Cash incentive made no difference to GP’s over high blood pressure management

A study was conducted on the impact of the new pay for performance scheme that was introduced as part of the new GP contract in 2004. GPs were awarded points for achieving targets aimed at improving care for patients across a range of diseases. A total of £1.8bn was available for GPs in England under the scheme, called the Quality and Outcomes Framework, and 20 per cent of that was awarded for achieving five targets related to blood pressure. The move was controversial as most GPs achieved near to maximum points, leading to critics saying the Labour government had negotiated a bad deal for the taxpayer. The research published in the British Medical Journal analysed the effect of the scheme on the care of patients with high blood pressure.

The team from Harvard University in Boston, America, and Nottingham Medical School in Britain found that there was no impact of the scheme, largely because doctors were already improving care and were acheiving the targets that had been set. Monitoring of blood pressure did not increase, prescribing of drugs for the condition did not change significantly and there was no change in the rates of strokes, heart attacks and other problems that are caused by high blood pressure, they found. Lead author Brian Serumaga, who works at both Nottingham University and Harvard in pharmaceutical policy research, wrote in the journal: "Our study has shown that explicit financial incentives did not improve the quality of care and clinical outcomes for patients with hypertension in primary care in the United Kingdom. "We found that the quality of care for hypertension was improving and already close to the threshold set for maximum payment in the pay for performance initiative. Some performance thresholds may have been set too low for the financial incentives to be effective. "It seems that doctors may be less responsive to performance based monetary incentives to improve the care of hypertension than most policy makers believe. "Furthermore, evidence from studies of educational interventions suggests that fewer, simpler messages are more likely to achieve behaviour change than more complex, diffuse messages. "Perhaps the resources devoted to pay for performance for hypertension would be better spent on implementing these interventions more widely."

Dr Laurence Buckman, Chairman of the British Medical Association's GPs Committee, said: "There is a mistaken belief that the Quality and Outcomes Framework is simply an incentive scheme, but it's much more than that. "It was designed to fund work by GPs that previously wasn't being funded, to ensure that patients received uniform high-quality care no matter where they lived in the country, and, by doing that, to improve public health over the long term and help reduce health inequalities. "The QOF is still relatively new. Other studies have shown that it has improved care and treatment for people with diabetes and reduced the number of heart attacks and deaths, particularly in deprived areas. We expect the true gains will be seen in the long term as more evidence becomes available."

A spokesman for the Department of Health said: "The Health Bill sets out the Government's vision for a patient-centred NHS that achieves health outcomes that are among the best in the world. "The Quality and Outcomes Framework and other incentives for GPs are insufficiently focused on outcomes, including patient experience. "We therefore intend to reform the current payment system so that GPs are rewarded appropriately for improving patient outcomes."

Source: Daily Telegraph

Now listen carefully - "Storytelling" found to aid blood pressure control

People who have trouble keeping their blood pressure in check might benefit from hearing about other patients' struggles with the same problem, a preliminary study suggests. The study, of 299 African-American patients with high blood pressure, looked at the effects of so-called "storytelling" on participants' blood pressure control. About three-quarters of the people in the study were women. Researchers randomly assigned half of the patients to watch a series of three DVDs featuring other patients -- not actors -- recounting their own struggles with learning to rein in their blood pressure numbers. The rest of the patients - who didn't get any DVDs -- served as a comparison group.

DVDs were distributed at the start of the study, three months after the start, and again six months after the start. Periodically, the researchers would ask participants how much time they'd spent watching the DVDs. On average, participants said they watched for a total of nearly 90 minutes over the entire length of the study. In general, the DVDs didn't make a difference to people whose high blood pressure was under control.

But the DVDs did seem to help those who had high blood pressure at the start of the study, the research team says. In those men and women, systolic blood pressure -- the first number in a blood-pressure reading -- dropped by 17 points, on average, after three months. Their diastolic pressure (the second number in a reading) dipped by about 7 points. That compared with declines of 6 points and 1 point, respectively, among patients with uncontrolled blood pressure who were in the comparison group.

