Family Practice Vol. 20, No. 1, 22-31
© Oxford University Press 2003
Clinical Research |
Gender, age and deprivation differences in the primary care management of hypertension in Scotland: a cross-sectional database study
Primary Care Clinical Informatics Unit, Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK.
Correspondence to Professor Philip Hannaford; E-mail: p.hannaford{at}abdn.ac.uk
Pears E, Hannaford PC and Taylor MW. Gender, age and deprivation differences in the primary care management of hypertension in Scotland: a cross-sectional database study. Family Practice 2003; 20: 22–31.
Received 17 January 2002; Revised 9 July 2002; Accepted 9 September 2002.
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Abstract |
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Background. Little is known about the community management of cardiovascular disease among different gender, age or deprivation groups, even though much of the long-term treatment takes place within primary care.
Objectives. Our aim was to determine whether important gender, age and deprivation differences exist in the primary care management of hypertension.
Methods. A cross-sectional analysis of computerized general practice data was carried out in 43 practices in Scotland contributing to the Continuous Morbidity Recording project. The main outcome measures were odds ratios of being under GP review; receiving different classes of antihypertensive treatments [thiazides, ß-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers]; and receiving other cardiovascular preventative treatments (statins and/or antiplatelets).
Results. Compared with males, female hypertensive patients were more likely to receive a thiazide and less likely to be given an ACE inhibitor, calcium channel blocker or secondary preventative treatment. Elderly hypertensive patients were less likely than the youngest patients to be under GP active review, more likely to be on a thiazide, calcium channel blocker or antiplatelet treatment, and less likely to be on a statin. More deprived hypertensive patients were less likely to be under GP review, or to be on a thiazide or a statin, but were more likely to be on a calcium channel blocker or an antiplatelet drug than the most affluent group.
Conclusions. Important gender, age and deprivation differences exist in three important components of the primary care treatment of hypertension in Scotland.
Keywords. Cardiovascular disease, hypertension management, primary care.
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Introduction |
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Hypertension is common, its prevalence being ~12% in Scotland1 and 18% in England.2 It is also an important risk factor for coronary heart disease3 and stroke,4 both major causes of morbidity and mortality in the Western world. Good management of hypertension can produce large reductions in these important clinical events.4 In spite of the research evidence, the ‘rule of halves’5,6 continues to apply.7 Thus, only about half of those with hypertension are known about; of these, only about half receive any treatment; and, of these, only about half have their hypertension adequately controlled.
Large gradients in cardiovascular health by social class, gender and age occur within many countries, including the UK.8,9 These gradients arise from a mixture of differences between groups in: the prevalence of risk factors for cardiovascular disease; the application of services to detect disease (including screening for asymptomatic risk factors such as hypertension and hypercholesterolaemia); and the provision of medical care to treat known cardiovascular disease or its risk factors. A number of studies have investigated the prevalence of cardiovascular risk factors within different groups.10–12 There have also been several studies looking at group differences in the hospital management of cardiovascular disease.13–15 These have tended to show that women, the elderly and the more socially deprived are disadvantaged. Less attention has been paid to the community management of cardiovascular disease among different groups, even though much of the long-term treatment takes place within primary care. Two relatively small studies conducted in The Netherlands16 and England17 have suggested a bias towards men compared with women for the secondary prevention of ischaemic heart disease.
Tackling health inequalities is high on the political agenda of many governments. As a preliminary to the design of effective interventions, it is important to know whether differences exist and, if so, at what point in the disease management process (e.g. at disease detection, initial management or longer term follow-up care). Computerized databases of general practice activity provide an opportunity to examine some of these issues.17 A potential major strength is the routine collection of information about everyday practice, thereby facilitating at minimal cost the identification of gaps in current care. Ideally, such data sources should cover a wide geographical area in order to maximize the chances of detecting differences. Morbidity and prescribing data are collected routinely throughout Scotland from practices participating in the Continuous Morbidity Recording (CMR) project. We used these data to examine whether women, the elderly or those in more deprived social groups with hypertension are likely to be treated differently in primary care for their condition, compared with men, those who are younger and those in more affluent groups with hypertension.
