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Background: Healthy lifestyle changes for patients with stage 1 hypertension are recommended before antihypertensive medication. Exercise has antihypertensive benefits; however, low adoption and high attrition are common. Patients need easily adoptable, effective and manageable exercise interventions that can be sustained for life. We present participant and stakeholder perceptions of an isometric exercise intervention for stage 1 hypertension delivered in the National Health Service (NHS, UK). Methods: An embedded qualitative study within a randomised-controlled feasibility study included intervention arm participants (n = 10), healthcare professionals from participating NHS sites (n = 3) and non-participating NHS sites (n = 5) taking part in semi-structured interviews to explore feasibility of delivering an isometric exercise intervention within the study design and an NHS context. Data was analysed using reflective thematic analysis. Results: Three themes were identified: study deliverability; motivators and barriers; support for study participation. Findings indicated that the study was well designed. Health benefits, unwillingness to take medication, altruism and interest in the study helped motivation and adherence. Study support received was good, but healthcare professionals were insecure in intervention delivery with regular training/supervision needed. Perception of health improvement was mixed, but, in some, uptake of wider lifestyle changes resulted from participation. Stakeholders felt that current service challenges/demand would make implementation challenging. Conclusions: Despite participant positivity, delivery of an isometric intervention in an NHS setting was considered challenging given the current service demand, although possible with robust effectiveness evidence. Findings support further effectiveness data and implementation development of the isometric exercise intervention. Trial registration: ISRCTN, ISRCTN13472393. Registered 18 September 2020. [ABSTRACT FROM AUTHOR]

The TIME study investigated whether taking blood pressure (BP) medications in the evening improves cardiovascular outcomes compared to taking them in the morning. The study involved 21,104 participants from the United Kingdom and found no difference in the primary outcome between the two dosing groups. There were also no differences in secondary outcomes or between pre-specified subgroups. The study concluded that patients can take their BP medications whenever it is convenient for them. However, adherence to medication is proven to be worse at bedtime, so taking medication in the morning is recommended. [Extracted from the article]

The article presents guidelines on prescribing comorbidity medications used in rheumatology practice to pregnant and breastfeeding women from the British Society for Rheumatology. The objective is to update previous guidelines on prescribing for drug categories like pain management, anticoagulants and anti-hypertensives. It excludes the management of infertility or acute pain relief during labour.

Chemical adherence testing is a reliable method to assess adherence to antihypertensive drugs. However, it is expensive and has limited availability in clinical practice. To reduce the number and costs of chemical adherence tests, we aimed to develop and validate a clinical screening tool to identify patients with a low probability of non-adherence in patients with uncontrolled hypertension. In 495 patients with uncontrolled hypertension referred to the University Medical Centre Utrecht (UMCU), the Netherlands, a penalised logistic regression model including seven pre-specified easy-to-measure clinical variables was derived to estimate the probability of non-adherence. Non-adherence was defined as not detecting at least one of the prescribed antihypertensive drugs in plasma or urine. Model performance and test characteristics were evaluated in 240 patients with uncontrolled hypertension referred to the Heartlands Hospital, United Kingdom. Prevalence of non-adherence to antihypertensive drugs was 19% in the UMCU and 44% in the Heartlands Hospital population. After recalibration of the model's intercept, predicted probabilities agreed well with observed frequencies. The c-statistic of the model was 0.63 (95%CI 0.53–0.72). Predicted probability cut-off values of 15%–22.5% prevented testing in 5%–15% of the patients, carrying sensitivities between 97% (64–100) and 90% (80–95), and negative predictive values between 74% (10–99) and 70% (50–85). The combination of seven clinical variables is not sufficient to reliably discriminate adherent from non-adherent individuals to safely reduce the number of chemical adherence tests. This emphasises the complex nature of non-adherence behaviour and thus the need for objective chemical adherence tests in patients with uncontrolled hypertension. [ABSTRACT FROM AUTHOR]

