financial (79 per cent) and employment reasons (71 per cent) and social concerns regarding integrating with a different year group (69 per cent). Additional concerns included a lack of time and motivation. Conclusion: The difficulties inherent for students in undertaking research including low confidence, lack of time, financial constraints and pressure to get out into the workforce should help to inform medical educators in developing solutions to encourage student participation in research.

A qualitative study of the role of Australian general practitioners in the surgical management of obesity

General practitioners (GPs) are increasingly managing patients with class 2 and 3 obesity (body mass index [BMI] > 35 and 40 kg/m2, respectively). Bariatric surgery is considered for patients with class 2 obesity and comorbidities or class 3 obesity where sustained weight loss using non‐surgical interventions has not been achieved. In Australia, GPs facilitate access to surgery through referral processes, but the nature of GP involvement in bariatric pre‐ and post‐surgery care is currently unclear. This qualitative study involved 10 in‐depth interviews with GPs and 20 interviews with adults who had all undergone laparoscopic adjustable gastric banding (LAGB) for weight management in Tasmania, Australia. Interviews were transcribed and analysed thematically. Referrals for bariatric surgery commonly occurred at the patients request or to manage comorbidity. Consistent with previous studies, for GPs, referral patterns were influenced by previous case experience and patients’ financial considerations. Accessibility of surgery was also a consideration. Post‐surgery, there was a lack of clarity about the role of GPs, with patients generally preferring the surgical team to manage the LAGB. In bariatric surgery, patient preference for surgery, access and comorbidity are key drivers for referral and post‐surgical monitoring and support. Greater role clarity and enhanced collaboration between surgeons, GPs and patients following surgery is likely to enhance the experience and outcomes for patients.

8 BARRIERS TO LIFESTYLE DISCUSSIONS IN HYPERTENSION: A QUALITATIVE STUDY OF AUSTRALIAN GENERAL PRACTITIONERS

Background: Despite hypertension being a leading cause of mortality and disease burden worldwide its management remains suboptimal. Lifestyle interventions have significantly beneficial effects on hypertension such that lifestyle risk factors should be identified and managed in all patients regardless of blood pressure measured. Design and methods: Six focus groups involving 30 general practitioners (GPs) were conducted. Focus groups were audio recorded and transcribed verbatim. An iterative thematic analysis was conducted. This paper, which aims to identify barriers specifically to lifestyle risk factor management in hypertension in Australian general practice is drawn from our previous work which identified and explored barriers to managing hypertension in general1. Results: Although participants felt they had the broad knowledge and skills required to provide lifestyle advice and counselling, they described an overwhelming lack of success in practice. Participants described the complex interplay of factors that impact on a patients ability to adopt and maintain lifestyle change. Patient ambivalence and reluctance were identified as major barriers, but interestingly GPs described shared responsibility for their patients failure. Other barriers included time constraints, inability to provide regular follow-up, lack of access to allied health practitioners, and broader determinants of health. Conclusion: There is a need to improve the self-efficacy of GPs so they continue to provide valuable lifestyle advice and counselling. The results emphasise the importance of ongoing lifestyle assessment and tailoring of management appropriate to the patients readiness to change. System issues exist and need to be addressed to better streamline provision of care. ReferencesHowes F, Hansen E, Williams D, Nelson MR. A qualitative study of barriers to initiating treatment in hypertension and treating to target levels in primary care. Australian Family Physician 2010; 39(7):511-516.

10 PRINCIPAL RESULTS OF THE ANKLE BRACHIAL INDEX DETERMINATION BY OSCILLOMETRIC METHOD IN GENERAL PRACTICE (ABIDING) STUDY

Background: Ankle-Brachial Index (ABI) is rarely done in primary care due to the need for specialised equipment and training. ABIDING investigated the utility of a pragmatic method for ABI determination of ABI and diagnosis of peripheral arterial disease (PAD) in primary care. Design and methods: Cross-sectional validation and diagnostic accuracy study in Australian general practice in 2009-10 of 250 persons with cardiovascular disease or high risk of said. ABIs were done by a research nurse using a mercury sphygmomanometer and Doppler (conventional) and a practice nurse using an oscillometric device (pragmatic). The Bland-Altman plot between the ABI readings was used to investigate the agreement between the two procedures. Correlations between the paired readings were also calculated. The diagnostic accuracy was evaluated using ROC analysis and quantified as the C statistic. We also examined likelihood ratios. Results: There was no systematic bias between the ABI measures, difference = 0.002 (95% CI -0.024, 0.020). However, the Bland-Altman plot of ABI readings for the lowest ABI revealed poor agreement, where 95% of the readings were within ± 0.36. Multivariable C statistic for the pragmatic ABI method for PAD diagnosis in comparison to the conventional method gave: sensitivity 53% (95% CI 35-70%); specificity 97% (93-99%); positive predictive value 75% (53%-90%); negative predictive value 92% (88–95%); +LR 7.3 (4.4, 12.0); -LR 0.42 (0.30, 0.59). The C statistic of diagnosis of PAD was 0.88 (0.87). Conclusion: The +LR provides moderate evidence that a pragmatic ABI <0.9 can diagnose PAD, but low -LR suggests >0.9 won’t exclude it.