PHYSICIAN ATTITUDES TO BLOOD PRESSURE CONTROL IN ELDERLY HYPERTENSIVE PATIENTS (SHARE SURVEY)

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Physician attitudes to blood pressure control: findings fromthe Supporting Hypertension Awareness and ResearchEurope-wide surveyJosep Redona, Serap Erdineb, Michael Bohmc, Claudio Ferrid, Rainer Kolloche,Reinhold Kreutzf, Stephane Laurentg, Alexandre Persuh,Roland E. Schmiederi, on behalf of the SHARE Steering Committee

Objectives The Supporting Hypertension Awareness andResearch Europe-wide (SHARE) physician survey aimed toqualify the key challenges that physicians face when tryingto get patients to blood pressure (BP) goal.

Methods The SHARE survey was open to physiciansinvolved in the treatment of patients with hypertension, wasanonymous, and was designed to take 15min to complete.The survey included 45 questions covering physicians’demographic information, views on the BP targetsrecommended by the European Society of Hypertension–European Society of Cardiology guidelines, opinions onacceptable levels of BP control, and perceptions about thechallenges associated with getting patients to BP goal.

Results The survey was conducted between May andDecember 2009, and 2629 European physicians responded.The mean (W SD) levels of SBP/DBP that physicians weresatisfied with, concerned about, or would cause them totake immediate action were 131.6W9.5 /81.9W5.6,148.9W11.3 / 91.6W5.8, and 168.2W17.1 /100.1W7.8mmHg, respectively. Overall, 95.0 and 90.1% ofthe physicians, respectively, felt that patients SBP/DBPneeded to be higher than the guideline recommended goallevels before taking immediate action.

Conclusion Clinical hesitation in relation to reducingelevated BP to goal levels is putting patients at increasedcardiovascular risk and contributing to the substantialhealth and economic burden associated with uncontrolled

BP. A number of strategies are discussed that have beenshown to be effective in countering this problem.J Hypertens 29:1633–1640 Q 2011 Wolters Kluwer Health |Lippincott Williams & Wilkins.

Journal of Hypertension 2011, 29:1633–1640

Keywords: antihypertensive agents, hypertension, patient compliance,physician–patient relations, treatment goals

Abbreviations: AMI, acute myocardial infarction; BP, blood pressure; CV,cardiovascular; HCP, healthcare professional; HF, heart failure; PFP, pay forperformance; SHARE, Supporting Hypertension Awareness and ResearchEurope-wide

aHypertension Clinic, Internal Medicine, Hospital Clinico, INCLIVA, University ofValencia, and CIBERObn Carlos III Health Institute, Valencia, Spain, bDepartmentof Cardiology, Cerrahpasa School of Medicine, Istanbul University, Cerrahpasa,Istanbul, Turkey, cKlinik fur Innere Medizin III, Universitatsklinikum des Saarlandes,Homburg, Saarland, Germany, dUniversita dell’Aquila, Facolta di Medicina eChirurgia, Dipartimento di Medicina Interna e Sanita Pubblica, L’Aquila, Italy,eEvangelisches Krankenhaus Bielefeld, Klinik fur Innere Medizin, Kardiologie,Nephrologie und Pneumologie, Bielefeld, fCharite, Universtitatsmedizin BerlinInstitute of Clinical Pharmacology and Toxicology, Berlin, Germany, gDepartmentof Pharmacology and INSERM U970, Hospital European Georges Pompidou,Paris Descartes University, Paris, France, hDivision of Cardiology, CliniquesUniversitaires Saint Luc (UCL), Brussels, Belgium and iMedizinische Klinik,University Erlangen-Nuernberg, Erlangen, Germany

Correspondence to Josep Redon, Hypertension Clinic, Internal Medicine,Hospital Clinico, INCLIVA, University of Valencia, Valencia, SpainTel: +34 9638 626 47; fax: +34 9638 626 47;e-mail: [email protected]

Received 21 December 2010 Revised 31 March 2011Accepted 13 May 2011

IntroductionIt is well established that hypertension is a major riskfactor for the development of cardiovascular disease,including cerebrovascular, renal and peripheral disease,and that throughout middle and old age there is a con-tinuous relationship between increasing blood pressure(BP) and the risk of cardiovascular events starting at SBPand DBP values in the normotensive range [1,2]. It iswidely recognized that lowering BP in hypertensivepatients can significantly reduce the risk of cardiovascularmorbidity and mortality, with more intense BP loweringproviding greater risk reductions [3–8].