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Methods |
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In Scotland, most (81%) practices use the General Practice Administration System for Scotland (GPASS) to record information about their clinical activities. Virtually all practices record information about repeat (chronic) prescriptions and the recall of patients for certain health promotion procedures. A smaller number of practices also record information about prescriptions generated in the consulting room (acute prescriptions) and clinical diagnoses. A small group of practices (currently 65) provide details of every face-to-face doctor–patient encounter for the CMR project co-ordinated by the Information and Statistics Division (ISD) of the Common Services Agency, National Health Service in Scotland. Information about consultations with practice nurses, other non-medical health care professionals or doctors outside the practice is not collected routinely. Each face-to-face doctor–patient encounter is recorded using the Read classification. Up to 10 problems can be recorded for each contact, and doctors are asked to be as specific as possible when using diagnostic terms to describe each problem. Information about repeat prescriptions includes the start date when the prescription was first issued, and the date when the last prescription was issued. Some of the CMR practices have joined the project only recently, and others have been upgrading their version of GPASS, which can lead to temporary disruptions in data collection. This paper therefore is based on information from 43 CMR practices who contributed data for the whole of 1998, serving a population of 252 830 patients (~5% of the total population in Scotland). The practices were distributed throughout Scotland and ranged in size from 1059 to 18 552 patients.
Out of the entire available population, 20 179 patients (8%) had a hypertension-related Read code (Appendix 1). This code could have been entered onto the computer at any time during the patient’s life. Nearly all of these ‘hypertensive’ patients (n = 19 352) could be assigned a deprivation category using the Carstairs and Morris Index.18 This index is based on 1991 census data relating to material deprivation and allows the allocation of one of seven ‘Depcat’ categories (1 being most affluent, 7 least affluent) depending on an individuals’ postcode. It is widely used in Scotland and has been validated mainly by comparing Depcat scores with area statistics for mortality.18 The 827 (4% of total) individuals without postcodes were excluded from the analysis.
Thus, 19 352 hypertensive patients remained in the analysis. These patients were analysed together, and separately in one of three subgroups:
- Under GP review (n = 8570, 44.3%): indicated by a doctor–patient encounter in 1998 in which a hypertension-related event was recorded (indicated by one of the Read codes shown in Appendix 1). This encounter may or may not have involved the issuing of a prescription for a hypertension-related drug.
- Under non-GP review (n = 7632, 39.4%): no record of a doctor–patient encounter for a hypertension-related event during 1998 but had a record of having been issued with a hypertension-related drug prescription during the same period. These patients will have received a prescription via the repeat prescription system; they may have also seen the practice nurse or another member of the primary care team whose activity is not recorded by GPASS.
- Not apparently under any active follow-up (n = 3150, 16.3%): no record of a doctor–patient hypertension-related event or the issue of a prescription for a hypertension-related drug in 1998.
The computer record of each hypertensive patient was examined to determine whether during 1998 they had been issued with at least one prescription for any of the following classes of hypertension-related drugs:
- Thiazides
- ß-Blockers
- Calcium channel blockers
- Angiotensin-converting enzyme (ACE) inhibitors
In addition, we determined whether a prescription for an antiplatelet drug or statin had been issued during the same period, these drugs often being used concurrently in patients with hypertension in order to prevent cardiovascular disease.
Each patient was characterized by gender, age (<44, 45–54, 55–64, 65–74, 75+), deprivation (Depcat 1 and 2, Depcat 3 and 4, Depcat 5, 6 and 7), number of different hypertension-related treatment groups received in 1998 (0, 1, 2, >2) and number of different hypertension-related co-morbidities (heart disease, cardiac failure, stroke, diabetes mellitus and hyperlipidaemia) ever recorded on GPASS (0, 1, 2, >2). Diabetes and hyperlipidaemia were included as they may be the reason for the detection of hypertension in the first place, and so any differences in the prevalence of these conditions between groups needs to be allowed for. The deprivation categories were aggregated because there were only a small number of individuals in the most deprived category (6 and 7). Reliable information on smoking habits, detailed patterns of blood pressure level and frequency of blood pressure measurement was not available.
Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each variable, with the first level of each variable being the reference group. When looking at type of review, ORs were calculated comparing GP active review with non-GP active review or no review combined. When looking at type of treatments used, ORs were calculated for the prescription versus non-prescription of each class of drug. All of the crude ORs were adjusted for the potential confounding effect of gender, age, deprivation category and number of co-morbidities using multiple logistic regression. The 95% CIs are presented only for adjusted ORs (AORs). For clarity, each OR and 95% CI was rounded to one decimal point. This sometimes meant that the upper or lower limit of the confidence limit appeared to be the same as the OR. All of the statistical analyses were performed using SPSS for Windows 9.01.
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Results |
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Prevalence of hypertension and characteristics of the hypertensive cohort
The recorded prevalence of hypertension as defined above was 8% (95% CI 7.6–8.4). Table 1
shows the characteristics of the hypertensive patients by type of review during 1998. More than half of the hypertensive patients were women (59% of the sample) and half were older than 65 years. Only 23% of the hypertensive patients were in the least affluent deprivation categories (5–7). Some 60% of the hypertension patients did not have a related co-morbidity recorded, and 76% had received at least one hypertension-related treatment in 1998. Univariate comparisons suggested significant differences between gender, age and deprivation groups, and the level of follow-up. The AORs in Table 2 show that the oldest, most deprived and those with more hypertension-related co-morbidities were significantly less likely to be under active GP review than those in the reference group for each variable. Conversely, individuals in deprivation categories 3–4 were significantly more likely to be under active GP review than those in deprivation categories 1–2. There was no difference in follow-up by gender.
