{"id":2161,"date":"2025-11-05T10:16:45","date_gmt":"2025-11-05T10:16:45","guid":{"rendered":"https:\/\/sites.exeter.ac.uk\/apex\/?p=2161"},"modified":"2026-01-15T10:53:42","modified_gmt":"2026-01-15T10:53:42","slug":"things-we-dont-know-by-associate-professor-chris-clark-professor-rupert-payne","status":"publish","type":"post","link":"https:\/\/sites.exeter.ac.uk\/apex\/2025\/11\/05\/things-we-dont-know-by-associate-professor-chris-clark-professor-rupert-payne\/","title":{"rendered":"Things we don\u2019t know, by Associate Professor Chris Clark & Professor Rupert Payne"},"content":{"rendered":"
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\"\"<\/figure><\/div>\n\n\n

Caring for people with long-term conditions takes up substantial resources. This isn\u2019t news, but it\u2019s surprising how much we still don\u2019t know. It\u2019s often simple stuff, that would really help us deliver care more effectively and efficiently. Work being undertaken by APEx academics in our Long-Term Conditions research theme is looking at some of these important unknowns.<\/p>\n\n\n\n

Postural hypotension<\/h3>\n\n\n\n

Take postural hypotension, for example \u2013 an abnormal drop in blood pressure on standing, which can be associated with serious consequences such as falls. Postural hypotension has been estimated to affect one-fifth of older adults. However, we are very poor at recognising when to test for it and infrequently record the diagnosis in primary care.1,2<\/sup> Most clinicians will recognise dizziness on standing as a symptom suggesting postural hypotension is present. But there are also a range of other symptoms of the condition that are under-recognised, and so don\u2019t trigger postural testing by clinicians. In addition, many people have recognised risk factors for postural hypotension without symptoms \u2013 they tend to miss out on testing as well.<\/p>\n\n\n\n

Postural hypotension commonly co-exists with hypertension. It\u2019s worse with uncontrolled hypertension but intensive blood pressure lowering brings more postural symptoms and increased falls. Antihypertensives are associated with postural hypotension so stopping them feels a logical treatment. Small, often post-hoc, studies of deprescribing give unclear and conflicting results. We lack definitive trial evidence, in populations representative of our patients, to help us choose between tight blood pressure control and postural symptom control.3<\/sup> NICE advises us to manage hypertension using standing blood pressure readings where there is postural hypotension, but here in APEx we\u2019ve found negligible evidence to link standing blood pressure control with cardiovascular risk reduction4<\/sup>. We just don\u2019t know what we are doing!<\/p>\n\n\n\n

Medication review<\/h3>\n\n\n\n

Another important aspect of long-term care is ensuring the safe and effective use of medications. Around \u00a310 billion is spent on medications in primary care each year, with twice as many prescriptions issued now compared to 30 years ago. Clearly, medications have revolutionised health and well-being for millions of people. However, medications can also cause important harms and place a burden on patients and health services alike, and a government report in 2021 suggested that 10% of all prescriptions might be inappropriate.5<\/sup><\/p>\n\n\n\n

Sorting that out seems a no-brainer \u2013 but how? Structured medication reviews were rolled out in recent years as a means of tackling inappropriate medication use and improving the safety and effectiveness of prescriptions. This has been supported by a substantial growth in GP-based clinical pharmacists. Yet the evidence supporting such reviews, and the way in which pharmacists are employed to tackle the issue, is lacking.6<\/sup> A major clinical trial (IMPPP) that we helped lead found that even when you conduct medication reviews in a very carefully structured way, together with the combined expertise of both GPs and pharmacists working together, and some additional \u201cbells and whistles\u201d to enhance clinicians\u2019 engagement with the whole process, medication safety doesn\u2019t improve7<\/sup>. Another example of how policy and practice is not backed up by science.<\/p>\n\n\n\n

Dealing with the unknowns<\/h3>\n\n\n\n

We live in a world of increasingly protocolised medicine \u2013 one driven by clinical guidelines and strict policy edicts, and one where clinicians feel compelled to \u201cfollow the recommendations\u201d. Too often, we forget that these are not always underpinned by hard evidence. Researchers in APEx are working to try to address some of these important gaps in clinical knowledge around long-term conditions. But in addition, we are helping to understand the uncertainty that results from such knowledge gaps, and to develop better approaches to shared decision-making which can be applied in such circumstances. Whether it be the management of postural hypotension, optimising long-term medicines, or one of many other important issues in primary care, this research will help clinicians and patients to deal with the unknowns together.<\/p>\n\n\n\n

Chris Clark and Rupert Payne<\/em><\/p>\n\n\n\n

References<\/h3>\n\n\n\n
    \n
  1. McDonagh S, Cross R, Masoli J, et al. Br J Gen Pract 2025:BJGP.2025.0025<\/a><\/li>\n\n\n\n
  2. Cross R, McDonagh STJ, Treadgold BM, et al. Br J Gen Pract 2025:BJGP.2024.0695<\/a><\/li>\n\n\n\n
  3. Clark CE. Br J Gen Pract 2023;73:6-7<\/a><\/li>\n\n\n\n
  4. Owusu O, McDonagh S, Skrobot O, et al. STanding blood pressure and its AssociatioN with major adverse cardiovascular disease and aDverse events (STANDD): a systematic review. British & Irish Hypertension Society Annual Scientific Meeting, Cambridge, Sept 2025 (abstract).<\/li>\n\n\n\n
  5. Department of Health and Social Care, National Overprescribing Review<\/a>. London 2021<\/li>\n\n\n\n
  6. Agwunobi AJ, Seeley AE, Tucker KL, et al. BMJ Open 2025;15:e097012<\/a><\/li>\n\n\n\n
  7. Payne RA, Blair PS, Caddick B, et al. Lancet Healthy Longev. 2025:100774<\/a><\/li>\n<\/ol>\n\n\n
    \n
    \"\"<\/figure><\/div>","protected":false},"excerpt":{"rendered":"

    Caring for people with long-term conditions takes up substantial resources. This isn\u2019t news, but it\u2019s surprising how much we still don\u2019t know. It\u2019s often simple stuff, that would really help us deliver care more effectively and efficiently. Work being undertaken by APEx academics in our Long-Term Conditions research theme is looking at some of these […]<\/p>\n","protected":false},"author":989,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[41],"tags":[69,161,153,151],"acf":[],"yoast_head":"\nThings we don\u2019t know, by Associate Professor Chris Clark & Professor Rupert Payne - Exeter Collaboration for Academic Primary Care (APEx) Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/sites.exeter.ac.uk\/apex\/2025\/11\/05\/things-we-dont-know-by-associate-professor-chris-clark-professor-rupert-payne\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Things we don\u2019t know, by Associate Professor Chris Clark & Professor Rupert Payne - Exeter Collaboration for Academic Primary Care (APEx) Blog\" \/>\n<meta property=\"og:description\" content=\"Caring for people with long-term conditions takes up substantial resources. 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