In contrast, patients whose high blood pressure was under control at the outset did not seem to benefit from the DVDs. The findings, reported in the Annals of Internal Medicine, suggest that at least some people with high blood pressure may respond to hearing from people similar to themselves -- rather than just their doctors. The theory, said lead researcher Dr. Thomas K. Houston, is that "the more you relate to the person in the story, the more engaged you become."

That's in contrast to hearing "just the facts" from your doctor, according to Houston, of the University of Massachusetts Medical School in Worcester. The researchers are not sure why patients who saw the DVDs tended to fare better. (In fact, they had to take the patient's word that he or she had actually watched the DVDs at all.) It's possible that people in the DVD group were more likely to stick with their medication, or make diet and exercise changes, according to Houston. But the study did not measure those behavior changes.

So, many questions remain for future studies.

One is how widely effective any set of collection of stories might be. In this study, the participants and the patients in the DVDs were all from the same inner-city Alabama medical clinic. "The question is, would these DVDs made in Alabama be useful if you gave them to patients in Chicago, or in LA?" Houston said in an interview. Or would individual medical centers have to create their own videos? Another question is how long any benefits of storytelling might last. Houston's team found that six to nine months after the study's start, patients' average blood pressure had started to move upward, though to a lesser degree in the DVD group. "We would anticipate that the benefit would be likely to wane," Houston said. He added, though, that any storytelling tactic would only be part of overall care for people with high blood pressure. "It might help," Houston said, "by opening the door to people talking more with their doctors."

In the study DVDs, one of the topics patients discussed was how they had learned to best communicate with their doctors. An editorial published with the study calls the findings "provocative," but also says storytelling is not yet ready for the medical mainstream. "Stories are unlikely to become a routine part of treatment until additional evidence shows that their effect is both sustainable and generalizable," write Drs. Kimberly R. Myers and Michael J. Green, of Penn State College of Medicine in Hershey, Pennsylvania. They add that an "intriguing" question is whether online social networks, like YouTube and Facebook, could be used for medical storytelling.

Houston pointed out that such videos need not be Hollywood production value. To create their DVDs, he and his colleagues took a low-cost approach -- complete with "bad lighting" and editing by the researchers themselves.

The study was funded by a national program of the Robert Wood Johnson Foundation called Finding Answers: Disparities Research for Change.

Source: Reuters Health/Amy Norton

Deep Brain Stimulation for Stubborn Hypertension

Case Study Suggests Stimulating Brain With Electrical Impulses May Treat High Blood Pressure

Using electrical pulses to stimulate nerve centers deep within the brain may reduce high blood pressure that can't be controlled with medication, a case report shows. Doctors in the U.K. made the discovery after implanting a device that works as an electric stimulator of a region of the brain in a 55-year-old man who had developed chronic pain on the left side of his body following a stroke. Though his pain eventually returned after four months, his doctors report that their patient's previously uncontrolled blood pressure has remained normal for nearly three years.

That was a surprise because experts had long thought that pain had to be reduced to see a reduction in blood pressure. "Pain creates stress and that can have an effect on one's blood pressure," says Nikunj J. Patel, MD, a neurosurgeon at Frenchay Hospital in Bristol, U.K., and an author of the case study.

Patel says that makes the impact of the case study "startling and exciting" because if studies bear the findings out, deep brain stimulation may one day help people with hypertension whose blood pressure remains uncontrolled on multiple medications. The case study is published in the Jan. 25 issue of Neurology.

While the case study is only an example of the phenomenon occurring in a single person, previous reports have observed the same kinds of reductions in blood pressure in people getting deep brain stimulation for pain, though researchers had believed that the blood pressure benefit was directly tied to the degree of pain relief the person experienced.

"What their case report shows is that blood pressure can be reduced in a sustained fashion in a patient with unsuccessful deep brain stimulation for pain," says Erlick Pereira, MD, a neurosurgeon at the University of Oxford. Pereira wrote about blood pressure reductions in a patient getting deep brain stimulation in the January 2010 issue of the Journal of Clinical Neuroscience.

