In the European health care system, the general practitioner is a patient’s primary medical contact and point of referral to specialist care. Although current guidelines strongly recommend the pharmacologic treatment of hypertension in patients,1–3 adequate blood pressure (BP) control is achieved in only <30% of patients.4

To improve the care of the hypertensive patient, the “Hypertension Specialist” was introduced by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7). Referral to a specialist is recommended for patients with resistant hypertension, severely complicated hypertension, and if a secondary form of hypertension is suspected.5

The aim of our study was to determine the appropriateness, in terms of efficiency and effectiveness, of referrals to specialized centers by general practitioners.

We reviewed the computer-stored data of 9874 Caucasian hypertensive patients (aged 3–101 years, 4794 men, 5080 women) consecutively referred by general practitioners to our hypertension clinic from 1989 to 2008. The first visit and the 5 follow-up visits were considered for each patient to assess and compare the patient’s management by the general practitioner and the specialist. BP values were classified and resistant hypertension was defined according to 2007 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines.5 Both pediatric hypertension and patients with comorbidities were included in the study. We subdivided the analysis into 3 different periods (1989–1994, 1995–2001, and 2002–2008), chosen on the basis of the publication years of the main hypertension guidelines. The time spent by doctors and patients for inappropriate referral was calculated. Means and standard deviations for descriptive variables and proportions for categoric variables were calculated. One-way analysis of variance (continuous variables) and chi-square test (categorical variables) were used to analyze data.

The mean age was significantly increased between the first and the last periods but the body mass index was unchanged. With regards to lifestyle, a significant decrease in smoking was observed with time although a lack of physical activity persisted. BP values (161/99–150/90 mm Hg, P<.0001) and the average number of antihypertensive drugs taken at the baseline visit (1.32 in the first period and 1.18 in the last, P<.0001) decreased with time. At the baseline visit, 16% of referred patients had controlled BP at the baseline visit and this significantly increased over the 3 periods (5.8% and 23.8% in the first and last periods, respectively) (Table I).

Table I.   Population Features at First Visit
Population features at first visitTotal period (n=9874)Period 1985–1994 (n=1714)Period 1995-2001 (n=3774)Period 2002–2008 (n=4386) P Valuea
  1. a P value = one-way analysis of variance for continuous variables and chi-square test for categorical variables.

Age, y52.7±14.450.6±14.251.5±13.854.8±14.8<.0001
<18 y, %<.0001
>60 y, %30.8252736.8<.0001
Sex, % female51.453.953.248.9<.0001
Body mass index, kg/m226.5±4.726.8±4.726.6±4.726.4±4.7<.0322
Smokers, %19.721.120.318.3<.0001
Sedentary life, %41.837.845.939.2<.0001
Alcohol, %33.533.129.737.0<.0001
Essential hypertension, %95.096.796.692.5<.0001
Systolic pressure, mm Hg154.6±22.8161.2±23.4156.2±21.9150.5±22.7<.0001
Diastolic blood pressure, mm Hg94±12.199.3±11.895.8±1190.4±12.1<.0001
HR, heartbeats per unit of time76.6±12.680.5±12.478.6±11.973.3±12.3<.0001
Patients in therapy, %6774.774.557.6<.0001
No. of drugs per patient1.3±1.21.3±1.11.4±1.11.2±1.3<.0001
Patient with pressure <140/90 mm Hg, %15.65.811.023.4<.0001

Regarding pharmacologic treatment, in the last period only 57.6% of patients were already treated with one drug when referred to our unit, compared with 74.7% in the first period. Overall, 51.63% of patients met at least one of the criteria for referral, with a higher percentage during the mid-period but with a marked reduction over the last period (41.54%). Of patients who were incorrectly referred, 40% were untreated, 31% were taking monotherapy, and only 29% took >1 antihypertensive drug.

The most common reasons for referral were complicated hypertension and comorbidities, followed by resistant hypertension. The referral process has implications for health care costs. In terms of time spent, about 130 hours per year were designated as unnecessary visits (considering approximately 30 minutes for each specialist consulation) and around 3 working hours lost by each patient (assuming 30 minutes for the visit and 45–60 minutes before and after the visit).

In agreement with previous reports,6–8 our study defines a significantly high proportion of referrals as inappropriate and not matching guidelines’ criteria for referral. This suggests that many primary care physicians choose to refer patients with uncomplicated hypertension to a hypertension specialist, rather than undertaking or maintaining the management of the patient. This trend seems to have paradoxically increased since the introduction of the Hypertension Specialist and the indications for referral in the JNC 7 guidelines, thus suggesting that the general practioner is either unaware of or ignores the guidelines.


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  2. References
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    Coulter A, Noone A, Goldacre M. General practitioners’ referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics. BMJ. 1989;6694:304306.
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    Akbari A, Mayhew A, Al-Alawi MA, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev. 2008:CD005471.
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    Egan BM, Lackland DT, Basile JN. American Society of Hypertension regional chapters: leveraging the impact of the clinical hypertension specialist in the local community. Am J Hypertens. 2002;15:372379.