Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice.

BACKGROUND

Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database.

METHODS AND FINDING

We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4-18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1-25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5-38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8-47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion.

CONCLUSIONS

Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.

Déclaration de conflit d'intérêts

I have read the journal's policy and the authors of this manuscript have the following completing interests: MF reports grants from Astra Zenica, grants, personal fees and non-financial support from Novo Nordisk, personal fees from Sanofi, outside the submitted work; SdL reports that for unrelated work in diabetes and vaccine safety he has received grants through University of Surrey from: Eli Lilly, GSK, Astra-Zeneca, and Takeda. RMC, MH and SJ have nothing to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.