"I think that's important because it paves the way for potentially studying patients without chronic pain and offering the treatment sometime in the future to reduce blood pressure," he says.

The doctors report that their patient, immediately following his stroke, had spiking blood pressure that ranged from 153/89 to 265/96. Normal blood pressure is 120/80 or lower. Even after taking a combination of four different hypertension medications, the man was unable to get his blood pressure down, and eventually, though he regained movement after being partially paralyzed by his stroke, he developed a chronic pain.

Doctors tried for three years to control their patient's pain, without success. So they agreed that he might be a candidate for deep brain stimulation, which can sometimes be helpful for people who can't find relief any other way.

At first, the neurostimulator seemed to help the pain, and when doctor's measured their patient's blood pressure, they were surprised to find that it had dropped significantly -- to as low as 80/53. They took the patient off all his hypertension medications, and his blood pressure normalized to an average of110/65 in the first eight weeks after surgery. Within 12 weeks, his blood pressure had inched back up only slightly to 124/76.

After four months, the pain relief from the electrical stimulation wore off, but his blood pressure stayed down. After more than two years, with blood pressure still near normal, his doctors tested his response by switching the neurostimulator on and off.

When the device was off, his blood pressure increased by about 18/5 points. When it was turned back on, his blood pressure dropped by 33/13 points.

Drug-Resistant High Blood Pressure

According to the National Center for Health Statistics, about one in three Americans has high blood pressure. Studies suggest that about one in eight people being treated for hypertension can't get their blood pressure under control, even on three or more medications. Uncontrolled high blood pressure can lead to myriad health problems including heart and kidney failure, eye damage and blindness, strokes and heart attacks, dementia, and erectile dysfunction.

When medication fails, newer surgical interventions -- including renal nerve ablation, where nerves in the major arteries of the kidneys are zapped and deactivated with radiofrequency energy, and carotid baroreceptor stimulation, where electrodes stimulate nerves near major arteries that supply blood to the brain -- may be options that can help reduce the risks of major complications from very high blood pressure.

"These treatments are not a panacea," Patel says. "One-third of the people who get these interventions are still not helped."

With further testing, experts think deep brain stimulation could become a third interventional option for patients. "It's a procedure with tiny, but important risks" says Pereira. Those risks include bleeding in the brain, infection, and reactions to the surgical anesthesia. "But if we can follow a group of patients over three years or more and show that the blood pressure reductions are sustained, this could become an important third option.

Deep Brain Stimulation and Blood Pressure

The region of the brain being stimulated in these procedures, which is called the periaqueductal gray (PAG)/periventricular gray (PVG) region, acts like a switchboard for pain signals throughout the body. It also controls the body's response to stress, the fight-or-flight response.

In response to a perceived threat, the body prepares for action by increasing the heart rate and blood pressure.

Some researchers think that stimulating the PAG/PVG region can help shut down an overactive stress response, letting blood pressure and heart rate return to normal levels. In deep brain stimulation, electrodes are implanted into areas of the brain. Wires attach the electrodes to small, metal electrical impulse generators that are implanted under the skin on the chest.

Deep brain stimulation is FDA approved to treat movement disorders, including Parkinson's disease and essential tremor. It is also has an FDA humanitarian device exemption for treatment of dystonia and severe cases of obsessive-compulsive disorder.

Source: Brenda Goodman / WebMD Health News

 

What you need to know about ACE inhibitors and high blood pressure.

ACE inhibitors are a popular "first choice" medicine for many GP's beginning a person with high blood pressure on medication. If you are under 55 and not from an African-Caribbean background then it is common for you to be given an ACE Inhibitor. If you have been given an ACE inhibitor your medicine's name will end in "-pril" – such as Ramapril or Lisinopril. Remember though that this is just the generic name – the brand name of your medicine may well be different. For Ramapril for instance, the brand name of your medicine might be Lopace or Triapin. If you have any doubt, ask your pharmacist.

