ORIGINAL ARTICLE The impact of implementing national hypertension guidelines on prevalence and workload in primary care: a population-based survey of older people R Thomson 1 , J Greenaway 1 , DJ Chinn 1 , R Wood 1 and H Rodgers 2 1 School of Population and Health Sciences (Epidemiology and Public Health) Medical School, Framlington Place, University of Newcastle upon Tyne, Newcastle upon Tyne, UK; 2 School of Clinical Medical Sciences, Medical School, Framlington Place, University of Newcastle upon Tyne, Newcastle upon Tyne, UK Recently revised UK and US hypertension guidelines have reduced thresholds for both diagnosis and treatment and differ in their recommendations. We have used data from a random, stratified community-based sample of 4784 people aged 65 years and over to compare the prevalence of treatable hypertension and the potential impact on patients and primary care from using current guidelines. BHS, NICE and JNC7 guidelines were applied to blood pressures obtained from primary care medical records (94%) or measured at a screening clinic (6%). Risk factors were obtained by questionnaire and from medical records, supplemented by epidemiological data. Workload was estimated for a representative practice population of 10 000 patients. Blood pressures were obtained on 4514 patients (94%). Prevalence of treatable hypertension was over 67%. Compared to BHS4, prevalence estimates using NICE guidelines were comparable for men but significantly lower for women (Po0.05). They were significantly higher using JNC7 compared with BHS4 and NICE guidance (Po0.05). A general practice of 10 000 patients could expect 1287 older hypertensive patients using BHS4 guidelines and 1231 patients using NICE guidelines. Under BHS4, an extra 94 patients will require annual, rather than 5-yearly review compared with that using the previous guideline. In conclusion, implementation of BHS4 guidelines, with their revised thresholds for diagnosis, will not add materially to the prevalence of treatable hypertension compared to pre- vious BHS3 guidelines but will have a major impact on practice workload. Use of NICE guidelines in preference to BHS4 will result in GPs treating fewer patients and reviewing untreated patients less often. Journal of Human Hypertension (2005) 19, 683–689. doi:10.1038/sj.jhh.1001896; published online 26 May 2005 Keywords: guidelines; diagnosis; prevalence; primary care Introduction National guidelines for hypertension have often been criticised for the variation shown between them, particularly in terms of treatment thresholds and drug therapy. 1 The 1999 British Hypertension Society (BHS) Guidelines (3rd issue) recommended that, in persons with mild hypertension, treatment should be initiated if the 10-year coronary heart disease (CHD) risk exceeded 15%. 2,3 However, the recently published BHS4 and National Institute for Clinical Excellence (NICE) guidelines recommend treatment be instigated if the 10-year cardiovascular disease (CVD) risk, incorporating both ischaemic heart disease and stroke, exceeds 20%. 4,5 The BHS3 guidelines 3 have been promoted widely and in the UK are reflected in health policy initiatives such as the UK’s National Service Frameworks for older people (stroke), 6 CHD, 7 and diabetes. 8 A study to assess the cost-effectiveness of BHS3 guidelines for new patients in primary care concluded that their implementation would be more expensive, but more effective in reducing cardiovascular risk compared with earlier guidelines. 9 The BHS3 guideline has now been superseded 4 and further recent guidance issued from NICE 5 redefines and lowers the thresholds for diagnosis and treatment based on a patient’s absolute risk. 4,5 Previously, when BHS3 guidelines were introduced, concerns were expressed about the capacity of primary care to meet the then new demands and Received 4 February 2005; revised and accepted 18 April 2005; published online 26 May 2005 Correspondence: Professor R Thomson, School of Population and Health Sciences (Epidemiology and Public Health) Medical School, Framlington Place, University of Newcastle upon Tyne, Newcastle upon Tyne NE24HH, UK. E-mail: richard.thomson@newcastle.ac.uk Journal of Human Hypertension (2005) 19, 683–689 & 2005 Nature Publishing Group All rights reserved 0950-9240/05 $30.00 www.nature.com/jhh