In order to maximise reduction of long-term cardiovas-cular risk, the 2007 European Society of Hypertension–

European Society of Cardiology (ESH–ESC) practiceguidelines for the management of arterial hypertensionrecommended that BP should be lowered to at leastbelow 140/90mmHg in all hypertensive patients and toat least below 130/80mmHg in patients with diabetes [9].However, at present, BP control rates among patientstreated for hypertension across Europe remain sub-optimal with less than 50% of patients achieving BP goal[10,11]. Barriers in clinical practice, that are not specifi-cally hypertension related, but which can preventpatients from achieving BP goals, can be split into threemain categories: physician related; patient related; andhealthcare system related [12,13]. Physician-relatedbarriers that prevent patients from achieving BP goalinclude clinical inertia, poor communication style, and

Original article 1633

0263-6352 ! 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/HJH.0b013e328348c934

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a lack of awareness/knowledge of the treatment guide-lines [12]. Of these, the most pertinent appears to beclinical inertia, defined as the failure of a healthcareprovider to initiate or intensify treatment appropriatelyin patients with uncontrolled BP [12,14]. In Europe, thisis a particular problem with only 14–26% of patientswith inadequately controlled hypertension having theirmedication increased [11].

Previously, a primary care physician survey in the UnitedStates [15] has shown that physicians were satisfied if BPin their hypertensive patients exceeded the goals recom-mended by the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of HIGH BloodPressure treatment guidelines [16]. The aim of thisinvestigation was to analyse responses from the Support-ing Hypertension Awareness and Research Europe-wide(SHARE) physician survey that aimed to investigatephysician approaches/perceptions in hypertension man-agement and the challenges that physicians face in get-ting their patients to BP goal. In particular, this analysisfocuses on physicians’ perceptions about the BP targetsrecommended in the 2007 ESH–ESC treatment guide-lines and perceptions about acceptable BP levels inhypertensive patients.

MethodsThis analysis utilized data derived from the Europeansample of physicians who completed the SHARE survey,a physician survey that aimed to quantify and qualify thekey challenges that physicians face when trying to getpatients to BP goal.

The SHARE survey was initiated following a meeting in2008 in which the challenges of ‘getting to goal’ weredebated by European experts in the field of hypertension.Subsequently, the SHARE Steering Committee wasformed and its inaugural meeting, at which the first draftof the SHARE survey questionnaire (containing 49 ques-tions) was developed, took place in February 2009. Inorder to test the functionality, viability, validity, and flowof the online survey questionnaire, several pilot sessionswere conducted with healthcare professionals (HCPs)prior to its launch on 17 May 2009. During the pilot-testing phase, the physician respondents were asked tocomplete all eight sections of the survey. Follow-up callswere then conducted in order to gain feedback relating toease of use, functionality, understanding of the questions,flow of questions, and any issues faced while completingthe survey. Finally, 45 questions were selected (seequestionnaire on the website).

The SHARE survey was conducted between May andDecember 2009 and was open to HCPs involved in thetreatment of patients with hypertension. The survey wasdesigned to take 15min to complete and was anonymous.However, physicians did have the option to input theircontact information at the end of the survey. In total,

there were 45 questions covering the following topics:physicians’ demographic information, views on the BPtargets recommended by the 2007 ESH–ESC guidelines,opinions on acceptable levels of BP control in hyper-tensive patients, and perceptions about the challengesassociated with getting patients to BP goal (seeTable 1 fora summary of the key questions). Physicians completedthe survey in the following ways: online at the SHAREwebsite (http://www.SHARE-hypertension.com), via ane-mail request from DocCheck, via an external marketresearch company (Turkey only) and at a selection of local/international European congresses (Sociedad Espanola deMedicos de Atencion Primaria, Sociedad Espanola deCardiologıa and the ESC congresses in Spain, the WorldOrganization of Family Doctors congress in Switzerlandand the ESH congress in Italy).