ACE inhibitors work by stopping your body from producing a chemical called angiotensin II. Angiotensin II does a number of things to your body. First it has the effect of narrowing your blood vessels when it enters the blood stream which raises your blood pressure as blood is forced to travel through these narrower vessels. Secondly, it triggers a hormone that encourages your body to retain water which can also cause your blood pressure to rise.

ACE inhibitors can help lower your blood pressure by reducing the amount of angiotensin II in your body. This helps your blood vessels to relax and widen and lowers the amount of fluid your body retains, both of which help lower your blood pressure.

The most common side-effect of ACE inhibitors is a persistent dry cough. If this happens to you speak to your Doctor as there are a range of medicines available to lower blood pressure.

Calcium channel blockers may cause hypotension if taken with some antibiotics

Older people who are taking common blood pressure medications called calcium channel blockers face an increased risk of developing dangerously low blood pressure and possibly going into shock if they take certain antibiotics, Canadian researchers warn. "Two common antibiotics, erythromycin and clarithromycin, if given to patients taking calcium channel blockers, can increase the risk substantially of being hospitalized for low blood pressure," said lead researcher Dr. David Juurlink, a scientist at Sunnybrook Research Institute in Toronto. For patients taking erythromycin along with a calcium channel blocker the risk goes up almost sixfold, while it increases almost fourfold for patients taking clarithromycin, he said.

Although the interaction between these drugs has been known for some 20 years, this is the first time the risk has been quantified, Juurlink said. Juurlink noted a cousin of these drugs, azithromycin, doesn't cause this problem. "One of the main suggestions of the study is, if you are on a calcium channel blocker and you need to go on an antibiotic in this class, azithromycin is a safer one to use," he said. The report is published in the Jan. 17 edition of the Canadian Medical Association Journal. For the study, Juurlink's team collected data on people aged 66 and older who were taking calcium channel blockers between 1994 and 2009.

The researchers sorted out who among these patients was hospitalized for low blood pressure (hypotension) and whether or not they had taken a macrolide antibiotic before being hospitalized. Juurlink's group found that 7,100 of these patients had been hospitalized for low blood pressure or shock, and that having taken either erythromycin or clarithromycin was associated with an increased risk of trouble. The reason these antibiotics have this effect is that they interfere with an enzyme in the liver that is needed to break down the calcium channel blocker. When this enzyme is "turned off," too much of the calcium blocker accumulates and causes blood pressure to drop dangerously low, Juurlink explained.

Dr. Barry J. Materson, a professor of medicine at the University of Miami Miller School of Medicine and a specialist in blood pressure, said that this study "is of practical interest." The researchers have established that the combination of a macrolide antibiotic and a calcium channel blocker can cause hypotension or even shock because of increased blood levels of the calcium channel blocker, Materson said. "This happens because of the interference with an enzyme that metabolizes the calcium blocker," Materson noted. Materson added that grapefruit juice can also interfere with the same enzyme and lead to elevated levels of calcium channel blockers. "Grapefruit juice is consumed much more frequently than macrolide antimicrobials," he pointed out.

One limitation of the study is not knowing how many of these patients had hypotension or shock from the infection for which they were receiving the antibiotic. "We also do not know how many, if any, consume grapefruit juice," Materson said. "Nevertheless, it is important for practitioners, pharmacists and patients to appreciate that both grapefruit juice and macrolide antibiotics, with the possible exception of azithromycin, can increase the blood level of the calcium channel blockers to an unpredictable degree and may rarely result in hypotension or even shock," he said.

Source: (HealthDay News)

Blueberries good for high blood pressure

Harvard researchers and scientists from University of East Anglia say blueberries protect from high blood pressure. The findings that the blueberries can stave off hypertension come from anthocyanins. In the study, researchers found eating one serving of the berries per day lowered their chances of developing high blood pressure 10 percent. Anthocyanins are members of the flavonoid family that are found in fruits, vegetables, grains and herbs. They are also present in high amounts in blackcurrants, raspberries, strawberries, aubergines, orange juice and blood oranges. The researchers studied blueberries because they are especially rich in the flavonoid that has antioxidant properties and commonly consumed in the U.S. Together the researchers studied 134,000 women and 47,000 men from the Harvard established cohorts, the Nurses' Health Study and the Health Professionals Follow-up Study over a 14 year span. The participant's health was assessed every 2 years via questionnaire and diet reviewed every 4 years.