Background: Medication non-adherence is a prevalent health problem in people with type 2 diabetes mellitus (T2DM). Interventions have previously been developed to improve medication adherence, but inconsistent outcomes have been reported. A potential explanation for this inconsistency is a 'one size fits all' approach, with interventions not tailored to the needs and preferences of individuals. Therefore, the aim of this study is to evaluate the effectiveness of a personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with T2DM.Methods: A parallel-group randomised controlled trial will be conducted in 40-50 community pharmacies in the Netherlands and the United Kingdom (UK). A total of 300 participants will be included and followed up for a period of 6 months. Participants will be people with T2DM identified as non-adherent to oral antidiabetic and/or antihypertensive medication, aged 35-75 years and mobile phone users. The intervention group will receive a personalised intervention programme that is based on one or more of the participants' pre-defined non-adherence profile(s), namely (I) Knowledge and perceptions, (II) Practical problems, (III) Side effects and (IV) Negative mood and beliefs. The intervention comprises of one or more supporting modules, namely (I) Brief messaging, (II) Clinical medication review, (III) Medication schedule, (IV) Reminding messaging, (V) Medication dispensing systems, (VI) Smart messaging, (VII) Referral to general practitioner and (VIII) Unguided web-based Self Help Application for low mood. The control group will receive usual care including access to a publicly available informative diabetes website. The primary study outcome is medication adherence measured with a telephone pill count. Secondary outcomes are systolic blood pressure, HbA1c level, self-reported medication adherence, attitude and beliefs toward medication, satisfaction with diabetes treatment, health status and medical consumption and productivity cost. In addition, a process evaluation will be undertaken to establish the fidelity, reach and the extent to which intervention delivery is normalised in the daily practice of community pharmacy teams.Discussion: The study can lead to a personalised intervention programme that improves medication adherence in people with T2DM that are non-adherent to oral antidiabetic and/or antihypertensive medication.Trial Registration: Dutch Trial Register, Trial NL8747 , registered 02 July, 2020; ISRCTN Registry, ISRCTN36009809 , registered 05 February, 2020. [ABSTRACT FROM AUTHOR]

Aims: Antihypertensive drugs have been implicated in coronavirus disease 2019 (COVID‐19) susceptibility and severity, but estimated associations may be susceptible to bias. We aimed to evaluate antihypertensive medications and COVID‐19 diagnosis and mortality, accounting for healthcare‐seeking behaviour. Methods: A population‐based case‐control study was conducted including 16 866 COVID‐19 cases and 70 137 matched controls from the UK Clinical Practice Research Datalink. We evaluated all‐cause mortality among COVID‐19 cases. Exposures were angiotensin‐converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta‐blockers (B), calcium‐channel blockers (C), thiazide diuretics (D) and other antihypertensive drugs (O). Analyses were adjusted for covariates and consultation frequency. Results: ACEIs were associated with lower odds of COVID‐19 diagnosis (adjusted odds ratio [AOR] 0.82, 95% confidence interval [CI] 0.77‐0.88) as were ARBs (AOR 0.87, 95% CI 0.80‐0.95) with little attenuation from adjustment for consultation frequency. C and D were also associated with lower odds of COVID‐19 diagnosis. Increased odds of COVID‐19 for B (AOR 1.19, 95% CI 1.12‐1.26) were attenuated after adjustment for consultation frequency (AOR 1.01, 95% CI 0.95‐1.08). Patients treated with ACEIs or ARBs had similar odds of mortality (AOR 1.00, 95% CI 0.83‐1.20) to patients treated with classes B, C, D or O or patients receiving no antihypertensive therapy (AOR 0.99, 95% CI 0.83‐1.18). Conclusions: There was no evidence that antihypertensive therapy is associated with increased risk of COVID‐19 diagnosis or mortality; most classes of antihypertensive therapy showed negative associations with COVID‐19 diagnosis. [ABSTRACT FROM AUTHOR]

