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Fleming et al,1 in this issue of the EMJ, present further evidence that hypertension identified in the emergency department (ED) should not simply be dismissed as secondary to pain, anxiety or “white coat” effect. Their finding that 28% of patients with “minor injuries” were hypertensive should not surprise, as the British Society for Hypertension reports that 42% of 35-64 year olds in the UK have hypertension.2 Clearly, we can screen for hypertension in the ED but should we do so?
Few would disagree that tight control of blood pressure across the UK population would prevent a significant number of deaths from myocardial infarction and stroke. Individually, however, hypertension is controlled in only a third of treated patients.3 In this study, only 40% of patients with identified hypertension returned for follow up and of these it is not known how many subsequently registered with a general practitioner (GP) and complied with medication. Fleming et al argue that for many patients (particularly in inner cities) the ED is their primary contact with health services and that without screening their hypertension would otherwise remain unidentified. Patients with no fixed abode would be expected to fall into this category, but hypertension was not identified in anyone from this sub-group.
Screening is not new to the ED. In fact, we have a duty to screen for conditions that may be presented to the ED rather than the GP, particularly where identification may immediately prevent further injury, such as in cases of intimate partner violence and non-accidental injury. A recent study from the authors’ own centre4 showed that screening and counselling of patients presenting to the ED with conditions associated with alcohol misuse resulted in a clear reduction in use of the ED by the same patients in the following 12 months. Both of the above are examples of targeted screening, which is more efficient and cost effective than universal screening but inevitably misses more cases. Although Fleming et al describe their screening as targeted, it is in essence universal screening of all patients assigned a triage category of 3–5. EDs do not have a duty, or the resources, to universally screen for asymptomatic, chronic conditions. Unless such screening can demonstrate an immediate health benefit or reduction in ED attendance, our focus should instead remain on improving our performance of core roles. This study, understandably, cannot demonstrate either benefit.
If money is made available to EDs for targeting hypertension it may be better used to assist patients who are not currently registered with a GP to do so. GPs, for their part, can be relied upon to monitor blood pressure, because, as of April 2004, part of their income has been related to the control of their patients’ hypertension. Furthermore, registration with a GP would allow health care needs other than blood pressure control to be addressed and may reduce future visits to the ED.
Fleming et al have demonstrated that screening for hypertension in the ED is feasible but will not convince all that screening for it in the ED is an effective or efficient use of resources. GP “referral” is the preferred option to address hypertension in hard to target groups.
Competing interests: none declared