French national health insurance has carried out two nationwide surveys as part of its programme intended to improve the care given to patients with hypertension, focusing on affiliates diagnosed with severe hypertension entitled to exemption from co-payments (patients are reimbursed 100 per cent for all care related to the corresponding disorder). The objective was to measure the difference between observed care and the quality of care delineated in the guidelines (1997) elaborated by the National Agency for Healthcare Accreditation and Evaluation (ANAES). The before and after comparison was designed to determine whether actual care is in accordance with the guideline's standards. The initial survey took place from 31 May to 12 November 1999 over the entire French territory (metropolitan and overseas departments) and concerned a representative sample of patients whose ages ranged from 20 to 80 years at the time they qualified for exemption from co-payments for severe hypertension. The method used for comparison involved the calculation of a number of different evaluation parameters, the principal one being blood pressure control, using the systolic (PAS) and diastolic (PAD) pressures reported by attending physicians. Other evaluation parameters included the quality of the therapeutic strategy utilized. A total of 10,665 patients were enrolled in the survey by using information gathered from 8377 practicing physicians. Extrapolated to the entire population in 1999, the results can be applied to 50,383 patients. The average age was 63 years and the patients had been treated for hypertension for an average of 9 years. In addition to severe hypertension, 64 per cent of the patients had other significant high-risk factors for cardiovascular disease: 44 per cent had dyslipidemia, 28 per cent had diabetes mellitus, 15 per cent were smokers. In 41 per cent of cases, the patients' blood pressures were well controlled (systolic and diastolic pressures below 140/90 mmHg or, for patients older than 60 years with only isolated systolic hypertension, systolic pressure equal to or lower than 160 mmHg); in 12 per cent of cases the patients' blood pressures were equal to the limit values; in 47 per cent of cases blood pressure was poorly controlled. Diabetics had poorly controlled blood pressure in 85 per cent of cases (systolic or diastolic pressures greater than 130/85 mmHg) and, similarly, 94 per cent of the patients who were in renal failure were poorly controlled (systolic or diastolic pressures greater than 125/75 mmHg). Preferential prescription with a particular therapeutic class, because of an existing comorbidity, was found in 68 per cent of patients whereas potentially contraindicated therapeutic classes were prescribed in 27 per cent. The daily cost of anti-hypertensive drug therapy was estimated at 8.05 francs per day per patient. Extrapolated to the study population in 1999, this represents 148.1 million francs. Less than 1 per cent of this observed cost (1.1 million francs) was economized by prescribing less expensive, alternative drug specialties in spite of the fact that an estimated 9.6 million francs could have been saved if these equivalent, alternative drugs had been prescribed. The potential saving corresponds to 6.5 per cent of the total observed cost. The care given to severely hypertensive patients is sub-optimum when compared with the ANAES guidelines (1997). In public health terms, the most preoccupying feature is poor blood pressure control because it occurs in a patient population with a high cardiovascular risk. These findings fully justify the continuation and amplification of the actions undertaken in this nationwide public health programme concerning the medical care given to hypertensive patients.

Antihypertensive Agents↗

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[Management of severe hypertension in France in 1999 and 2000: intermediate results of a health insurance intervention program].