Background: The LiGHT trial (Laser-1st versus Drops-1st for Glaucoma and Ocular Hypertension Trial) is a multicentre randomised controlled trial of two treatment pathways for patients who are newly diagnosed with open-angle glaucoma (OAG) and ocular hypertension (OHT). The main hypothesis for the trial is that lowering intraocular pressure (IOP) with selective laser trabeculoplasty (SLT) as the primary treatment ('Laser-1st') leads to a better health-related quality of life than for those started on IOP-lowering drops as their primary treatment ('Medicine-1st') and that this is associated with reduced costs and improved tolerability of treatment. This paper describes the statistical analysis plan for the study.Methods/design: The LiGHT trial is an unmasked, multi-centre randomised controlled trial. A total of 718 patients (359 per arm) are being randomised to two groups: medicine-first or laser-first treatment. Outcomes are recorded at baseline and at 6-month intervals up to 36 months. The primary outcome measure is health-related quality of life (HRQL) at 36 months measured using the EQ-5D-5L. The main secondary outcome is the Glaucoma Utility Index. We plan to analyse the patient outcome data according to the group to which the patient was originally assigned. Methods of statistical analysis are described, including the handling of missing data, the covariates used in the adjusted analyses and the planned sensitivity analyses.Trial Registration: The trial was registered with the ISRCTN register on 23/07/2012, number ISRCTN32038223 . [ABSTRACT FROM AUTHOR]

Background: A common complication after stroke is development of cognitive impairment and dementia. However, effective strategies for reducing the risk of developing these problems remain undefined. Potential strategies include intensive lowering of blood pressure (BP) and/or lipids. This paper summarises the baseline characteristics, statistical analysis plan and feasibility of a randomised control trial of blood pressure and lipid lowering in patients post-stroke with the primary objective of reducing cognitive impairment and dementia.Methods: The Prevention Of Decline in Cognition After Stroke Trial (PODCAST) was a multi-centre prospective randomised open-label blinded-endpoint controlled partial-factorial internal pilot trial running in secondary and primary care. Participants without dementia were enrolled 3-7 months post ischaemic stroke or spontaneous intracerebral haemorrhage, and randomised to intensive versus guideline BP lowering (target systolic BP <125 mmHg versus <140 mmHg); patients with ischaemic stroke were also randomised to intensive or guideline lipid lowering (target LDL cholesterol <1.4 mmol/L versus <3 mmol/L). The primary outcome was the Addenbrooke's Cognitive Examination-Revised; a key secondary outcome was to assess feasibility of performing a large trial of one or both interventions. Data are number (%) or mean (standard deviation). The trial was planned to last for 8 years with follow-up between 1 and 8 years. The plan for reporting the main results is included as Additional file 2.Results: 83 patients (of a planned 600) were recruited from 19 UK sites between 7 October 2010 and 31 January 2014. Delays, due to difficulties in the provision of excess treatment costs and to complexity of follow-up, led to few centres taking part and a much lower recruitment rate than planned. Patient characteristics at baseline were: age 74 (SD 7) years, male 64 (77 %), index stroke ischaemic 77 (93 %), stroke onset to randomisation 4.5 [SD 1.3] months, Addenbrooke's Cognitive Examination-Revised 86 (of 100, SD 8), Montreal Cognitive Assessment 24 (of 30, SD 3), BP 147/82 (SD 19/11) mmHg, total cholesterol 4.0 (SD 0.8) mmol/L and LDL cholesterol 2.0 (SD 0.7) mmol/L, modified Rankin Scale 1.1 (SD 0.8).Conclusion: Limited recruitment suggests that a large trial is not feasible using the current protocol. The effects of the interventions on BP, lipids, and cognition will be reported in the main publication.Trial Registration: ISRCTN85562386 registered on 23 September 2009. [ABSTRACT FROM AUTHOR]

