A novel approach to office blood pressure measurement: 30-minute office blood pressure vs daytime ambulatory blood pressure.

PURPOSE: Current office blood pressure measurement (OBPM) is often not executed according to guidelines and cannot prevent the white-coat effect. Serial, automated, oscillometric OBPM has the potential to overcome both these problems. We therefore developed a 30-minute OBPM method that we compared with daytime ambulatory blood pressure. METHODS: Patients referred to a primary care diagnostic center for 24-hour ambulatory blood pressure monitoring (ABPM) had their blood pressure measured using the same validated ABPM device for both ABPM and 30-minute OBPMs. During 30-minute OBPM, blood pressure was measured automatically every 5 minutes with the patient sitting alone in a quiet room. The mean 30-minute OBPM (based on t = 5 to t = 30 minutes) was compared with mean daytime ABPM using paired t tests and the approach described by Bland and Altman on method comparison. RESULTS: We analyzed data from 84 patients (mean age 57 years; 61% female). Systolic and diastolic blood pressures differed from 0 to 2 mm Hg (95% confidence interval, -2 to 2 mm Hg and from 0 to 3 mm Hg) between mean 30-minute OBPM and daytime ABPM, respectively. The limits of agreement were between -19 and 19 mm Hg for systolic and -10 and 13 mm Hg for diastolic blood pressures. Both 30-minute OBPM and daytime ABPM classified normotension, white-coat hypertension, masked hypertension, and sustained hypertension equally. CONCLUSIONS: The 30-minute OBPM appears to agree well with daytime ABPM and has the potential to detect white-coat and masked hypertension. This finding makes 30-minute OBPM a promising new method to determine blood pressure during diagnosis and follow-up of patients with elevated blood pressures.

Encounters for common illnesses in general practice increased in obese patients.

BACKGROUND: Obese patients are known to have more chronic medical conditions. OBJECTIVE: To compare the frequency of encounter for episodes of the 10 most common illnesses in general practice between obese and non-overweight patients. METHODS: Data were derived from the Continuous Morbidity Registration, containing data from four general practices in and around Nijmegen (The Netherlands). In this research and registration network, a matched cohort study was performed. Each obese patient (body mass index > or = 30 kg/m(2)), aged 20-75 years, was matched for age, gender, socio-economic status and general practice, to approximately two patients without the diagnosis 'overweight' or 'obesity'. Over a period of 5 years (January 1, 2000 to December 31, 2004), the frequency of encounter for episodes of the 10 most common illnesses was compared, taking chronic medical conditions into account. RESULTS: At the start, 550 patients with obesity could be identified and were matched to 954 controls. Obese patients presented more common illnesses than non-overweight patients (incidence rate ratio 1.28, 95% confidence interval 1.12-1.47), in particular common cold (without fever), myalgia of the upper girdle, dermatophytosis and bruise (contusion, haematoma). CONCLUSION: Obese patients present more common illnesses to their GP, such as common cold (without fever), myalgia of the upper girdle, dermatophytosis and bruise (contusion, haematoma). This is in addition to their higher co-morbidity of chronic medical conditions.

Hypertension patients participating in trials differ in many aspects from patients treated in general practices.

OBJECTIVE: To determine to what extent participants in randomized controlled hypertension trials (RCTs) could be compared to patients with hypertension in general practices. STUDY DESIGN AND SETTING: We analyzed RCTs that had been used in hypertension guidelines or were available for future hypertension guidelines. The characteristics of the participants of these RCTs were compared with those of the patients with hypertension in general practices. In addition, inclusion and exclusion criteria of the RCTs were applied to the hypertension patients in the general practices. RESULTS: Twenty-one trials were analyzed. Participants' characteristics often differed from those of the patients with hypertension in general practices, in particular in the older trials where the participants showed lower cardiovascular risk. More recent trials showed participants' profiles that better reflected those of the patients under treatment in a general practice. Less than half of the patients undergoing treatment in a general practice would have been included in the hypertension trials. CONCLUSION: Participants taking part in trials differed from patients with hypertension in a general practice in a number of important aspects. This hampers their external validity. Inclusion of participants with comorbidity and other general practice characteristics would improve translation of study findings to daily practice recommendations.

Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity.

BACKGROUND: Patients with heart failure often suffer from multiple co-morbid conditions. However, until now only cardiovascular co-morbidity has been well described. AIMS: To understand heart failure in the context of multi-morbidity, by describing the age and sex specific patterns of non-cardiovascular co-morbidity in elderly patients with heart failure in general practice. METHODS: All patients aged 65 years and over, diagnosed with heart failure in four practices of the Nijmegen Academic Practice-based Research Network (NPBRN) between January 1999 and December 2003 were selected, and the prevalence of 27 cardio- and non-cardiovascular co-morbidities determined. RESULTS: Of the 269 patients identified (mean age 79 years; 57% women), 80.2% had four or more co-morbidities. With increasing age, a significant increase in the prevalence of non-cardiovascular conditions like visual and hearing impairments, osteoarthritis, dementia and urine incontinence; and a decrease in cardiovascular conditions like myocardial infarction and in women, hypertension, was observed. In patients aged 85 years and over, non-cardiovascular disorders predominated over cardiovascular disorders. CONCLUSIONS: In elderly patients with heart failure, the prevalence of non-cardiovascular co-morbidity is very high and exceeds the prevalence of cardiovascular conditions. Diseases such as dementia and osteoarthritis must be taken into account in the management of elderly patients with heart failure.