Statistical analysisQuantitative parameters are expressed as mean values[! standard deviation (SD)]. Qualitative parameters areexpressed as absolute and relative frequencies. Compari-sons between quantitative parameters were performedusing t-tests. P values (two sided) were interpreted inan exploratory sense. Comparisons between qualitativeparameters were performed using z-tests and x2 tests,whereas logistic regression methods were used to assessassociations. Two-sided P values less than 0.05 wereconsidered to indicate a formal statistically significantdifference and P values less than 0.1 were consideredto indicate statistical trends. In some instances, somequestions had missing responses. To account for this,the number of responses available for each analysisis reported, and, if applicable, relative frequencies arereported as adjusted percentages excluding missingvalues. In relation to the survey question (Q19) pertainingto the BP levels that physicians are satisfied with, con-cerned with, and would take immediate action at,in relation to initiation of treatment, in their generalhypertension patients, the results have been expressedas relative frequency density (%/mmHg) curves whichrepresented the best fit to the actual BPs stated by physi-cians, using the ‘normal’, bell-shaped distribution. Theshape of each curve is characterizedby themean andSDofBPs. The relative frequency density for a given level of BPrepresents the fitted percentage of physicians stating each1mmHg increment in BP within the specified ranges of110–202mmHg (SBP) and 70–116mmHg (DBP).

ResultsIn total, 2629 of the 2716 physicians who completedthe SHARE survey were from Europe. The geographicdistribution and characteristics of the Europeanphysicians are shown in Tables 2 and 3, respectively.These physicians were from a wide range of specialitiesincluding primary [n" 1563 (59%)] and secondary care[n" 1066 (41%)]. The mean (! SD) age of the physicianswas 45.6! 10.6 years and 68% were man. In total, 51% of

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physicians were office based and the majority (63%)had more than 10 years’ experience of treating patientswith hypertension.

Physicians’ opinions on the 2007 European Society ofHypertension–European Society of Cardiologyguideline-recommended BP targets and on achievingthese targets in practiceThe majority of physicians said that the BP targetlevels recommended in the 2007 ESH–ESC treatmentguidelines were ‘about right’, whereas 5.4% said theywere ‘not tight enough’ and 18.2% said they were ‘tootight and not achievable’. Significantly more generalpractitioners (GPs) (22.5%) than cardiologists (7.5%) orinternists (7.1%) felt that the recommended BP targetlevels were ‘too tight and not achievable’ (P< 0.05 vs.cardiologists or internists). In addition, significantly lowerproportions of GPs than cardiologists or internists feltthat the recommended BP target levels were either‘about right’ or ‘not tight enough’ (Fig. 1). Overall,physicians said that on average, 52.6% of their patientswere attaining ESH–ESC-recommended targets andthree-quarters (77.4%) of physicians said that it is achallenge to get their patients to these targets in practice.When physicians were asked what BP measure they use

as a guide to take care of their hypertensive patients,the majority (93.2%) said both SBP and DBP, althougha statistically significantly greater proportion of GPsthan cardiologists or internists used both SBP andDBP (P< 0.05) (Fig. 2). However, when these physicianswere subsequently asked which reading is a bettermeasure, the majority said SBP, although the preferencefor SBP over DBP was less clear-cut among GPs incomparison with cardiologists or internists (Fig. 2).

