Objective: The purpose of this study was to assess whether, and to what ext
ent, usual practice in the management of patients with mild to moderate hyp
ertension differs from that recommended in the Sixth Report of the Joint Na
tional Committee on Prevention, Detection, Evaluation, and Treatment of Hig
h Blood Pressure (JNC-VI). The results were used as input for a clinical de
cision analytic model to assess the cost-effectiveness of a new treatment f
or hypertension.
Methods: A Delphi panel survey of general practitioners and cardiologists i
n the United States was conducted to determine current strategies for the t
reatment of mild to moderate uncomplicated hypertension. The purpose of the
panel survey was to reach consensus on 3 key facets of the JNC-VI guidelin
es and how they relate to the respondents' clinical practices: (1) the defi
nition of mild to moderate hypertension, (2) the treatment that adult patie
nts with uncomplicated mild to moderate hypertension should receive, and (3
) the management of patient follow-up.
Results: Of the 20 physicians contacted for the survey, 10 responded to bot
h rounds of the questionnaire. There was considerable variation in the resp
onses for defining the ranges of healthy, acceptable, unacceptable, and ser
ious blood pressure. In general, the Delphi panel respondents cited higher
limits than stated in the JNC-VI guidelines. Physicians followed the guidel
ines similar to 60% of the time. Primary determinants of initial drug choic
e among the panelists were comorbid conditions and the severity of hyperten
sion; patients' age, race, and sex were secondary determinants. Follow-up t
ypically occurred 1 month after therapy initiation. Panelists reported titr
ating the dose of new therapies upward once or twice before discontinuing t
he drug for lack of efficacy. Once adequate blood pressure control was achi
eved, patient follow-up was reported to occur every 3 to 4 months.
Conclusions: This Delphi panel study highlights the differences between cli
nical practice and the JNC-VI guidelines in the treatment of hypertension.
The results were used as a basis for defining a structure for a cost-effect
iveness model and provided the management practice and prescribing practice
patterns required by the model.