https://orcid.org/0000-0001-5257-6261
Abstract
Purpose
To explore hypertension management in primary healthcare (PHC).
Design
Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021.
Setting
Seventy-six PHCCs in eight regions of Sweden.
Main outcome measures
Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up.
Results
The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% (p < 0.001) and 61% to 43% (p = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in ≥96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300–11300) patients.
Conclusions
The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.
Key points
Hypertension is mainly handled in primary healthcare (PHC), and this study shows important dissimilarities in organization and clinical management.
Several variants in techniques and measurements of blood pressure were found between PHC centres.
Lifestyle, clinical and laboratory assessments decreased at follow-ups compared to at diagnosis, specifically for lipids, microalbuminuria and electrocardiograms.
Nearly half of the PHC centres reported that they had dedicated hypertension teams.
Introduction
Hypertension is a common condition and the most important risk factor for renal and cardiovascular disease and premature death [Citation1]. The causes of hypertension are partly unknown, but both genetic factors and lifestyle habits, such as high caloric and alcohol intake, smoking and physical inactivity, contribute [Citation2]. The prevalence of hypertension among adults is estimated to be between 20% and 30%, and for seniors, it is more than 50% [Citation3,Citation4]. Treatment consists of lifestyle interventions and antihypertensive drugs, which have been shown to lower blood pressure (BP) and prevent or postpone complications [Citation5]. Optimal drug treatment is important, and there are several drugs that are both effective and inexpensive. Despite this, several studies have shown that only about 50% of patients with hypertension achieve treatment goals [Citation6,Citation7], even if blood pressure control has improved gradually over the last decades [Citation8].
Most patients with hypertension are diagnosed, treated and followed up within primary healthcare (PHC) [Citation9]. Team-based hypertension management has been shown to improve the success of treatment goals [Citation10]. Working in teams that usually include physicians and nurses has been shown to reduce BP and postpone incidence of stroke compared with the care of physicians only [Citation11,Citation12]. In Sweden, registered nurses can be authorized by physicians in charge to change doses and order laboratory analyses when needed. In contrast, they cannot prescribe or renew prescriptions of antihypertensive drugs.
The PHC in Sweden is organized into 21 separate regions. They are politically controlled organizations that finance regional healthcare through taxes. Thus, both private and public PHC centres (PHCCs) are financed by taxes. For the management of patients with hypertension, physicians and other healthcare staff can lean on international guidelines [Citation13] that are often modified based on national, regional or local expert opinions. In Sweden, the Law on Medical Committees for Medicinal Products from 1996 regulates regional Medical Committees for medicinal products. They issue recommendations for treatments of a broad array of diseases including hypertension and regularly publish updated recommendations [Citation14]. The recommendations can vary between different regions, as the regions have strong political autonomy within the healthcare system. Also, PHCCs within a region manage their patients with chronic conditions and diseases differently, as shown in the quality register of PHC in the Västra Götaland region, where in 2022, the proportion of PHCCs reaching the BP goal <140/90 mmHg ranged from 21 to 87% [Citation7]. This can jeopardize equity of care, which is a prioritized goal in healthcare worldwide [Citation15].
The aim of the current study was to explore the organization and management of hypertension in Sweden, specifically, the organization of care based on, for instance, dedicated teams, the diagnostic process, methods of BP measurements, lifestyle interventions and long-term surveillance of patients.
