-----Original Message-----
From: Dr. Paul Kamill [mailto:[log in to unmask]]
Sent: 24 September 1998 14:44
To: Sudheer Manthri
Subject: Re: RE: follow-up-BP checks...
Sudheer
Just some observations.
You said "Elderly patients are more likely to miss out on follow-up care for
hypertension due to various constraints."
Yes, but........ Elderly folks also have more comorbidity and are more
likely to be seen than the under 65s by their GPs, even if it is for other
things. I assume that by 'various constraints' you mean the problems
associated with comorbid conditions such as the apparent inability of the
doctor to deal with multiple conditions - don't be upset, please, by this
remark, I have been there and done that. There's also a paper that suggests
this is true.
(Steinbrook,Robert. Patients with Multiple Chronic Conditions -- How Many
Medications Are Enough? NEJM 1998 21st May) Also the potential drug
interactions with polypharmacy occasioned by the multiple morbidity. We then
have the problem of the 'rule of halves' concerning treatment of
hypertension, in particular, and also other conditions like heart failure.
A group of us working on guidelines on Heart Failure to be disseminated to
General Practice through our MAAG could find no 'evidence' that the outcome
of heart failure in terms of morbidity or mortality was improved by an
'annual checkup' for BP. It came down to 'custom and practice' or opinion
based 'good practice'. In other words we do things because they have always
been done this way even if they consume resources! Even so most of the
patients that were looked at in our audit were being seen regularly for
other things because they were elderly.
I have recently been asked about the use of echocardiography. Specifically
the question of post MI follow up in patients who have not been given ACE
inhibitors. If they are asymptomatic, when and how often should they be
reviewed? and are clinical findings adequate or do we need to perform an
echocardiogram? If so How often? And so on. There is no clear answer - for
General Practice Patients. The recent issue of Spectrum Bias as discussed on
the list seems to apply here. Cynthia Mulrow's paper about the clinical
examination and several others do not deal with the population, nor do they
give an answer.
Doctors are not constrained by EBM to not use their clinical judgement. Some
time ago there was a discussion on the list about where the statement that
there was 'good evidence for less than 20% of what we do' came from. Several
people have suggested that this is now not accurate, but even so there is a
large chunk of what we do that is not evidence-based. So 'Judgement' has to
come into it.
Dr. Paul Kamill, MPH, MRCGP
SpR in Public Health Medicine
Bradford Health Authority
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"He who knows does not speak. He who speaks does not know."
Lao-tse [Lao-tzu] (c604-c531 B.C.)
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