Background: Angiotensin-converting enzyme (ACE) inhibitors and/or in combination with calcium channel blockers (CCBs) are generally recommended as the first-line antihypertensive therapy for people with hypertension and kidney dysfunction. Evidence from large randomized controlled trials comprehensively comparing renal effects of different classes of antihypertensive drugs is lacking.Methods: We used a Mendelian randomization study to obtain unconfounded associations of genetic proxies for antihypertensives with kidney function. Specifically, we used published genetic variants in genes regulating target proteins of these drugs and then applied to a meta-analysis of the largest available genome-wide association studies of kidney function (estimated glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio (UACR), and albuminuria). Inverse variance weighting was used as the main analysis and to combine estimates from different sources.Results: Genetically predicted ACE inhibition was associated with higher eGFR (effect size 0.06, 95% confidence interval (CI) 0.008, 0.11), while genetic proxies for beta-blockers were associated with lower eGFR (- 0.02, 95% CI - 0.04, - 0.004) when meta-analyzing the UK Biobank and CKDGen. Genetic proxies for CCBs were associated with lower UACR (- 0.15, 95% CI - 0.28, - 0.02) and lower risk of albuminuria (odds ratio 0.58, 95% CI 0.37, 0.90) in CKDGen. The associations were robust to using different analysis methods and different genetic instruments.Conclusions: Our findings suggest the reno-protective associations of genetically proxied ACE inhibitors and CCBs, while genetic proxies for beta-blockers may be related to lower eGFR. Understanding the underlying mechanisms would be valuable, with implications for drug development and repositioning of treatments for kidney disease. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) Health Check programme was introduced in 2009 in England to systematically assess all adults in midlife for cardiovascular disease risk factors. However, its current benefit and impact on health inequalities are unknown. It is also unclear whether feasible changes in how it is delivered could result in increased benefits. It is one of the first such programmes in the world. We sought to estimate the health benefits and effect on inequalities of the current NHS Health Check programme and the impact of making feasible changes to its implementation.Methods and Findings: We developed a microsimulation model to estimate the health benefits (incident ischaemic heart disease, stroke, dementia, and lung cancer) of the NHS Health Check programme in England. We simulated a population of adults in England aged 40-45 years and followed until age 100 years, using data from the Health Survey of England (2009-2012) and the English Longitudinal Study of Aging (1998-2012), to simulate changes in risk factors for simulated individuals over time. We used recent programme data to describe uptake of NHS Health Checks and of 4 associated interventions (statin medication, antihypertensive medication, smoking cessation, and weight management). Estimates of treatment efficacy and adherence were based on trial data. We estimated the benefits of the current NHS Health Check programme compared to a healthcare system without systematic health checks. This counterfactual scenario models the detection and treatment of risk factors that occur within 'routine' primary care. We also explored the impact of making feasible changes to implementation of the programme concerning eligibility, uptake of NHS Health Checks, and uptake of treatments offered through the programme. We estimate that the NHS Health Check programme prevents 390 (95% credible interval 290 to 500) premature deaths before 80 years of age and results in an additional 1,370 (95% credible interval 1,100 to 1,690) people being free of disease (ischaemic heart disease, stroke, dementia, and lung cancer) at age 80 years per million people aged 40-45 years at baseline. Over the life of the cohort (i.e., followed from 40-45 years to 100 years), the changes result in an additional 10,000 (95% credible interval 8,200 to 13,000) quality-adjusted life years (QALYs) and an additional 9,000 (6,900 to 11,300) years of life. This equates to approximately 300 fewer premature deaths and 1,000 more people living free of these diseases each year in England. We estimate that the current programme is increasing QALYs by 3.8 days (95% credible interval 3.0-4.7) per head of population and increasing survival by 3.3 days (2.5-4.1) per head of population over the 60 years of follow-up. The current programme has a greater absolute impact on health for those living in the most deprived areas compared to those living in the least deprived areas (4.4 [2.7-6.5] days of additional quality-adjusted life per head of population versus 2.8 [1.7-4.0] days; 5.1 [3.4-7.1] additional days lived per head of population versus 3.3 [2.1-4.5] days). Making feasible changes to the delivery of the existing programme could result in a sizable increase in the benefit. For example, a strategy that combines extending eligibility to those with preexisting hypertension, extending the upper age of eligibility to 79 years, increasing uptake of health checks by 30%, and increasing treatment rates 2.5-fold amongst eligible patients (i.e., 'maximum potential' scenario) results in at least a 3-fold increase in benefits compared to the current programme (1,360 premature deaths versus 390; 5,100 people free of 1 of the 4 diseases versus 1,370; 37,000 additional QALYs versus 10,000; 33,000 additional years of life versus 9,000). Ensuring those who are assessed and eligible for statins receive statins is a particularly important strategy to increase benefits. Estimates of overall benefit are based on current incidence and management, and future declines in disease incidence or improvements in treatment could alter the actual benefits observed in the long run. We have focused on the cardiovascular element of the NHS Health Check programme. Some important noncardiovascular health outcomes (e.g., chronic obstructive pulmonary disease [COPD] prevention from smoking cessation and cancer prevention from weight loss) and other parts of the programme (e.g., brief interventions to reduce harmful alcohol consumption) have not been modelled.Conclusions: Our model indicates that the current NHS Health Check programme is contributing to improvements in health and reducing health inequalities. Feasible changes in the organisation of the programme could result in more than a 3-fold increase in health benefits. [ABSTRACT FROM AUTHOR]

