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  • Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care: a longitudinal cohort study in the Clinical Practice Research Datalink

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General practice / Family practice
Research
Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care: a longitudinal cohort study in the Clinical Practice Research Datalink
  1. James P Sheppard1,
  2. Sarah Stevens1,
  3. Richard J Stevens1,
  4. Jonathan Mant2,
  5. Una Martin3,
  6. F.D. Richard Hobbs1,
  7. Richard J McManus1
  1. 1 University of Oxford, Oxford, UK
  2. 2 University of Cambridge, Cambridge, UK
  3. 3 University of Birmingham, Birmingham, UK
  1. Correspondence to Dr James P Sheppard; james.sheppard{at}phc.ox.ac.uk

Abstract

Objectives Evidence to support initiation of pharmacological treatment in patients with uncomplicated (low risk) mild hypertension is inconclusive. As such, clinical guidelines are contradictory and healthcare policy has changed regularly. The aim of this study was to determine the incidence of lifestyle advice and drug therapy in this population and whether secular trends were associated with policy changes.

Design Longitudinal cohort study.

Setting Primary care practices contributing to the Clinical Practice Research Datalink in England.

Participants Data were extracted from the linked electronic health records of patients aged 18–74 years, with stage 1 hypertension (blood pressure between 140/90 and 159/99 mm Hg), no cardiovascular disease (CVD) risk factors and no treatment, from 1998 to 2015. Patients exited if follow-up records became unavailable, they progressed to stage 2 hypertension, developed a CVD risk factor or received lifestyle advice/treatment.

Primary outcome measures The association between policy changes and incidence of lifestyle advice or treatment, examined using an interrupted time-series analysis.

Results A total of 108 843 patients were defined as having uncomplicated mild hypertension (mean age 51.9±12.9 years, 60.0% female). Patientsspent a median 2.6 years (IQR 0.9–5.5) in the study, after which 12.2% (95% CI 12.0% to 12.4%) were given lifestyle advice, 29.9% (95% CI 29.7% to 30.2%) were prescribed medication and 19.4% (95% CI 19.2% to 19.6%) were given both. The introduction of the quality outcomes framework (QOF) and subsequent changes to QOF indicators were followed by significant increases in the incidence of lifestyle advice. Treatment prescriptions decreased slightly over time, but were not associated with policy changes.

Conclusions Despite secular trends that accord with UK guidance, many patients are still prescribed treatment for mild hypertension. Adequately powered studies are needed to determine if this is appropriate.

  • blood pressure
  • interrupted time series
  • electronic health records
  • cardiovascular disease prevention
  • general practice

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjopen-2018-021827

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    Footnotes

    • Contributors JPS conceived and designed the study, secured funding, undertook the main analysis and drafted the manuscript. SS was responsible for the data management, assisted with the analysis and revised the manuscript. RJS assisted with the study design, assisted with the analysis and revised the manuscript. JM assisted with the study design and revised the manuscript. UM assisted with the study design and revised the manuscript. RH assisted with the study design and revised the manuscript. RJM conceived the study, assisted with the study design and revised the manuscript.

    • Funding This work was funded by an Medical Research Council (MRC) Strategic Skills Post-doctoral Fellowship (MR/K022032/1) held by JPS. JPS now receives funding from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust and an NIHR Professorship which is held by and also funds RJMcM (NIHR-RP- R2-12-015). FDRH acknowledges support from the NIHR as Director of the NIHR SPCR, Director of the NIHR CLARHC Oxford, Theme Leader of the NIHR Oxford BRC, NIHR Oxford DEC and also from Harris Manchester College.

    • Disclaimer The views and opinions expressed are those of the authors and do not necessarily reflect those of the MRC, NHS, NIHR or the Department of Health.

    • Competing interests RJS is a member of the CPRD’s Independent Scientific Advisory Committee (ISAC), but was not involved in the approval of this study.

    • Patient consent Not required.

    • Ethics approval The present study protocol (16_ 008 R) was approved by this committee in March 2016, prior to obtaining the data cut (protocol given in the online supplementary appendix). A project summary was published on the CPRD website (https://www.cprd.com/isac).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data used in this analysis was provided by the Clinical Practice Research Datalink under a Gold Licence and cannot be shared with other parties.