Hypertension is the most commonly reported long-term condition in the UK, estimated to affect one in three adults;1 however, it is underdiagnosed, and it is often suboptimally managed when diagnosed.2 This is despite well-established evidence that lifestyle modification and therapeutic treatment are highly effective in reducing fatal and non-fatal events, and morbidity. In this issue of the BJGP, two articles explore some of the obstacles to effective management of hypertension.3,4
CONTINUITY OF CARE
Xu and colleagues explore the influence of continuity of care on cardiovascular disease (CVD) prevention for individuals with hypertension in Hong Kong.3 They consider a team-based continuity of care model by comparing the impact of being cared for by the same physician-team (typically comprising three physicians) versus multiple different teams. The study finds that patients with hypertension managed by the same physician-team are less likely to develop CVD or die than those cared for by a wider range of teams, with benefits of continuity greater in patients under the age of 65 and in those with fewer comorbidities. This study raises the question of whether continuity is an important element for effective blood pressure management.
Understanding exactly what is meant by continuity of care can be complicated: continuity of care is defined, assessed, and delivered in a variety of ways, including individual-based, team-based, and organisational continuity of care.5
Even within the same organisational setting, such as UK general practice care, there has been a decline in individual-based continuity of care.6 Although prevalent throughout the 20th century, the model of a single doctor providing all care is no longer sufficient for the needs of a 21st century society. Health care is more complex, and electronic records provide important and accessible records of care, meaning an expanded team of nurses, pharmacists, healthcare assistants, locums, and registrars are taking on the ongoing review of many long-term conditions, such as hypertension, and stretching the concept of team-based continuity of care still further.
On the basis of multiple studies, including Xu et al, some form of continuity of care is preferable to patients and can influence outcomes, though it may be more relevant in some settings such as palliative care or complex comorbidity.3,7,8 Even allowing for known variables, people organised to plan ahead and ensure they see the same clinicians on a regular basis may differ in social characteristics and risk factors from those accessing any available doctor. In this circumstance, the effect of confounding on outcomes is likely to be substantial. To date, trial evidence on the benefit of continuity of care is lacking, yet both patients and GPs express a preference for continuity of care.8 A 2023 YouGov survey of 4000 patients in the UK commissioned by the Rebuild General Practice campaign found that a majority (57%) thought it important to see the same GP each time they visit their local surgery.9 The consequent access versus continuity conundrum is well recognised, and possible solutions include the team-based approach of Xu et al, as well as identifying those most likely to require continuity of care.3,8 A potential first step in the latter is identifying population groups most in need of additional support to successfully manage their hypertension.
(IN)EQUITY OF CARE
Many individuals with hypertension can and do manage their condition appropriately; the latest NHS England Quality and Outcomes Framework (QOF) data show that 76% of adults with hypertension met their age- adjusted blood pressure target — but this also means almost one-quarter of patients with hypertension do not, and there is not an equitable distribution of poor control.2 In our study, published in this issue of the BJGP, we explored health inequities in the monitoring and management of hypertension in North East London.4 Our results align with several previous studies — for example, individuals with hypertension from Black ethnic groups were almost 10% less likely to have controlled blood pressure than those in White ethnic groups. Patients under the age of 50 were 40% less likely to have controlled blood pressure than those older. This inequity affects a significant number of people as almost one in five people with hypertension in North East London are under the age of 50.4
OLD ENOUGH TO TREAT?
The lower likelihood of younger adults to have controlled hypertension may, in part, lie with National Institute for Health and Care Excellence guidelines.10 For individuals diagnosed with hypertension and a 10-year risk of CVD of 10% or more, clinicians are recommended to discuss starting antihypertensive drug treatment. For individuals with a 10-year risk below 10%, clinicians are only asked to ‘consider’ treatment. This may mean some younger individuals may not be treated. As age is a major contributor to cardiovascular risk, this is, in effect, waiting for patients to be ‘old enough to treat’. The recently published 2023 European Society of Hypertension guidelines for the management of hypertension eschew cardiovascular risk cut-offs and advise ‘earlier in-life treatment of hypertension as well as treatment implementation also when CV risk is still low-to-moderate’.11 In contrast, Jackson and Wells propose that treatment should not be predicated on blood pressure — since all adults with a blood pressure over 115/75 mmHg are past the blood pressure inflection point where risk of CVD directly corelates with rising blood pressures and could arguably be deemed hypertensive — but rather that ‘the magnitude of their predicted (absolute) vascular risk […] should inform the intensity and type of management’.12 Notwithstanding this debate on thresholds, the management of hypertension in younger individuals and in Black ethnic groups deserves to be better.
ACCESS TO (THE RIGHT) CARE
Continuity of care and access to care are unevenly distributed.13 More information is needed from Black ethnic groups and younger age groups about their experience in hypertension management. We need to reach out to underserved communities to co-develop appropriate services.14
Access need not necessarily be more frequent, but rather simpler, more efficient, and patient centred (and, for certain individuals, more continuous); treatment regimes including low-cost combined antihypertensive pills (cheaper also for patients) and patient-centred management plans could improve control rates.11,15 For some, home monitoring may be attractive and effective, and for some in Black ethnic groups there may also be a need for more intensive treatment strategies.10,11,15
Recognising who needs what kind of additional support is the first step toward addressing the problem.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2023