Search

Despite improvements in the control of hypertension in the United States, there is evidence that considerable numbers of people still have uncontrolled high blood pressure (BP). Because mortality and morbidity are reduced in proportion to BP reduction, it is important to identify the major causes of failure to control hypertension. This article summarizes the results of various studies of BP control: population surveys, assessments of usual practice, worksite programs, large-scale special projects, and quality assurance programs. The evidence suggests that patient characteristics and behaviors explain much of the poor BP control in patients under care. The most important of these patient factors is compliance. However, other factors associated with poor BP control are excessive alcohol intake, life stress, lower income, younger age, black race, male sex, and unmarried state. In evaluating BP control, the clinician and researcher must also be aware of various measurement effects that may lead to erroneously high BP readings.

In an institutional quality assurance program in hypertension, performance of tests, control of blood pressure, and follow-up were monitored through a computer program that was developed to audit records in an automated record system. Two types of feedback previously shown to be effective were provided quarterly for a period of one year to experimental providers. For all hypertensives considered together, there were no differences between scores of Experimental and Control providers based on percentage of patients meeting pre-set criteria in testing--87% vs 87%--, blood pressure control--58% vs 59%--, or follow-up--79% vs 77%. Only small but significant differences occurred in the subgroup of moderate to severe hypertensives. There appear to be limitations to what can be accomplished through hypertension quality assurance interventions directed at providers of care in this institutional setting. Interventions designed to deal directly with patients whose blood pressures are uncontrolled may be more effective.

An automated surveillance system utilizing a computer-based medical record system (COSTAR) was designed to improve the follow-up of patients with newly identified elevated diastolic blood pressure. A population of patients was selected where, in the 6-month period following the initial measurement of an elevated diastolic blood pressure, there were fewer than two visits during which blood pressure was recorded. In a randomized controlled clinical trial, this poor follow-up population was divided into two groups, with computer-generated reminders being automatically generated for only patients in the experimental group. Follow-up was significantly improved in the group receiving the reminders, both in terms of rate of follow-up attempted or achieved by the responsible physician and in the repeated recording of blood pressure. We conclude that a computer-based reminder system improves follow-up of newly discovered elevation in diastolic blood pressure.