Background: Stroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused.Methods and Findings: We analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated. In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs. The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients' adherence to medication or medication targets, such as blood pressure levels.Conclusions: In our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and antihypertensive drugs is important to reduce the incidence and burden of stroke and TIA. [ABSTRACT FROM AUTHOR]

The 2004 UK Quality and Outcomes Framework (QOF) remunerates general practitioners for achieving a target blood pressure (BP) of 150/90 mm Hg for patients with ischaemic heart disease, stroke and hypertension. Using the DIN-LINK GP database, we investigated whether introducing the target altered BP recording. We extracted 3 164 189 BP measurements from 236 467 patients, with the above diagnoses from 2000 to 2005. Treatment was assessed by Read codes indicating prescriptions for antihypertensive drugs. Over this period, recorded systolic BP (SBP) fell: 36% had an SBP >150 mm Hg in 2000–2001, and only 19% in 2004–2005. However, there was a trend towards recording systolic values just below, rather than just above the 150 cut-off. In 2000–2001, 2.3% of patients had 148–149 recorded and 1.8% had 151–152. In 2004–2005, the figures were 4.2 and 1.3%, respectively. By smoothing the distribution we estimate that the true percentage of patients with SBP>150 mm Hg in 2004–2005 was 23%, rather than the 19% recorded. Moreover, patients with a recorded SBP=148–149 were more likely to have a recorded diastolic BP90 (93%) than patients with SBP=151–152 (78%). However, patients just below the 150 mm Hg cut-off received more antihypertensive treatment than those just above it (odds ratio=1.20, 95% confidence interval 1.01–1.41). We conclude that blood pressure levels in UK primary care have continued to fall through the introduction of QOF, offering significant public health benefits in the future. This fall has been exaggerated due to values being clustered just below the QOF target, but there is no evidence of adverse effects of this on clinical management. [ABSTRACT FROM AUTHOR]

PurposeTo examine trends and demographic factors affecting persistence with ocular hypotensive therapy, from a period before prostaglandins were available to when they were the most common therapy.MethodsComputerised patient records from 94 general practices across the Unitd Kingdom, identified 5670 registered patients newly prescribed an ocular hypotensive drug (1993–2005). Persistence was defined as continuing therapy without a 90-day gap in prescription for (i) any ocular hypotensive and (ii) initial monotherapy. Time to failure with the treatment was compared using proportional hazard analyses, adjusted for age, gender, practice, year of initial treatment, and a sociodemographic indicator. Study findings were set in the context of a review of the literature.ResultsPercentage persistent at 1-year rose after 1997 when prostaglandins were introduced; from 61% in 1994–1996 to 70% in 2002–2004. Persistence with any treatment did not differ between those initiated on β-blockers compared to prostaglandins (1.05, 95% CI 0.93–1.17). However, 20% of subjects initiated on β-blockers received a prostaglandin by 1 year. Conversely, 8% of those initiated on prostaglandins received a β-blocker. When failure with initial therapy was considered, β-blockers appeared worse (1.35, 95% CI 1.21–1.50); this was consistent with findings from six studies in the review (1.40, 95% CI 1.34–1.46). Neither gender nor social factors were associated with persistence, but younger subjects (35–64 years) were significantly more likely to fail as were those over 85 years.ConclusionsIntroduction of prostaglandins may explain an improvement in persistence over a decade. However, whether the higher cost of initiating patients on prostaglandins is justified remains questionable unless clinically indicated.Eye (2009) 23, 1098–1110; doi:10.1038/eye.2008.213; published online 11 July 2008 [ABSTRACT FROM AUTHOR]