The value of reasons for encounter in early detection of colorectal cancer.

BACKGROUND: Symptoms with a high predictive power for colorectal cancer (CRC) do not exist. OBJECTIVE: To explore the predictive value of patients' reason for encounter (RFE) in the two years prior to the diagnosis of CRC. METHODS: A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date. RESULTS: We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR + and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3-6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3-6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53). CONCLUSION: Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.

GPs' assessment of patients' readiness to change diet, activity and smoking.

BACKGROUND: The Stages of Change Model is increasingly used for lifestyle counselling. In general practice, the use of algorithms to measure stage of change is limited, but for successful counselling it is important to know patients' readiness to change. AIM: To assess the accuracy of the assessment of patients' readiness to change fat consumption, physical activity, and smoking by GPs and general practice registrars. DESIGN OF STUDY: Cross-sectional questionnaire-based survey. SETTING: One hundred and ninety-nine patients at elevated cardiovascular risk aged 40-70 years, 24 GPs, and 21 registrars in Dutch general practices. METHOD: Patients were asked to complete an algorithm to measure their motivation to change fat consumption, physical activity, and smoking. GPs and registrars were given descriptions of the stages of change for the three lifestyles, and were asked to indicate the description that matched their patient. Cohen's kappa was calculated as measure of agreement between patients and GPs/registrars. RESULTS: Registrars' patients were younger, and less often overweight and hypertensive than GPs' patients. Cohen's kappa for smoking was moderate (0.50, 95% confidence interval [CI] = 0.34 to 0.67 for GPs and 0.47, CI = 0.27 to 0.68 for registrars). Agreement for fat and activity was poor to fair. No differences in accuracy were observed between GPs and registrars (P = 0.07-0.83). CONCLUSIONS: Low accuracy indicates that counselling in general practice is often targeted at the wrong people at the wrong time. Improvements can possibly be achieved by making registration of lifestyle parameters in patient records common practice, and by simply asking patients where they stand in respect to lifestyle change.

Web-based targeted nutrition counselling and social support for patients at increased cardiovascular risk in general practice: randomized controlled trial.

BACKGROUND: Using the Internet may prove useful in providing nutrition counselling and social support for patients with chronic diseases. OBJECTIVE: We evaluated the impact of Web-based nutrition counselling and social support on social support measures, anthropometry, blood pressure, and serum cholesterol in patients at increased cardiovascular risk. METHODS: We conducted a randomized controlled trial among patients with increased cardiovascular risk in Canadian family practices. During 8 months, patients in the intervention group and control groups received usual care. Patients in the intervention group also had access to a Web-based nutrition counselling and social support tool (Heartweb). Site use during the study was monitored. We measured social support, body mass index, waist/hip ratio, blood pressure, and cholesterol levels at baseline and at 4 and 8 months to assess the effectiveness of the intervention. RESULTS: We randomized 146 patients into the Web-based intervention (n=73) or the control group (n=73). Within the Web-based intervention group, Heartweb was used by only 33% (24/73) of patients, with users being significantly younger than nonusers (P=.03). There were no statistically significant differences between the intervention group and the control group in changes in social support, anthropometry, blood pressure, and serum cholesterol levels. CONCLUSIONS: Uptake of the Web-based intervention was low. This study showed no favourable effects of a Web-based nutrition counselling and social support intervention on social support, anthropometry, blood pressure, and serum cholesterol. Improvements in reach and frequency of site use are needed to increase the effectiveness of Web-based interventions.

Stage-matched nutrition guidance: stages of change and fat consumption in Dutch patients at elevated cardiovascular risk.

OBJECTIVE: To assess the effects of stage-matched nutrition counseling on stages of change and fat intake. DESIGN: Controlled clinical trial. SETTING: 9 family practices in a family medicine practice network. PARTICIPANTS: 143 patients at elevated cardiovascular risk, aged 40 to 70 years. INTERVENTION: Intervention patients received stage-matched counseling from their family physician and a dietitian. Control patients received usual care. MAIN OUTCOME MEASURES: Stages of change and fat intake were measured at baseline and after 6 and 12 months. ANALYSIS: Chi-squared tests, t tests, and regression analyses (alpha = .05) were conducted. RESULTS: More patients in the intervention group than in the control group were in the postpreparation stage after 6 months (70% vs 35%; P < .01) but not after 12 months (70% vs 55%; P = .10). Between 0 and 12 months, the reduction in total fat intake (-5.6% kcal vs -2.4% kcal) was largest in the intervention group. CONCLUSIONS AND IMPLICATIONS: Stage-matched nutrition counseling promotes movement through stages of change, resulting in a reduced fat intake. Our results partly support stages of change as a tool for behavior change. Movement across stages of change was not an intermediating factor in the intervention effects. Research should focus on feasible ways to keep patients in the postpreparation stage.

Current treatment of chronic heart failure in primary care; still room for improvement.

UNLABELLED: RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care. METHODS: In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires. RESULTS: Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice. CONCLUSIONS: Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.