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Provision of hypertension-related treatments
Compared with male hypertensive patients, females were significantly more likely to receive a thiazide and significantly less likely to receive an ACE inhibitor and a calcium channel blocker (Table 3
). Similar findings were seen when the patients were examined separately according to whether they were under GP or non-GP follow-up (data not shown; results available on request).
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In general, older hypertensive patients were more likely to receive a thiazide and calcium channel blocker than the youngest patients (Table 3
). On the other hand, middle-aged people appeared to be those most likely to receive a ß-blocker or ACE inhibitor. A similar pattern with age was seen for hypertensive patients under GP review. Among those under non-GP review, older patients were more likely to receive a thiazide and calcium channel blocker (e.g. AOR in those aged 75+ 1.6, CI 1.2–2.1 and AOR 1.3, CI 1.0–1.8, respectively), but less likely to receive a ß-blocker or ACE inhibitor (AOR 0.5, CI 0.4–0.6 and AOR 0.4, CI 0.3–0.6, respectively).
Compared with the most affluent group, the most deprived patients were significantly less likely to be given a thiazide and significantly more likely to be given a calcium channel blocker (Table 3). When the patients were examined by level of review, patients in the least affluent group under GP review were significantly less likely to receive a thiazide (AOR 0.7, CI 0.6–0.8). Among those under non-GP review, the least affluent group were less likely to receive a thiazide (AOR 0.8, CI 0.7–0.9) and more likely to receive a calcium channel blocker (AOR 1.4, CI 1.2–1.6).
As the number of documented hypertension-related co-morbidities increased, the use of thiazides decreased and the use of ACE inhibitors and calcium channel blockers increased (Table 3). Similar patterns were seen in those under both GP and non-GP review.
In Table 3, the AORs allowed for differences between groups in the number of hypertension-related co-morbidities, a factor which is likely to influence strongly the choice of treatments prescribed. It is possible, however, that residual confounding could still have occurred. Table 4 details the use of hypertensive treatments among the different groups using data restricted to hypertensive patients without a recorded history of any related co-morbidity (60% of the entire cohort). Similar trends to those found in Table 3 were observed.
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Use of preventative treatments for cardiovascular disease
Those with a large number of co-morbidities were more likely to be prescribed a statin than those with hypertension alone (Table 5
). Although a similar trend appeared to exist for older patients when unadjusted ORs were examined, this pattern was reversed after adjustment. Those in the most deprived categories were less likely to receive a statin.
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Patients with a large number of hypertension-related co-morbidities, older patients and those in the most deprived categories were more likely to be prescribed an antiplatelet drug than those in the reference group for each variable (Table 5
). Women were less likely than men to receive a prescription for an antiplatelet drug. Similar patterns were seen when the data were analysed separately according to level of review (data not shown; results available on request). |
Discussion |
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Our study found important gender, age and deprivation differences in three key aspects of the primary care management of hypertension: level of review; class of antihypertensive drug treatments used; and use of preventative treatments for cardiovascular disease. The broadly similar results in those under active GP or non-GP review suggests that the treatment differences were not due simply to variations in the amount of contact that patients have with their GP.
Major advantages of the CMR data set are its large size, involving many practices across Scotland; the inclusion of information about all face-to-face GP–patient encounters; and the collection of data using trained staff working within a quality-assured system. Each practice receives regular feedback on indicators of data quality and is audited periodically to check that there is corroborative evidence in a patient’s manual records to support diagnoses entered onto the computer. The CMR database is representative of the whole of Scotland for age and sex, although it has a relative deficit of severely deprived individuals.19 Nonetheless, the Scottish White Paper Fair Shares for All20 found that contact rates between affluent and deprived patients in the CMR database were not significantly different from those found in the Scottish Health Survey, suggesting broad generalizability of the data. A study of CMR data looking at respiratory morbidity found similar recorded rates and patterns of disease to those previously reported.21 There were no significant age or gender differences between the 43 practices included in this study and the 22 who could not be included. It is unlikely, therefore, that the exclusion of some practices will have introduced bias.