The overall findings showed lower risk of high blood pressure from eating foods with anthocyanins, the bioactive component found in blueberries. Other foods considered high in flavonoids included tea - a main contributor - strawberries, apples, orange juice, blueberries, red wine, and strawberries. During the study, 35,000 participants developed high blood pressure. None had hypertension at the study start. The findings showed those consuming the highest amounts of flavonoids that came mostly from strawberries and blueberries in the US had an 8 percent reduced risk of hypertension. Blueberries offered stronger protection than strawberries.

Professor Aedin Cassidy of the Department of Nutrition at UEA's Medical School says, "Anthocyanins are readily incorporated into the diet as they are present in many commonly consumed foods. Blueberries were the richest source in this particular study as they are frequently consumed in the US. Other rich sources of anthocyanins in the UK include blackcurrants, blood oranges, aubergines and raspberries." The researchers are taking things further to study individual foods containing anthocyanins. The intention is to discover optimal dosing of foods like blueberries, strawberries and raspberries that can guide public health recommendations.

The findings show berries, especially blueberries, and other fruits contain beneficial compounds that can keep high blood pressure at bay. Cost of hypertension in the US is currently estimated at $300 billion annually and affects 25 percent of the global population, according to background information from the authors.

Worried about the housework? Stop – it’s bad for your blood pressure

If you have a very busy household regime that keeps you too much engaged in the jobs, you may fall victim to the problem of having a high blood pressure. In a recent study by the scientists from the University Of Pittsburgh School Of Medicine in the US, it suggests that stresses and strains of life remains alive even after the work hours of the day and it rises when one reaches home. The group conducted a research on 113 men and women, who work full time and at the same time maintain household chores to come to the conclusion.

The report of the study was published in the journal Psychosomatic Medicine. Each of the participants gave the details of their daily working hours, levels of responsibility they took for running their home, and the works specifically they did during these working hours. The observation period was for 3 weeks during which these women went for a regular BP checks in the local clinics and finally they were given a BP monitor to wear for a day to track the changes in the BP at different times of the day.

The results revealed that all those men and women who felt that they have more responsibilities to shoulder were at a greater risk of having a high BP. The researchers said, 'The perceived responsibility for household tasks, rather than the time spent doing those tasks, is what's most distressing."

Combination pills improve blood pressure management and outcomes

A combination of drugs is better than a single one in treating high blood pressure, a UK study has suggested. The study in the Lancet involved 1,200 people and found starting treatment with two drugs gave better and faster results, with fewer side effects. The approach challenges conventional medical practice where doctors give a patient one drug, then add another later if blood pressure stays high.

A team led by researchers at the University of Cambridge, University of Glasgow and University of Dundee followed 1,254 patients with high blood pressure in 10 countries. They compared the effects of giving one drug (either aliskiren or amlodipine) or a combination of both. Patients given the combination of drugs had a 25% better response during the first six months compared with those on conventional treatment, the study found. This equates to a 6.5mm Hg greater reduction in systolic blood pressure. Participants were also less likely to stop taking their medication due to side effects. The two drugs can be given as a single pill, making it easier for patients to take.

Professor Morris Brown of the University of Cambridge said the study "breaks the mould for treating hypertension". He said: "Most patients can now be prescribed a single combination pill and know that they are optimally protected from strokes and heart attacks."

The British Heart Foundation, which is funding follow-up research, said good control of blood pressure is hard to achieve in many patients.

Associate medical director Professor Jeremy Pearson said: "This study adds significantly to the evidence that starting treatment for patients with high blood pressure with two medicines rather than one is safe, and more effective than waiting to add the second medicine later."

The research was funded by the pharmaceutical company Novartis, which makes amlodipine and aliskiren.

Source: BBC News