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  • Title: [Management of severe hypertension in France in 1999 and 2000: intermediate results of a health insurance intervention program].
    Author: Tilly B, Guilhot J, Salanave B, Fender P, Allemand H.
    Journal: Arch Mal Coeur Vaiss; 2002; 95(7-8):687-94. PubMed ID: 12365081.
    Abstract:
    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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