Physicians’ perceptions about the challengesthat prevent patients from achieving bloodpressure targetsWhen asked to rank the challenges that prevent patientsfrom achieving ESH–ESC BP targets from one to seven,with one being low importance and seven being highimportance, physicians ranked patient-related factorssuch as low patient accountability, compliance, and aware-ness (mean scores 5.5! 1.4, 5.4! 1.4 and 5.29! 1.4,respectively) significantly higher (P< 0.0001) than otherfactors, including tighter BP goals (4.6! 1.7), ineffectivenonmedical treatment strategies (4.3! 1.7), frequentphysician inertia (4.0! 1.7), low health authorities’support (3.8! 1.8), and ineffective medical treatmentstrategies (3.7! 1.7).

Physician attitudes to blood pressure control Redon et al. 1635

Table 1 Supporting Hypertension Awareness and Research Europe-wide survey: key questions relating to blood pressure control [allphysicians (NU2629)]

Physician respondents [n (%)]

Q18.1 What blood pressure measure do you use as a guide to take care of your hypertension patients? 2280 (86.7)(a) SBP(b) DBP(c) Both

Q18.2 If both, what is your preferred guide? 2068 (78.7)(a) SBP(b) DBP

Q19 Taking into consideration your hypertension patients, please indicate the levels of SBP that(a) you are satisfied with 2525 (96.0)(b) you become concerned and monitor more closely 2503 (95.2)(c) you are concerned and take immediate action 2476 (94.2)

Taking into consideration your hypertension patients, please indicate the levels of DBP that(a) you are satisfied with 2513 (95.6)(b) you become concerned and monitor more closely 2499 (95.0)(c) you are concerned and take immediate action 2466 (93.8)

Q22 Roughly, what percentage of your patients are you currently:(a) satisfied with 1942 (73.9)(b) concerned about and monitor more closely 1938 (73.7)(c) concerned about and take immediate action 1938 (73.7)

Q25 Is it a challenge to get your patients to guideline target BP as recommended by ESH-ESC? 2333 (88.8)Q33 On average, how many of your patients are attaining ESH-ESC recommended goal BP? 1879 (71.5)Q34 How would you rank the challenges that prevent patients attaining ESH-ESC recommended BP goal?

(1" low importance and 7" high importance)(a) Low patient compliance with medication 2228 (84.8)(b) Low patient awareness of risk of hypertension 2221 (84.5)(c) Low health authorities support 2150 (81.8)(d) Frequent physician inertia 2172 (82.6)(e) Tighter recommended BP goals 2199 (83.6)(f) Ineffective medical treatment strategies 2178 (82.8)(g) Ineffective nonmedical treatment strategies 2183 (83.0)(h) Low patient accountability for own health 2218 (84.4)

Q43 Perceptions of BP target levels: 1985 (75.5)(a) guidelines are not tight enough(b) guidelines are too tight and not achievable(c) about right

BP, blood pressure; ESC, European Society of Cardiology; ESH, European Society of Hypertension.


Blood pressure levels that physicians are satisfied with,concerned with, and would take immediate action at, ingeneral hypertensive patientsThe SBP and DBP levels that physicians were satisfiedwith, concerned with, and would take immediate actionat in their general hypertensive patients varied widelyand are shown in Fig. 3.

The mean SBP and DBP levels that physicians weresatisfied with were 131.6! 9.5 and 81.9! 5.6mmHg,respectively, and 18.9 and 7.3% of physicians, respect-ively, said that they were satisfied if SBP or DBPexceeded the ESH–ESC guideline-recommendedtargets of 140/90mmHg. Variations were also observedin the SBP and DBP levels that would cause physiciansconcern (mean 148.9! 11.3 and 91.6! 5.8mmHg,respectively) and at which they would take immediateaction (168.2! 17.1 and 100.1! 7.8mmHg, respect-ively). Overall, 95.0 and 90.1% of the physicians,respectively, said that they would not take action untiltheir patients’ SBP or DBP was higher than the guidelinerecommended levels.