Materials and methods
Participants
From the central administration offices in each of the eight participating regions (Jämtland-Härjedalen, Jönköping, Stockholm, Värmland, Västerbotten, Västra Götaland, Örebro and Östergötland), lists of all PHCCs were retrieved. These PHCCs were then randomly ordered using a random number generator. The managers were contacted consecutively by the authors. E-mail was used, and in cases of no response, an e-mail reminder was sent twice, with subsequent phone calls before they were deemed non-responding. In Stockholm, due to many non-responders at the start, several e-mails (up to 10 in the latest stages) were sent out at the same time. PHCCs in which any of the authors worked were excluded. The structured interviews were carried out from December 2019 to January 2021. The reasons for nonparticipation (if given) of those answering but declining the request to participate were noted. On acceptance to participate, the manager of the PHCC chose a suitable co-worker (physicians, nurses or other persons with knowledge management of care of hypertension in the PHCC) for the interview and a time for the interview was agreed upon. Informed consent was obtained from all participating interviewees. When 10 PHCCs per region had agreed to participate, the recruitment was stopped. Characteristics [geographic location, number of listed patients and Care Need Index (CNI)] of all eligible PHCCs were retrieved, regardless of participation in the interviews, from the central administration offices in each region. CNI is a region-adjusted index measuring health status in a population using sociodemographic factors and is used for remuneration to PHCCs. It is based on, for instance, age, marital status, foreign-born status, employment and education [Citation16]. Socioeconomic status is important, as it can influence the outcomes of care for patients with cardiovascular risk factors [Citation17]. Further, for this study, the PHCC locations were defined as rural according to a study-specific definition of both less than 10,000 inhabitants and more than 20 km from an emergency department.
Structured questionnaire
A study-specific structured questionnaire was developed and tested by the authors with managers, physicians and nurses working at PHCCs, and these persons were not interviewed during data collection. After feedback, a revision was performed and discussed until all authors agreed on the questions. The questionnaire with predefined questions was used during the structured telephone interviews and, in some cases, physical interviews (five in Stockholm) at the PHCC. It began with the interviewees’ vocation and organizational questions, such as number of listed patients, the staffing of the PHCCs (general practitioners (GPs), pre-registration house officers, senior house officers, locums and registered nurses) and distance to the nearest emergency hospital. The presence of specialized teams according to the interviewees’ discretion for the care of patients with hypertension was noted, along with the use of guidelines, questions on the procedure of diagnosing hypertension, what BP equipment was used for measurements, laboratory tests and other diagnostic measures and referrals to specialist clinics. Patients’ lifestyles and how lifestyle advice was given were surveyed, and finally, questions on the organization of follow-up and long-term management were asked. Most interviews were recorded to ensure that all data were captured.
The answers were typed by the authors to Smart-Trials (SMART-TRIAL© 2019 version 2.0 ApS), a data repository managed by the University of Örebro. Basic data from the non-participating and declining PHCCs were added in a separate file.
Statistical analyses
Descriptive analyses were performed to present the basic characteristics of the contacted PHCCs. Distributions and variations were illustrated with mean, maximum, minimum, median and 95% confidence intervals. For comparisons of paired data, McNemar’s test was used and a p-value less than 0.05 was considered significant. Statistical analysis was performed using SPSS (IBM Corp., SPSS, Version 28.0).
Results
The characteristics of the eligible PHCCs in the eight regions are shown in and Appendix A. Most PHCCs were public and a third were located in rural areas. There was a lower proportion of interviews from the Stockholm region (5%) and from Gothenburg in the Västra Götaland region (14%). The CNI varied from 0.66 (most affluent) to 4.55 (least affluent). There was a large variation in the number of staff between the PHCCs and GPs constituted about half of the physicians (). If adding up the permanent GPs, residents and locum doctors, the PHCCs had seven full-time working physicians in median. The number of patients (median) was 2500 per GP.
Table 1. Included regions and their total population.
Table 2. Number of staff working in the 76 participating primary health care centres and number of listed patients per staff category.
Forty-six percent of the interviewees were physicians, 51% were nurses and 53% had a medical managing or chief position. The use of information technology (IT), in electronic reports of data from patients for instance, was reported by 27 of 76 (36%). About half of the PHCCs had teams dedicated to hypertension care. Most of these teams were organized so that patients were predominantly managed by nurses (31 of 38, 82%; Appendix A).
In patients with a single raised BP reading, different methods were used to determine the hypertension diagnosis. Most PHCCs used both home and office BP, but 33% never used home BP measurements (). A combination of both digital and manual BP measurements was the preferred method in the office, but 32% used only digital measurements and 25% used only manual measurements. Only two (3%) PHCCs never used 24-hour measurements at home (ambulatory blood pressure measurements (ABPM)). Most PHCCs (75%) used the sitting position in office measurements, and 13% also routinely measured standing BP. Nearly half of the PHCCs measured BP in only one arm. The median resting time before measurements was 10 min (range 0–20 min).
