In cooperation with the Institute of family medicine and Public Health of the University of Tartu, the National Audit Office assessed the treatment of over 400 first-time patients. According to the expert analysis, only 35% of the patients in the sample achieved the target level of blood pressure within the 2–3 months recommended in the treatment guideline. The treatment of 31% of patients interrupted within six months of diagnosis.
Healthy lifestyles play a key role in preventing hypertension and its complications. The expert analysis showed that the teams of family physicians do not adequately assess the risk factors related to the lifestyle of patients and provide too little counselling.
According to the National Audit Office, the long-term monitoring of patients with hypertension is incomplete and treatment adherence, i.e. how consistently patients take their medication and adhere to their treatment plan, is inadequate. Managing hypertension requires regular monitoring, tests and advice. According to the treatment guideline, patients must be counselled at least once a year. Getting an appointment depends largely on the patient’s own behaviour, but the proactive role of the family physician’s team in monitoring the patient is also important. The 2019 analysis by the National Audit Office of patients who were diagnosed for the first time showed that only 37% of patients had at least one contact with a family physician, family nurse or cardiologist every year in the period 2019–2024. Approximately half of the highest risk patients had regular contact.
Prescription data suggest that many patients also take their medication inconsistently: around half did not buy enough medication in six years to last them for the whole period. This increases the risk of complications and increases the burden on more expensive specialist care.
“Adherence to the treatment plan does not improve by itself. As the success of treatment depends largely on the patient’s own behaviour, the treatment plan must be clear and easily accessible to the patient. Patients must also have an easy option to contact the family physician’s team, receive consistent counselling and timely reminders – both about appointments and prescriptions,” said Rauno Vinni, Audit Manager at the National Audit Office. “When this support is systemically available, there are fewer treatment interruptions and fewer avoidable complications.”
According to the National Audit Office, the discontinuous treatment of hypertension indicates that the system of chronic disease management designed by the Health Insurance Fund does not work efficiently enough and contains systemic deficiencies, not individual errors. The Health Insurance Fund does not monitor the implementation of the treatment guideline on a consistent basis and does not make the necessary improvements to the treatment arrangements in the event of shortcomings. The current management and motivation tools of the Health Insurance Fund do not ensure a consistent quality of care, as the Primary Health Care Quality Bonus System mainly measures the actions taken, not whether the patient achieved the desired outcome, and no meaningful steps are taken to improve the situation if quality criteria are not met.
As a result, the quality of care for the chronically ill is uneven across patient lists and regions. The role of family nurses in the teams of family physicians has already increased, but the burden on family physicians could be further reduced if more of the lighter monitoring and counselling tasks were taken over by family nurses and other specialists.
The fact that the Health Insurance Fund has not sufficiently developed digital solutions to support proactive monitoring, such as reminders for appointments and prescriptions and a comprehensive overview of patients at risk, increases the problem. However, this makes it more difficult both for family physicians to plan their work and for them to identify patients at risk early.
“Hypertension can progress for years without any noticeable symptoms, so you we cannot expect people to come in for a health check at the right time. The system must first support the timely detection of the disease and from there proactive monitoring of the patient – so that the necessary appointments, tests and continuation of treatment are not left to chance,” said Rauno Vinni, Audit Manager at the National Audit Office.
Other primary care stakeholders are also underused in the management of chronic diseases, and the Ministry of Social Affairs has not established organisational and legal solutions that would allow the information they collect to reach family physicians smoothly. The management of hypertension cannot be limited to what can be done in primary health care. The National Audit Office found that the potential of occupational health specialists and pharmacists in early detection and support for treatment adherence is underused. There are no working solutions and agreements to seamlessly transfer the information on risks and blood pressure measured in occupational health or pharmacies to family physicians.
The audit showed that there is no comprehensive management and monitoring at the level of the state. The Ministry of Social Affairs and the Health Insurance Fund do not have a common regular monitoring system that would give an accurate picture of the continuity and effectiveness of hypertension treatment and allow a clear targeting of deficiencies. There are no clear targets and indicators, and accountability for and data of cardiovascular disease management are fragmented. This makes it difficult to assess the effectiveness of the measures and to harmonise their quality.
The National Audit Office recommends that the Ministry of Social Affairs, in cooperation with the Health Insurance Fund and the Institute for Health Development
- set up a system that supports the teams of family physicians and makes it possible to adhere to the treatment guideline. Further develop the Primary Health Care Quality Bonus System so that it also makes it possible to monitor performance indicators, helps to identify the causes of regional disparities and provides a basis for quality improvement activities;
- create IT solutions to support the monitoring of chronic conditions in daily practice – including automated reminders for both family physicians and patients, a treatment plan that is visible to all stakeholders, and monitoring of treatment adherence;
- improve cooperation and information exchange between primary care stakeholders to ensure that the patients at risk detected in occupational health or a pharmacy are monitored by their family physicians and treatment continues without interruption;
- set clear targets and indicators for the prevention and management of hypertension and other cardiovascular diseases to ensure coordinated management and evaluation of the effectiveness of actions.
Background
Cardiovascular diseases are responsible for nearly half of all mortality in Estonia, compared to an average of one third in the European Union (EU). Compared to the EU average, mortality from cardiovascular diseases per 100,000 people is 1.7 times higher in Estonia.
Hypertension is the most prevalent chronic disease among these diseases in Estonia and the condition with the highest disease burden. According to the Global Burden of Disease Study, hypertension was associated with about 31% of all deaths in Estonia in 2023. According to the treatment invoices of the Health Insurance Fund, there are almost 400,000 people with a diagnosis of hypertension in Estonia. In 2023, the Estonian population lost 78,832 healthy life years due to hypertension, which accounted for 19% of the total health loss (a statistical indicator characterised by the number of healthy life years lost due to premature mortality and morbidity).
Hypertension is the main risk factor for major cardiovascular diseases, and its management at the level of primary care is also a good indicator of broader chronic disease management. Chronic diseases reduce people’s capacity for work, which means less workforce, lower productivity and lower tax revenues for the state. Effective and consistent management of hypertension can help improve quality of life and reduce complications, as well as prevent hospitalisations and more expensive specialist care.
The audit of the National Audit Office assessed whether the diagnosis, treatment and monitoring of hypertension at the primary level support the achievement of treatment objectives and whether there is comprehensive management and monitoring of hypertension at the level of the state. Treatment success was assessed on the basis of the medical records of 434 first-time patients, and treatment consistency was analysed on the basis of the treatment invoices of patients first diagnosed in 2019 for the years 2019–2024.