Table 3 Characteristics of the European physicians who completedthe Supporting Hypertension Awareness and Research Europe-wide survey

Physician characteristics All physicians (N"2629)a

Sex, [n (%)]Man 1795 (68.3)Woman 724 (27.5)Age, mean (SD) 45.6 (10.6)

Speciality, [n (%)]General practitioner/family physician 1563 (59.5)Internistb 387 (14.7)Cardiologist 496 (18.9)Other 183 (7.0)

Location, [n (%)]Office based 1340 (51.0)Hospital based 924 (35.2)

Number of years of experience of treating patients with hypertension, [n (%)]<1 50 (1.9)<3 178 (6.8)4–10 479 (17.8)>10 1666 (63.4)

Average number of hypertensive patients seen per month, [n (%)]General hypertensive patients<25 140 (5.3)26–50 447 (17.0)51–100 738 (28.1)101–250 678 (25.8)>250 253 (9.6)

New diagnosed hypertensive patientsNone 3 (0.1)<10 986 (37.5)11–25 669 (25.4)26–50 377 (14.3)51–100 143 (5.4)>101 36 (1.4)

SD, standard deviation. a Not all physicians answered every question; percentagesrelate to the overall number of participating physicians. b Includes: diabetologist/endocrinologist (1.8% of total), internal medicine (11.0%), nephrologist (2.2%),and respiratory medicine specialists (0.04%).

Table 2 Geographic distribution of the European physicians whocompleted the Supporting Hypertension Awareness and ResearchEurope-wide survey

Country of practice, [n (%)] All physicians (N"2629)a

#50 respondentsBelgium 91 (3.46)France 352 (13.39)Germany 321 (12.21)Italy 336 (12.78)Spain 477 (18.14)Switzerland 80 (3.04)Turkey 536 (20.39)United Kingdom 286 (10.88)

<50 respondentsAndorra 2 (0.08)Austria 26 (0.99)Belarus 1 (0.04)Bosnia 1 (0.04)Bulgaria 6 (0.23)Croatia 7 (0.27)Cyprus 1 (0.04)Czech Republic 5 (0.19)Estonia 4 (0.15)Finland 2 (0.08)Georgia 4 (0.15)Greece 6 (0.23)Hungary 2 (0.08)Ireland 5 (0.19)Latvia 3 (0.11)Lithuania 4 (0.15)Luxembourg 1 (0.04)Malta 3 (0.11)Poland 13 (0.49)Portugal 11 (0.42)Romania 5 (0.19)Russia 6 (0.23)Serbia 9 (0.34)Slovenia 1 (0.04)Sweden 6 (0.23)The Netherlands 14 (0.53)Ukraine 2 (0.08)

a Not all physicians answered every question.Fig. 1

Pro

port

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of p

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76.4

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About right Not tight enough Too tight and not achievable

All physicians (n = 1985)Cardiologists (n = 294)Internists (n = 310)GPs (n = 1322)

*

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Opinions about the ESH-ESC BP targets

Physicians’ opinions about the blood pressure targets recommended inthe 2007 European Society of Hypertension–European Society ofCardiology treatment guidelines. n"number of physicians whoprovided a response. $P<0.05 vs. cardiologists and internists. BP,blood pressure; GP, general practioner; ESH–ESC, European Societyof Hypertension–European Society of Cardiology.


DiscussionThe variations in the BP levels that European physiciansin the SHARE survey were satisfied with, concernedwith, and would take immediate action at, in terms ofinitiation of treatment, in their general hypertensivepatients indicate that there are inconsistencies inphysicians’ treatment approaches in the managementof hypertension, despite guideline recommendations.