Table 3. Blood pressure measurements prior to hypertension diagnosis.
At diagnosis of hypertension, the parameters most often investigated were kidney function (creatinine/cystatin C), potassium, blood lipids and blood glucose, and this was similar among the regions (). There was a significant decrease in the number of registered parameters at routine follow-ups compared to diagnostic appointments. Kidney function was frequently analyzed both at diagnosis and at routine follow-ups. In 95%, the estimated glomerular filtration rate was retrieved from the laboratory, and 92% got a numeric creatinine value. One PHCC used cystatin C as a complement to measure kidney function.
Table 4. Routine laboratory analyses, anthropometric data and electrocardiogram registered at diagnosis of hypertension and at routine follow-ups.
Patients were routinely asked about their lifestyles at diagnosis in accordance with recommendations from the national Board of Health and Welfare: physical activity in 100%, smoking habits in 96%, food habits in 97% and alcohol use in 96% (). Everyday stress was specifically asked about in 41% of the appointments. Follow-up questions on lifestyle were primarily included in routine follow-up with a nurse or physician ().
Table 5. Questions of lifestyle factors and offered support for lifestyle changes at diagnosis and addressed at follow-up.
Discussion
This study showed that hypertension management varied in several ways among the PHCCs in the studied regions in Sweden. The most prominent difference was the technique for registration of BP, while the use of core laboratory analyses was similar in the regions and between different PHCCs. Moreover, there was a great inequality in the number of patients per tenured GP and about half of the PHCCs reported teams dedicated to the management of patients with hypertension. More than half of the interviewees were registered nurses probably reflecting the organization of PHC in Sweden, where a large part of PHCCs are managed by registered nurses and have nurse led teams caring for patients with hypertension.
Strengths and limitations
A strength of the study is that it covers a large area of Sweden and that the PHCCs were randomly selected. Further, all interviewing researchers were knowledgeable about hypertension care, and the questionnaire was discussed and revised on several occasions before it was used. This study also has several limitations. First, the data were self-reported, which could mean that some items could be over- or underestimated. An even greater drawback was that the response rates differed between the regions. In the rural and smaller regions, the willingness to participate was greater, increasing the proportion of participating PHCCs. This could be due to the personal knowledge of the participating researchers (the co-authors), who were well known in the smaller areas and regions. The reasons for nonparticipation, if stated, were often lack of time. A smaller proportion of PHCCs were included in the larger regions, as we interviewed staff in only 10 PHCCs per region. Participation in the study could also be biased towards the PHCCs most interested in hypertension care. Since patient data such as blood pressure levels and efforts of increasing adherence of life-style recommendations, were not part of this study no general conclusions on patient outcomes can be drawn based on the these interviews. Finally, our study did not address the consequences of hypertension morbidity and mortality in cardiovascular diseases.
General discussion
Guidelines used in practice were often reported to be local or regional but based on guidelines from the European Society of Hypertension and the European Society of Cardiology [Citation13]. These guidelines recommend repeated, standardized BP measurements to confirm the diagnosis, since hypertension is a condition that needs chronic, often lifelong, medication. Five minutes of rest before measurements are now recommended in the guidelines. In our study, rest ranged from 0 to 20 min, which can lead to inaccurate values and thus might confer inadequate treatment. These results emphasize the need for readily available instructions and repeated information in BP measuring techniques. Also, nowadays, the sitting position is recommended and most PHCCs in our study had adopted this mode. Digital devices used to measure BP usually give more accurate values than manual measurements, where the registered value is often rounded off to the nearest fifth or tenth digit (digit preference) [Citation18]. In our study, the digital mode was used in most PHCCs, but 25% reported that they only used manual measurements. Digital preferences have been shown to differ between regions in Sweden [Citation18]. Home BP measurements and ABPM can be used to validate the diagnosis and detect white-coat and masked hypertension [Citation19,Citation20]. Home BP measurements were offered sometimes or often by two-thirds of the PHCCs, and ABPM was offered in most PHCCs. In fewer PHCCs, BP was measured both sitting and standing. This is particularly important for older patients who might suffer from orthostatic BP, which requires special awareness, although the choice of treatment is unclear [Citation21]. Measuring BP in both arms is important for detecting atherosclerotic lesions in the central vessels [Citation22]. Slightly more than half of the interviewees in our study reported measurement in both arms; this simple way of detecting atherosclerosis should be used more widely.