The objective of this study was to investigate the association between NSAID use and blood pressure (BP) among a sample of treated hypertensive patients. A controlled observational study was designed in UK primary care setting. Patients with diagnosed hypertension and currently being prescribed antihypertensive medication registered with four general practices, comparing patients also prescribed NSAIDs (exposed) to those not prescribed NSAIDs (unexposed). Majority of the patients were elderly. Systolic and diastolic pressure were the outcome measures. Data were collected for 184 NSAID users and 762 nonusers with a mean age of 68 years. There was no difference in either systolic (adjusted difference 1.9?mmHg, 95%CI-0.7 to 4.5, P=0.15) or diastolic (adjusted difference 1.0?mmHg, 95%CI-0.3 to 2.3, P=0.15) blood pressure. There was no evidence of any interactions according to categories of age, sex, or number of antihypertensive drugs prescribed. Among NSAID users, there was no evidence of any differences in blood pressure according to NSAID type or dose. In conclusion we found no evidence for an association between NSAID usage and BP control in known hypertensive patients receiving antihypertensive medication in primary care. The reported association between NSAID use and BP control appears much less substantial than has been previously suggested.Journal of Human Hypertension (2005) 19, 445-450. doi:10.1038/sj.jhh.1001839 Published online 10 March 2005 [ABSTRACT FROM AUTHOR]

Background/Aim: We have previously reported a study on the adequacy of management of hypertension in patients developing end-stage renal failure (ESRF) over a period of 3 years from a single health district in the UK (n = 107). There were significant shortcomings in all aspects of management of hypertension including blood pressure (BP) control. Methods: In this report, we have compared BP control in the same cohort of patients before and after starting renal replacement therapy (RRT). Results: BP control improved significantly after the patients were established on dialysis (mean 158/ 87 mm Hg pre-RRT vs. 152/82 mm Hg post-RRT; p < 0.0001), and fewer antihypertensive agents were prescribed to control BP (mean 2.45 vs. 1.74) in this period (p < 0.0001). Moreover, patients on continuous ambulatory peritoneal dialysis (n = 50) had a better systolic BP control compared with the haemodialysis patients (n = 57; p = 0.03). Conclusions: This study shows significant improvement in BP control in a cohort of patients with ESRF following the start of dialysis. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Inexpensive antihypertensive drugs are at least as effective and safe as more expensive drugs. Overuse of newer, more expensive antihypertensive drugs is a poor use of resources. The potential savings are substantial, but vary across countries, in large part due to differences in prescribing patterns. We wanted to describe prescribing patterns of antihypertensive drugs in ten countries and explore possible reasons for inter-country variation. Methods: National prescribing profiles were determined based on information on sales and indications for prescribing. We sent a questionnaire to academics and drug regulatory agencies in Canada, France, Germany, UK, US and the Nordic countries, asking about explanations for differences in prescribing patterns in their country compared with the other countries. We also conducted telephone interviews with medical directors of drug companies in the UK and Norway, the countries with the largest differences in prescribing patterns. Results: There is considerable variation in prescribing patterns. In the UK thiazides account for 25% of consumption, while the corresponding figure for Norway is 6%. In Norway alpha-blocking agents account for 8% of consumption, which is more than twice the percentage found in any of the other countries. Suggested factors to explain inter-country variation included reimbursement policies, traditions, opinion leaders with conflicts of interests, domestic pharmaceutical production, and clinical practice guidelines. The medical directors also suggested hypotheses that: Norwegian physicians are early adopters of new interventions while the British are more conservative; there are many clinical trials conducted in Norway involving many general practitioners; there is higher cost-awareness among physicians in the UK, in part due to fund holding; and there are publicly funded pharmaceutical advisors in the UK. Conclusion: Two compelling explanations the variation in prescribing that warrant further investigation are the promotion of less-expensive drugs by pharmaceutical advisors in UK and the promotion of more expensive drugs through "seeding trials" in Norway. [ABSTRACT FROM AUTHOR]

The article provides information on the results of a study which showed that delays in treatment of high blood pressure are associated with increased risk of cardiovascular events and death in patients with hypertension in primary care practices in Great Britain. It discusses the examination of hypertension treatment strategies defined by systolic blood pressure target, time to intensification and time to follow-up after medication intensification.