The majority of physicians (approximately 82%) thoughtthat the 2007 ESH–ESC guideline-recommendedBP target of less than 140/90mmHg for general hyper-tensive patients was ‘about right’ or ‘not tight enough’

although a minority (19%) were satisfied if SBP exceeded140mmHg and 7% were satisfied if DBP exceeded90mmHg. One potential explanation could be that thesephysicians are currently underestimating the increasedcardiovascular risk that is associated with BP being abovetarget, which was consistent with themean SBP andDBPlevels that physicians said would cause them concernbeing markedly higher than the guideline-recommendedBP targets. Another possible explanation could be thatbased on other findings in this survey, these physiciansare not comfortable that their patients’ BP exceeds thetargets but accept it because they find it hard to get theirpatients to these targets in practice and perceive that only


Fig. 2

5.11.7

93.2

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SBP DBP Both

Which BP do you use?

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All physicians (n = 2280) Cardiologists (n = 388)

Internists (n = 319) GPs (n = 1496)

60.3

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If both, preferred guide

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All physicians (n = 2068) Cardiologists (n = 322)

Internists (n = 275) GPs (n = 1402)

*

*

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Physicians’ responses about the blood pressure measures that they take as a guide to care for their hypertensive patients. n"number of physicianswho provided a response. $P<0.05 vs. cardiologists and internists. BP, blood pressure; GP, general practitioner.

Fig. 3

BP physicians satisfied with

(a) (b)

BP physicians concerned with BP physicians take immediate action at

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Relative frequency density (%/mmHg) of all physician votes on blood pressure levels in the general hypertensive population that they are satisfiedwith, concerned with, or would cause them to take immediate action. BP, blood pressure.


about half of their patients achieve BP goals. Thisapparently low rate of goal achievement may be due tobarriers presented by the disease of hypertension per serather than physician-related factors.

These survey findings also represent a potential causefor concern as studies have demonstrated the importanceof getting patients to BP goal rather than just close to goalto reduce cardiovascular events [17–20]. However,the reappraisal of the ESH-ESC Guidelines publishedin 2009 [21] emphasized that no evidence base exists forsome of the recommendations previously released. Infact, no studies have supported the view that BP shouldbe lowered below 130mmHg in diabetes, or below140mmHg in the elderly.

The finding that a higher proportion of physicians wassatisfied for SBP to exceed the recommended targetof less than 140mmHg than for DBP to exceed therecommended target of less than 90mmHg was note-worthy given that a higher proportion of physicians saidthat they would choose SBP over DBP as a guide to carefor their patients. A primary care physician survey inthe United States has also shown that physicians aremore willing to accept an elevated SBP rather thanan elevated DBP in their hypertensive patients [15].Similarly, a previous study, which evaluated a predictivemodel to estimate the probability of therapeutic inertiain hypertension, found that the most important factorsrelated to inertia were the BP values measured in theoffice, which accounted for 19% of the variability. SBPless than 160mmHg but more than 140mmHg andDBP less than 100mmHg but more than 90mmHg wererecorded in more than 80% and more than 95% of thevisits with inertia, respectively [22]. Historically, DBPwas used to assess cardiovascular risk, and it is only in thelast 10 years that elevated SBP has been acknowledged tobe a more accurate predictor of cardiovascular morbidityand mortality [2,23]. However, as elevated SBP is harderto treat than elevated DBP [24], physicians do not alwaysexpect to achieve SBP targets.

The mean SBP and DBP levels that physicians saidwould cause them to take immediate action in theirgeneral hypertensive patients were much higher thanthe recommended BP targets, indicating a tendencytowards clinical inertia. When physicians in the surveywere asked to rank the challenges that preventedpatients from achieving BP goals, they rated physicianinertia as less of a barrier than patient-related factors,tighter BP goals, and ineffective nonmedical treatmentstrategies. This suggested they may be currentlyunderestimating the impact and extent of clinicalinertia and that physician education about the dangersof clinical inertia, and implementation of strategiesto eradicate clinical inertia and improve BP controlrates by physicians and healthcare systems, would bedesirable.