Home monitoring of BP could be an effective way to manage many patients with hypertension in PHC. Standardized home monitoring of BP has been shown to be of equal quality and predicts the risk of cardiovascular complications just as well as ABPM, and even better than office BP measurements [Citation19]. A review of clinical trials, however, found that BP was reduced in clinical trials only when home BP measurements were combined with strong motivational support from healthcare providers [Citation20]. A newly published clinical trial from Sweden with an intervention using IT combined with health information showed no BP-lowering effect after one year [Citation23]. In our study, the use of IT in communication with patients was reported by about one-third of PHCCs.
The evaluation and follow-up of kidney function, specifically estimated glomerular filtration rates, are important to individualize the drug treatment and in most PHCCs, this was performed. Potassium analysis is also important, as many antihypertensive drugs influence the balance of electrolytes and are therefore important to monitor. It was more surprising, though, that albuminuria was rarely evaluated, as this is a valuable predictor of high cardiovascular risk calling for treatment [Citation24].
Lifestyles (physical activity, eating habits, alcohol consumption and smoking) of the patients were asked about often, and advice was given regarding changes in lifestyle according to the guidelines [Citation13]. Specifically, in all PHCCs, physical activity was asked about, which is important for lowering BP. Regularly physical activity of at least 150 min per week divided by 3–7 occasions corresponds to taking one antihypertensive drug and also prevents cardiovascular complications regardless of the BP-lowering effect [Citation25]. Alcohol consumption was asked about, sometimes combined with an audit for more detailed information, which is important because alcohol consumption can contribute to high BP. Smoking is a risk factor for cardiovascular complications, and smoking cessation is an effective way to improve health. In around half of the PHCCs, the counselling was followed up at ordinary scheduled controls, and one-third had extra control visits to follow up on lifestyle factors.
The unequal staffing in different PHCCs was clear in this survey, not only for physicians and GPs, but also for nurses. Both play an important role in the care of patients with chronic conditions and diseases [Citation26]. This unequal staffing has an impact on all types of care offered by PHCCs and could pose an increasing problem in the future, as elderly people will increase in number and often suffer from chronic conditions such as complications from hypertension [Citation27]. Continuity of care by working in teams [Citation28] has been shown to be efficient, and hypertension increases treatment efficiency [Citation29]. The organization of PHC in the countries of the European Union differs in several aspects [Citation30]. Most countries have single practices which might preclude team work, but in contrast could increase the continuity of care. Even if Swedish PHC usually is organized in PHCCs with several health professionals, we found that only half of the PHCCs reported working in dedicated teams to care for patients with hypertension. The effect of teams on the management of patients is an important avenue for future studies. The well-founded risk of too many specialized teams to take care of the multitude of patients with chronic conditions could be diminished by having teams that take care of patients with highly prevalent co-morbid conditions. Hypertension, obesity, dyslipidaemia, diabetes, cardiovascular complications such as coronary heart disease, stroke, heart - and kidney failure are conditions that could be managed in that way.
Meaning of the study
This study showed that the management of hypertension varies in many respects between PHCCs in Sweden, despite clear recommendations in guidelines. As valid measurements are crucial for diagnosis and treatment, this should be highlighted in national and local guidelines. At follow-up, a significant drop in the assessment of clinical and laboratory variables was reported. The organization of care for patients with hypertension in specialized teams was used by half of the PHCCs.
Ethical approval
Ethical approval was applied for and granted by the Swedish Ethical Review Authority, registration number 2019-0169 and an amendment for the addition of regions 2020-00478.
Acknowledgements
The authors thank the interviewees for sharing their knowledge, providing data for this study and the time they set aside for the interviews. The author also thank Ulf Johansson, who supported the management of the SMART-TRIAL registrations during our study and Susanne Andersson for valuable advice. For conducting some of the interviews, the author thank the three resident doctors Mattias Liljemark, Marina Ohlsson Wintherstar and Pontus Olofsson.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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