Press release

Thiazide therapy the best medicine for hypertension

p. 25  Systematic review of antihypertensive therapies: Does the evidence assist in choosing a first-line drug? — James M. Wright, MD, PhD; Cheng-Han Lee, BSc; G. Keith Chambers, MD [full article]

One of the main components in treating a patient with high blood pressure is deciding which drug to prescribe as a first-line therapy. Many new (and expensive) medications are now available for the treatment of hypertension, however, clear evidence of a drug's ability to prevent adverse health outcomes is not always available.

In the most comprehensive review yet published, James Wright and colleagues examined 23 trials (representing 50 853 patients) of antihypertensive drugs used as first-line therapy for uncomplicated hypertension and compared not only their effectiveness in lowering blood pressure but also how well they prevented adverse outcomes. The authors report that no other treatment has proved to be more effective in preventing the latter than standard and inexpensive, low-dose thiazide therapy.

p. 37  Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial — G. Worrall, MB, BS, MSc; et al [full article]

Depression is a common disorder and is often treated by family physicians. Concerns that depression may be underdiagnosed and undertreated led Graham Worrall and colleagues to test whether better education would lead family physicians to make more use of clinical practice guidelines (CPGs) to provide better detection and management of this common disorder.

Between July and December 1997, Worrall and his colleagues randomly assigned 42 Newfoundland family physicians to 1 of 2 groups. Physicians in both groups received CPGs on depression, but those in the first group also received a 3-hour, case-based educational session on the CPGs and access to a psychiatrist for consultation.

The authors report that while family doctors in the group that received extra education did not diagnose significantly more patients with depression (4.1 v. 2.8), considerably more of their patients were still taking their medication at the 6-month follow-up (56% v. 39.3%). Similarly, family physicians from the first group referred considerably more patients to psychiatrists (15.4% v. 3.5%) than physicians from the other group.

The authors conclude that while the educational strategy had some positive effects on the outcomes of patients with depression, considerable concern remains about the low rates of drug treatment and referral to mental health professionals by family physicians.

p. 33  Use of hormone replacement therapy among cardiac patients at a Canadian academic centre — Michelle R. Wise, MD; Donna E. Stewart, MD; Peter Liu, MD; Beth L. Abramson, MD [full article]

p. 42  Estrogen replacement for women with cardiovascular disease: Why don't physicians and patients follow the guidelines? — Steven A. Grover, MD, MPA [full article]

Although hormone replacement therapy (HRT) is associated with a reduced risk of coronary artery disease (CAD), use of this treatment among postmenopausal women is not widespread.

Michelle Wise and colleagues examined the use of HRT among 80 postmenopausal women who had or were at risk for CAD and found that only 13% of women with definite CAD and 22% who were at risk were using HRT. The authors recommend improving physician awareness and adherence to optimal patient management information.

In an accompanying editorial, Steven Grover discusses the implications of the low use of HRT among postmenopausal women at risk for coronary artery disease, especially in light of a recent randomized clinical trial showing that HRT does not benefit women with established CAD.

p. 52  Assessment of physician performance in Alberta: the Physician Achievement Review — William Hall, MD; et al [full article]

p. 44  Power to the people: taking the assessment of physician performance outside the profession — V.A. Kazandjian, PhD, MPH [full article]

The College of Physicians and Surgeons of Alberta has devised a process to test the competence of physicians every 5 years. In a pilot study designed to evaluate the process, William Hall and colleagues asked 308 physicians to assess themselves and to identify colleagues, consultants to whom they refer patients, nonphysician coworkers and patients to assess them. The study found that only 28 (9.1%) of the physicians had results that varied more than 1 standard deviation from the peer group for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers).

The authors report that further assessment or directed education may be appropriate for around 10% of the physician population. Encouragingly, two-thirds of the physicians in the study considered implementing changes to their practice based on their results.

In an accompanying editorial, Vahé Kazandjian, an expert in performance indicators, cautions against confusing variation with a lack of quality. He concludes that accounting for the expectations of people other than physicians in the assessment tool may prove to be a groundbreaking initiative in the field of assessment.