The benefits of structured physician education and afeedback system for improving clinical inertia and BPcontrol in hypertension management have been shownin a recent study in Germany [25]. Primary care-basedphysicians were randomized to an information groupwhere they received detailed training on hypertensionguidelines, feedback on BP target-level attainment anda reminder to intensify treatment after each patientvisit, or to a control group where they did not receiveany information. Clinical inertia, defined as the absenceof medication changes despite failure to control BP,occurred less frequently (approximately 6% lower rate)in the information group than in the control group.Furthermore, guideline-recommended BP targets wereattained by a significantly higher proportion of patientstreated by physicians in the information group (56.8%)compared with the control group (52.5%) [25]. Theintroduction of national professional education programshas also been shown to successfully reduce clinicalinertia. One example of such a program is the CanadianHypertension Education Program (CHEP) that wasinitiated in 1999 with the aim of improving hypertensionmanagement and reducing the burden of cardiovasculardisease in Canada [26]. Subsequent analyses of nationaldata from Canada have shown that there was an 84.4%increase in antihypertensive prescriptions between 1996and 2003, and a 65.1% increase in the number ofindividuals diagnosed with hypertension, in the adultCanadian population. These were accompanied bylarge reductions in mortality rates from stroke, heartfailure, and acute myocardial infarction, particularlyafter the initiation of the CHEP in 1999 [27]. Anotherinitiative that has been used to improve BP control rateshas been introduced in the UK where physicianshave been provided with financial incentives to achieveBP targets [28]. Since 2004, this so-called ‘pay forperformance’ (PFP) approach has been shown to improvethe annual rates of treatment and control of hypertensionin the UK (changes per annum of 2.2 and 2.2%, respec-tively, after the introduction of PFP), especially inwomen [29].

Compliance with treatment is essential for successfultreatment of chronic conditions like hypertension, butpolypharmacy and complexity of treatment regimensare known to be determinants of poor medication com-pliance [30]. In most trials of antihypertensive therapy,combinations of two or more drugs have been the mostwidely used effective treatment regimens in terms of BPreduction goal achievement. The use of combinationtherapy has been found to be even more frequentlyneeded in diabetic, renal and high-risk patients, andwhenever the achievement of lower BP goal levels ispursued [9]. However, despite the evidence that themajority of patients require two or more antihypertensiveagents to achieve BP goal and that combination therapy ismore efficacious than monotherapy, there is sometimes



reluctance among physicians to use multiple agentsbecause of concerns that the increased pill burdenassociated with combination therapy could negativelyaffect patient compliance. This problem can be at leastpartly overcome by the use of fixed dose, single pillcombinations which have been shown to improvecompliance compared with free-dose combinations[30,31]. In particular, a meta-analysis of data from ninestudies of fixed-dose combinations, in which 11 925patients on fixed-dose combinations were comparedagainst 8317 patients on free-drug component regimens,and which reported data on patient compliance, hasindicated that fixed-dose combinations resulted in a26% decrease in the risk of noncompliance comparedwith free-drug component regimens. The availabilityof fixed-dose antihypertensive combinations may thushelp to reduce physician hesitation in relation to reducinglevels of BP above guideline recommended levels andprovides a simple and straightforward way to helpphysicians treat patients more strongly to improve BPcontrol rates.

Physician surveys such as SHARE are subject to anumber of possible limitations. For example, althoughthe use of web-based surveys on the internet has nowbecome one of the most popular ways of collatingquantitative data from respondents, due to its ability toreach a large target audience in a shorter space of time,there is a certain demographic subset of respondents whoare more likely to complete internet surveys than others.This is typically because they will have better access to acomputer and the internet and will be better educated onhow to use such tools. As a result, the respondentswho completed SHARE may not completely mirrorthe demographic characteristics of physicians who treathypertension. Similarly, some physicians who completedthe SHARE survey were offered a small honorarium to doso, and some physicians were recruited to complete thesurvey questionnaire at meetings related to the treatmentof hypertension. In the latter case, this may have intro-duced a potential for bias towards inclusion of physiciansin the survey who had particular interest in themanagement of patients with hypertension. Thus, thephysicians’ perceptions about acceptable BP levels inhypertensive patients recorded in the survey may reflectmore positive attitudes than exist in reality and, as aresult, the sample achieved for the SHARE survey maynot be entirely representative of the wider Europeanphysician population involved in the management ofhypertension. In addition, the SHARE survey wasdesigned so that respondents had the option of complet-ing the survey in a selection of languages, includingEnglish, French, Spanish, Dutch, Italian, and Turkish.The intention of this approach was to try and recruit asmany respondents as possible from across Europe. How-ever, the possibility that the absence of other languagesmay have excluded some physicians from participating in

