The peer review programme was not successful for changing the treatment of chronic patients, although the programme focused on dealing with barriers perceived by the participants. Not all problems perceived can be solved in a peer group discussion.

OBJECTIVE -To assess the quality of hypertension care in patients with type 2 diabetes in general practice and identify physician, organizational, and patient factors associated with suboptimal care.RESEARCH DESIGN AND METHODS -Data from 895 randomly selected diabetic patients were extracted from the electronic medical records of 95 general practitioners. Physician and organizational characteristics were collected with a questionnaire. We conducted a multilevel analysis to identify associations with blood pressure registration, hypertension treatment, and achievement of target blood pressure levels.RESULTS -For 652 patients (73%), a blood pressure measurement was recorded in the last year. Of these patients, 132 (20%) reached a target level of 135/85 mmHg. In total, 595 patients were classified as having hypertension, of whom 192 received no treatment (32%), 193 received an ACE inhibitor (32%), and 210 received other antihypertensives. Patients visiting a diabetes facility, referred to a specialist, with a female general practitioner, or with a general practitioner with Յ10 years work experience had better recordings of their blood pressure. Suboptimal treatment was higher in older patients and smoking patients. Treatment was better in patients with coronary comorbidity, hyperlipidemia, or those referred to a specialist. Not achieving the blood pressure target was related to older age of the patients.CONCLUSIONS -Hypertension management of type 2 diabetic patients in primary care is suboptimal. Characteristics of general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with better processes of care, but blood pressure outcomes are not as clearly related to these factors. Diabetes Care 27:123-128, 2004T reatment guidelines uphold stringent target levels for blood pressure control in patients with diabetes because this significantly reduces the risk of developing cardiovascular and microvascular diseases. This has not resulted in adequate blood pressure control (1). Suboptimal management in both diagnosis and treatment of hypertension in type 2 diabetic patients has repeatedly been shown (1-6).The quality of diabetes management can be influenced by physician, organizational, and patient factors (7). Variation in quality of care has been found between physicians as well as patients (5,6,8 -11). Factors of influence are the age and work experience of the physician, size of the practice, presence of a recall system, and proportion of patients attending hospital clinics (5,9,11). Patient characteristics influencing the quality of diabetes and blood pressure management include age, sex, ethnicity, and presence of comorbidities, such as coronary artery disease (6,10,(12)(13)(14).To determine which aspects interventions should target for change, the influence of physician-related factors on the quality of care must be assessed in relation to the impact of patient-related factors (15). In a multilevel approach, one can account for possible confounding effects of patie...

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BackgroundThe aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice.MethodsBarriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling.ResultsGPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses.ConclusionVariation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of care.

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