Factors that impact on the application of guidelines in general practice: a review of medical records and structured investigation of clinical incidents in hypertension

Abstract

Introduction: The management of hypertension in the older individual is complicated by the need to take into account the effect of the ageing process. However, older hypertensive patients are at higher risk of vascular disease, and therapy may be more cost-effective in this age group. Methods: A retrospective review of case notes at two general practices serving over 19 000 patients in the UK. Patients were aged 75 years or older and treated for hypertension for at least one year at the time of survey. The latest recorded blood pressure was used to identify patients who remained hypertensive despite drug treatment. Therapy prescribed, patient preferences recorded, investigations performed, scope for further therapy and documented plans for management were compared. In the second part the general practitioners were asked to explain why some patients were offered more medication than others. Results: Three-hundred and twelve records were surveyed. Differences in the management of cases between the two practices were noted. One-hundred and nine patients were prescribed three or more classes of therapy. A significantly greater proportion of these cases were prescribed higher doses or additional therapy at their last consultation. Patients who were offered a more 'active' approach were thought to be better informed and better advocates for themselves. Discussion: Overall the data suggest inconsistency in the management of a group with the same disorder. Contrary to expectations, patients who were already prescribed three or more anti-hypertensive agents were more likely at their most recent consultation to be offered even higher doses or additional drugs, than those on fewer agents. Subjective biases, faulty generalisations and lost opportunities for reviewing therapy may account for differences in the management of the same patient group. Further research into factors that influence the application of clinical guidelines with reference to the consultation in primary care is warranted.