the survey has to be considered and the numbersof physicians who declined to participate in thesurvey cannot be estimated. Furthermore, a majority ofthe respondents (approximately 77%) were from fivecountries (Turkey, Spain, France, Italy, Germany), withother countries making small contributions to the sampleof respondents (0.04–10.88%) which means that cautionshould be exercised in drawing conclusions from thissurvey in relation to physician practice in the wholeof Europe.

In conclusion, despite agreeing with the BP targets ofless than 140/90mmHg recommended in the 2007ESH–ESC treatment guidelines, most of the Europeanphysicians who were surveyed (>90%) would not takeimmediate action until their patients’ BP exceeded thesevalues. This clinical inertia is putting patients atincreased cardiovascular risk and contributing to thesubstantial health and economic burden associated withuncontrolled BP. The SHARE survey results suggestthat efforts continue to be made to increase awarenessabout the importance of treating patients to BP goal andpoint to the need to implement strategies to improve BPcontrol such as structured information programmes,national educational programs, financial incentives inthe healthcare system, and use of fixed dose combinationtherapies.

AcknowledgementsThis study was supported by Daiichi Sankyo. TheSHARE survey was developed by Huntsworth Healthin collaboration with the SHARE Steering Committee.

Statistical support was provided by Winfried Koch ofHaaPACS GmbH, Schriesheim, Germany, and PeterChannell of Huntsworth Health Ltd, Morris of Marlow,Buckinghamshire, United Kingdom. Medical writingservices from Joanne Bentley and Simon Lancaster,inScience Communications, a Wolters Kluwer Business,were funded by Daiichi Sankyo. SHARE survey resultshave been presented as posters at the ESH 2010 and ESC2010 congresses. M.B.: Speaker honoraria and researchsupport from Astra Zeneca, Daiichi Sankyo, BoehringerIngelheim, Pfizer and Sanofi Aventis. S.E.: Honoraria forlectures, advisory board activities, participation in clinicaltrials or research funding Daiichi Sankyo, BoehringerIngelheim, Novartis, Sanofi-Aventis, Servier, Pfizer,Menarini. C.F.: None. R.K. received advisory boardand speakers fees from several companies includingDaiichi Sankyo, Novartis, Menarinin, Berlin-Chemie,Boehringer Ingelheim, Servier, MSD. R.K.: Honorariafor lectures, advisory board activities, participationin clinical trials or research funding Bayer-Schering,Berlin-Chemie, Boehringer-Ingelheim, Bristol-MyersSquibb, Daiichi Sankyo, Merck-Serono, Menarini,Novartis, Sanofi-Aventis, Servier. S.L. received grants,honoraria as speaker or chairman, or consultation fees foradvisory board fromAstra-Zeneca, Atcor, Bayer-Schering,



Boehringer-Ingelheim, Chiesi, Daiichi-Sankyo, Esteve,Esaote, Menarini, Negma, Novartis, Omron, Recordati,and Servier. A.P. received grants from Daiichi-Sankyo(hospital accounts), J.R. received grants, honoraria asspeaker or chairman, or consultation fees for advisoryboard fromDaiichi Sankyo andMenarini. R.E.S. receivedgrants, honoraria as speaker or chairman, or consultationfees for advisory board from Daiichi Sankyo andMenarini.

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PHYSICIAN ATTITUDES TO BLOOD PRESSURE CONTROL IN ELDERLY HYPERTENSIVE PATIENTS (SHARE SURVEY)

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