There are some important limitations with our study. Hypertensive patients were identified by the presence on an individual’s computer record of an appropriate Read code; diagnostic criteria were not used. Although different practitioners may use different thresholds when diagnosing hypertension, it seems unlikely that individual doctors will use different diagnostic thresholds for different groups within the practice population. Certainly, guidance available at 1998 did not specify different diagnostic criteria for different groups.22 Prescribing advice tends to be related to target levels of blood pressure control rather than suggesting different treatments for different gender, age or deprivation groups.22
Gaps in the data inevitably exist. For example, our prevalence of recorded hypertension-related disease (8%) was lower than that recorded in the 1995 Scottish Health Survey (12%).1 This is probably because the Scottish Health Survey was a community-based survey whereas ours was a study of individuals with hypertension mostly detected and recorded by primary care services. It is possible that there were systematic differences in the recording of hypertension-related activity. For instance, information relating to hospital care may be under-recorded, and blood pressure checks made whilst consulting for another reason may be omitted. These deficiencies are most likely to affect the results relating to type of review, particularly among the elderly or those with multiple pathology. Individuals with cardiovascular co-morbidities may be under medical specialist care, with their hypertension monitored in hospital. Erroneous conclusions could be reached about the level of review if such individuals do not also see their GP for a hypertension-related matter. Our findings relating to treatments given, however, are less likely to be affected by these problems as they are based primarily on repeat prescription data and, in the National Health Service, almost all prescriptions for chronic disease are issued in primary care.
Although we tried to adjust for some important potential confounding factors, data on other potentially confounders were missing, notably smoking habits, alcohol consumption, dietary and exercise habits, and body mass index. Neither did we have data on the level of blood pressure at time of diagnosis, duration of hypertension, level of blood pressure at different time points whilst on treatment, total history of antihypertensive drug treatments, compliance with therapy or side effects experienced; all factors which will influence choice of treatment. Residual confounding, therefore, could account for at least part of our findings. It is noteworthy that important differences between groups remained when the analysis was restricted to those without a recorded history of hypertension-related co-morbidity. This suggests that our findings were not due simply to some individuals being prescribed particular drugs (e.g. a calcium channel blocker) for associated disease (e.g. angina) rather than for their hypertension. Information on the last recorded blood pressure reading (taken before or during 1998) was available for 17 646 individuals. Fewer individuals under active GP review had controlled blood pressure (defined as last systolic blood pressure <160 mmHg and last diastolic blood pressure <90 mmHg); 59.5% compared with 64.0% of those under non-GP review and 69.9% of those not apparently under review. These results suggest that many individuals not apparently under review may have blood pressure levels that had returned to normal and that further follow-up was no longer deemed necessary. It is noteworthy, however, that 39% of individuals in this group had at least one hypertension-related co-morbidity, which suggests that an annual check may be beneficial.
The cross-sectional nature of the study meant that we were unable to examine temporal changes in treatment. Our findings may reflect differences among groups in response to treatment or experience of side effects. For example, females might be more likely to be on a thiazide because their blood pressure is more readily controlled than men by this class of drug. Men may be changed from thiazides to other treatments because of unwanted side effects. In the recent Hypertension Optimal Treatment (HOT) study, women were able to achieve target blood pressure more easily than men, using slightly simpler therapeutic regimes.23 Women in this study were more likely to be treated with diuretics while males were more likely to receive ACE inhibitors or calcium channel blockers. Possible explanations for better control include biological factors and greater compliance with treatment. If women are more compliant with treatment, first line treatments such as thiazides may be effective and there would be no need to use alternative treatments. A review of 24 studies found that women tended to have better awareness, treatment and control of their hypertension than men.24 In our study, women appeared to have levels of controlled blood pressure similar to those of men (overall 62.2% controlled compared with 64.0% of men). Blood pressure control was also broadly similar in different deprivation (overall 65.9% in category 1 and 2, 61.8% in category 3 and 4, and 63.1% in category 5–7) and co-morbidity groups (overall 63.6% in none, 58.3% in one, 63.5% in two, and 65.8% in three or more co-morbidities). On the other hand, blood pressure control tended to decrease with age (overall from 81.1% in those aged <45 to 54.4% in those aged 75+).
Important differences in the primary care management of hypertension are likely to exist elsewhere. A Finnish study of 30 primary care health centres found that hypertensive women were more likely to receive a diuretic and men more likely to receive an ACE inhibitor.25
Even with their limitations, analyses such as those described here provide a quick and inexpensive means of exploring whether important differences between groups exist. Given that the ultimate aim of blood pressure control is to prevent cardiovascular disease, future research should determine whether differences detected are due to variations in management. Further work to explain our findings, particularly regarding possible differential use and response to treatments, should help identify primary care interventions that might reduce these differences.
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Acknowledgments |
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We would like to thank the practices who contribute to CMR, Dr Julie Simpson for her statistical advice, Mr Colin Simpson for additional CMR data extraction, and Dr Blair Smith for his useful comments on an earlier draft. The Primary Care Clinical Informatics Unit is supported by the Scottish Executive Department of Health.
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