The results of the present study, showed under- as well as overtreatment in the majority of the presented cases, emphasizing the need for better use of guidelines for the treatment of hypertension.
Case-based questionnaires aim to illustrate how judgment concerning treatment is made in cases of different severity. The cases provide a description of a real clinical challenge in a realistic clinical setting. It is important to receive a high response rate, and in order to achieve this the amount of information for the case presentation has to be reasonable. In this study, the participating GPs were randomly selected. Together with the high participation rate, this adds to the credibility of the results.
In addition, the cases were reasonably varied in terms of overall cardiovascular risk factor burden.
Our study has some limitations. A questionnaire is not the same as clinical practice, where decisions on treatment take place in concordance with the wishes of the patient, and in itself, the questionnaire may induce a more active approach than real life. Also, although guidelines do exist, there are no correct answers as such for individual cases. It should also be pointed out that the responders completed the questionnaires during office hours with a normal patient load and may thus not have had adequate time to consider the clinical implications for each case. This may have caused inconsistencies regarding the answers.
Perceived lack of time may also show the difficulty of implementing the SCORE system as a method for use in clinical practice. It could be used as a guideline, but not for automatically translating data from population studies to clinical practice. On the other hand, cases may be used as an educational method to increase the awareness of treatment options, as well as a method of priority [7
Assessment by the ESH and SCORE methods has been questioned, particularly their failure to indicate the same CV risk levels [8
]. For example, the SCORE system does not include diabetes as a risk factor. Also, further risk assessment tools tailored to primary care have recently been proposed [9
]. Regarding the generalisability of the results, the answers came from a particular setting, but the cases used should be familiar in the Western world. The results show that correctly assessing risk is difficult, affecting the consequent choice of treatment.
Finally, our questionnaire has not been validated, which makes the reproducibility of the responses uncertain. It would be difficult to find a method of validation since all information of the patient cannot be provided.
Recently, the awareness-to-adherence model has been presented [10
] in an attempt to explain failures to reach the blood pressure target. This model could also show that guidelines are on their own insufficient, and should be complemented by educational efforts.
Self-report studies have described treatment in clinical practice [11
]. However, these studies have been limited to BP targets and the reasons for not intensifying treatment. Further questions, such as drug choices and familiarity with research methods, were addressed in a large survey [13
]. Some geographic differences in attitudes concerning age and the cost of medication have also been reported [14
]. When co-morbidity is taken into consideration, younger physicians are more likely to follow guidelines [15
], a finding we could not confirm. This may also be true for non-pharmacological recommendations [16
Although frequently commented by our responders, we have not quantified this particularly.
A case-based method could be of help in the assessment of judgments made by the clinicians. Indeed, this has been used for other diagnoses [17
], but the use of the method is rare for the treatment of high BP, and thus we find our study adding to present knowledge.
The difficulty in showing adherence to guidelines due to different risk levels was described by Milchak et al [18
]. Previous studies [19
] have also shown limited correlation between increased number of risk factors and increased levels of treatment. Another study [20
] showed that physicians tend to focus rather on diastolic blood pressure when choosing treatment, leaving systolic hypertension less well controlled. Our findings rather contradict this and thus, our findings confirm that there is much room for improvement in the assessment of CVD risk. E.g., this is illustrated in case 5, where the low treatment rate may be due to reluctance to treat older patients, although this may be the group which would have the greatest benefit from treatment [21
]. However, when it comes to treatment of the oldest, a Swedish study showed that lower systolic blood pressure may be associated with greater mortality in patients aged 85 or more. [22
Factors causing reluctance to treat high BP may thus include hesitance about the guidelines, partly due to doubts concerning the effectiveness of additive treatment (referred to by some as “over-treatment”), difficulty in being up-to date, but also lack of time with patients and GPs concerns about lack of compliance.
The importance for adequate prevention for patients at risk is evident. This leads to the objective to increase adherence to guidelines, to put into practice what is considered an improved treatment, and in this process the cases in the questionnaire may be complemented by a structured study program showing the relative impact of different risk factors. Then it is of major importance that the guidelines give similar recommendations for treatment.