AIM: Within the framework of its long-term public health program aimed at improving the clinical management of hypertension (HBP), the French health care funds performed two nationwide surveys concerning affiliates who were recently waived from making co-payments for severe hypertension. The aim was to measure the difference between observed clinical management and benchmark care, defined by the 1997 ANAES guidelines (National Agency for Accreditation and Health Evaluation), at the onset (May 1999) and during the program (November 1999) in order to detect any changes in clinical management between the two study periods, the timeframe corresponding to the intervention period. METHODS: The patient samples used in the two studies involved affiliates aged between 20 and 80 years old living in France or one of its overseas territories who were recently waived from making co-payments (ETM) for severe hypertension (these patients are reimbursed 100% for all care related to the disorder). The evaluation was based on retrospective data furnished by attending physicians. The indicators isolated in order to compare the two study periods were blood pressure control, suggested life-style changes and prescribed drugs. RESULTS: The first survey took place between May and November 1999 and enrolled 10,665 patients (corresponding to a weighted patient population of 50,383) while the second studied 2,649 patients in November 2000. The study population in 1999 was, on the average, younger than the study population in November 2000: 63.1 years +/- 0.2 vs 65.4 years +/- 0.4. Nearly two patients out of three presented at least one other major cardiovascular risk factor in addition to HBP (cigarette smoking, diabetes mellitus or dyslipidemia): 63.9% in 1999 and 64.4% in 2000. Nearly one patient out of seven had associated coronary artery disease: 14.1% in 1999 and 15.3% in 2000 and more than one out of ten had associated cerebro-vascular disease: 12.7% in 1999 and 12.2% in 2000. There were more diabetic patients in the 1999 group than in the 2000 group: 27.5% +/- 1.0 vs 23.9% +/- 1.6. The proportion of patients who had poorly controlled blood pressure (systolic > 140 mmHg or > 160 mmHg in subjects aged between 60 and 80 years with isolated systolic hypertension, or a diastolic > 90 mmHg) did not change: 46.8% +/- 1.1 in 1999 and 45.7% +/- 1.9 in 2000. If the guideline recommendations for diabetics (blood pressure < 130/85) are applied. 85.4% of the diabetic patients were poorly controlled in 1999 and 86.6% in 2000. Similarly, in hypertensive patients with kidney failure (guideline recommendations: < 125/75 mmHg), 94.5% were poorly controlled in 1999 and 96.3% in 2000. Recommended life-style changes (reduction in salt intake, weight loss, lower alcohol consumption, increased physical activity) were not well followed in both studies: in 1999, fewer than one patient out of four completely implemented the desired changes (23.7%) while only 24.5% did so in 2000. Physicians prescribed specifically indicated therapeutic agents considering associated diseases in 68.0% of the patients in 1999 and in 67.6% in 2000. Prescriptions contained a potentially contraindicated drug in 27.3% of the cases in 1999 and in 28.0% in 2000. CONCLUSION: A comparison of the results of the two surveys performed in 1999 and 2000 concerning the management of patients with severe hypertension failed to demonstrate any significant differences in blood pressure control or treatment modalities. While not questioning the value of the interventions of the health funds, these findings illustrate how difficult it is to change clinical practice over a short time period, especially in a disorder involving a number of different elements which include, among others, individual patient behavior. In order to significantly improve clinical management, it will probably be necessary to continue the dialogue between medical advisors of the health care funds (médecins conseils) and clinicians and to renew campaigns aimed at helping patients become more responsible.

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PubMedDate not supplied

[A comparison of the management of severe high blood pressure between 1999 and 2003 in France].

AIM: To measure the change in blood-pressure control in two populations of patients with severe high blood pressure between 1999 and 2003. METHOD: The French National Healthcare Fund performed two observational, cross-sectional surveys on the medical management of high blood pressure, the first in 1999 and the second in 2003. Each survey enrolled patients aged between 20 and 80 years old who filed a first-time request for exemption from co-payments for this long-term disorder. Study data was collected by the health fund's salaried physician advisors who directly examined the patients and from information gathered from each patient's attending physician. Adequate blood pressure control was defined according to the guidelines set out by the ANAES in 1997 and determined by calculating the average of the last three blood pressure figures recorded by the patient's attending physician (systolic [SBP] and diastolic [DBP] arterial blood pressures). RESULTS: 10,665 patients were enrolled in the 1999 survey and 2,584 were enrolled in the 2003 survey. The average age was 63.1 +/- 0.2 years in 1999 and 64.4 +/- 0.4 years in 2003. The proportion of diabetic patients in the two surveys remained stable: 27.5% +/- 1.0 in 1999 and 28.4% +/- 1.7 in 2003. Between 1999 and 2003, the percentage of patient who were treated for hypercholesterolemia increased from 44.0% +/- 1.1 to 54.3% +/- 1.9. Between 1999 and 2003, the proportion of patients who were considered well-controlled (SBP and DBP < 140/90 mmHg) or, if older than 60 years with isolated systolic high blood pressure (DBP < 90 mmHg and SBP < or = 160 mmHg) increased almost 5% points, going from 40.8% +/- 1.1 in 1999 to 45.5% +/- 1.9 in 2003. In diabetic patients, in whom the cut-off threshold is 130/85 mmHg, 6.7% +/- 1.1 were considered well-controlled in 1999 while 5.4% +/- 1.7 were deemed well-controlled in 2003. The proportion of well-controlled patients in the sub-group of hypertensive patients with renal failure (cut-off thresholds: 125/75 mmHg) remained relatively stable between 1999 and 2003: 5.2% [2.5; 7.9] versus 2.8% [0.5; 8.6]. CONCLUSION: There was a significant increase in the proportion of well-controlled hypertensive patients between 1999 and 2003. This increase occurred at the same time as a number of initiatives (scientific societies, federal government as well as the National Health Fund) intended to sensitize physicians to the need to obtain adequate blood pressure control.

Aged↗

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[From one's actual life to its expression in verbal behavior].

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