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Department of Veterans Affairs
Veterans Health Administration
Office of Quality & Performance |
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Title: Diagnosis and Management of Patients
with Hypertension in the Primary Care Setting
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| Citation |
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Diagnosis and Management of Hypertension
in the Primary Care Setting. Washington, DC: VA/DoD Evidence-Based
Clinical Practice Guideline Working Group, Veterans Health Administration,
Department of Veterans Affairs , and Health Affairs, Department of
Defense, November 1999. Office of Quality and Performance publication
10Q-CPG/HTN-99.
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Completion Date:
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May 1999
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| Release Date: |
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November, 1999
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| Source(s): |
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Washington (DC): The Hypertension Guideline was
developed by and for clinicians from the Department of Veterans Affairs
(VA) and the Department of Defense (DoD); 1999. Various Pages.
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| Adaptation: |
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The guideline draws heavily from the Sixth Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC-VI), 1997.
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| Guideline Status: |
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This is a current release of the guideline. An
update is targeted for late 2001.
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| Developer(s): |
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Veterans Health Administration (VHA), Department
of Veterans Affairs (VA) - Federal Government Agency [U.S.] Department
of Defense (DoD) - Federal Government Agency [U.S.]
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| Funding Source: |
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U.S. Government
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| Committee: |
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The Hypertension Working Group
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| Working Group Composition: |
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The list
of contributors to the guideline includes nurses, nephrologists,
cardiologists, pharmacists, internal medicine and primary care physicians,
and experts in the field of guideline and algorithm development.
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| Disease/Condition: |
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Hypertension
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| Category: |
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Screening, Diagnosis, Treatment, and Management
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| Intended Users: |
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Clinical staff including physicians, nurses,
nurse practitioners, physician assistants, and clinical pharmacists
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| Target Population: |
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Persons eligible for care in the VA or DoD health
care delivery system.
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| Contact Person(s):
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VHA:
Peter Glassman, MD
VA Medical Center
11301 Wilshire Blvd.
Los Angeles, CA
(310) 478-3711 x48337
peter.glassman@med.va.gov
DOD :
Robert Manaker, LtCol, MC, USAF
Chief, Medical Staff
75th Medical Group
75MDG/SGH
7321 11th Street, Bldg. 570
Hill AFB, UT 84056
801-777-4553
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GOALS/OBJECTIVES
- Describe the critical
decision points in the management of hypertension.
- Provide a clear and comprehensive guideline
incorporating current information and practices for practitioners throughout
the DoD and Veterans Health Administration system.
- Improve local management
of patients with hypertension and patient outcomes.
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INTERVENTIONS AND PRACTICES
The Guideline consists of two algorithms—a screening algorithm and a treatment
algorithm. The treatment algorithm addresses distinct aspects of:
- Assessment and Triage
- Pharmacotherapy
- Diet and Lifestyle Modification
- Follow-up
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OUTCOMES CONSIDERED
Systolic and diastolic blood pressure readings.
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MAJOR RECOMMENDATIONS
The guideline is formatted as two algorithms, with annotations. Presentation
of the algorithms is intended to assist the clinician in reviewing and identifying
key points that are comprehensively discussed in the guideline document.
- The diagnosis of hypertension is usually
not made on a first visit; blood pressure elevations can be classified.
- A subset of hypertensive patients requires
drug therapy; risk stratification should determine therapy.
- Clinicians should begin by prescribing lifestyle
modification in all patients with hypertension.
- Clinicians should enlist patient participation
in lifestyle modification.
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CLINICAL ALGORITHM(S) ARE PROVIDED
FOR:
H1
- Screening for HTN
H2
- Diagnosis for Treatment
H3
- Follow up
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TYPE OF EVIDENCE
The guideline is supported by the literature in a majority of areas, with
evidence-based tables and references throughout the document. The evidence
consists of key clinical randomized controlled trials and longitudinal studies
in the area of hypertension. Where existing literature is ambiguous or conflicting,
or where scientific data are lacking on an issue, recommendations are based
on the expert panel’s opinion and clinical experience. The guideline contains
a bibliography and discussion of the evidence supporting each recommendation.
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DESCRIPTION OF METHODS TO COLLECT EVIDENCE
The algorithm and annotations were based on an exhaustive
review of the literature. The goal of the literature review was to provide
a systematic basis for the development of an evidence-based guideline.
The inclusion criteria for the literature search were related to the population
being studied (adult) and the treatment setting (primary care).
The Medical Subject Headings (MeSH) terms used for the search included
key therapies in hypertension, study characteristics, and study design.In
this search, study characteristics were those of analytic studies, case-control
studies, retrospective studies, cohort studies, longitudinal studies,
follow-up studies, prospective studies, cross-sectional studies, clinical
protocols, controlled clinical trials, RCTs, intervention studies, and
sampling studies.
Study design included crossover studies, double-blind
studies, matched pair analysis, meta-analysis, random allocation, reproducibility
of results, and sample size.
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METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE
EVIDENCE
The literature search was followed by critical analysis
of the literature, primarily by the clinical experts. To promote the evidence-based
approach, the quality of evidence was rated using a hierarchical rating
scheme. The value of a hierarchical rating scheme is that it provides
a systematic means for evaluating the scientific basis for health care
services (3).
The rating scheme used for this guideline is based on a system used by
the Agency for Health Care Policy and Research. Decision points in the
algorithm are annotated, and the primary source documents for the annotation
are graded.
The Grading Scheme Used For The Guideline
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Quality of Evidence (QE)
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| Grade |
Description |
| I |
Evidence is obtained from at least
one properly randomized controlled trial. |
| II-1 |
Evidence is obtained from well-designed
controlled trials without randomization. |
| II-2 |
Evidence is obtained from well-designed
cohort or case-control analytic studies, preferably from more than
one center or research group. |
| II-3 |
Evidence is obtained from multiple
time series with or without the intervention. Dramatic results in
uncontrolled experiments could also be regarded as this type of evidence. |
| III |
Opinions of respected authorities
are based on clinical experience, descriptive studies in case reports,
or reports of expert committees. |
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Strength of Recommendation (SR)
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| Grade |
Description |
| A |
There is good evidence to support
the recommendation that the condition be specifically considered. |
| B |
There is fair evidence to support
the recommendation that the condition be specifically considered |
| C |
There is insufficient evidence to
recommend for or against the inclusion of the condition, but a recommendation
may be based on other grounds. |
| D |
There is fair evidence to support
the recommendation that the condition be excluded from consideration
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| E |
There is good evidence to support
the recommendation that the condition be excluded from consideration
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REVIEW METHODS
Peer Review
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ENDORSER(S)
VHA’s National Clinical Practice Guideline Council
DoD/VA Clinical Practice Guideline Working Group
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QUALIFYING STATEMENTS
Clinical practice guidelines, which are increasingly
being used in health care, are seen by many as a potential solution to
inefficiency and inappropriate variations in care. Guidelines should be
evidenced-based as well as based upon explicit criteria to ensure consensus
regarding their internal validity. However, it must be remembered that
the use of guidelines must always be in the context of a health care provider's
clinical judgment in the care of a particular patient. For that reason,
the guidelines may be viewed as an educational tool analogous to textbooks
and journals, but in a more user-friendly format.
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GUIDELINE AVAILABILITY
Electronic copies available from the Office of Quality and Performance
website.
Print copies available from:
The Office of Quality and Performance (10Q)
Veterans Health Administration, Department of Veterans Affairs
810 Vermont, NW
Washington, DC 20420
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Copy Statement: No copyright restrictions apply
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