[Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal Saudi J Kidney Dis Transpl 2011;22(5):941-948 © 2011 Saudi Center for Organ Transplantation Saudi Journal of Kidney Diseases and Transplantation Original Article Adherence of Primary Health Care Physicians to Hypertension Management Guidelines in the Aseer Region of Saudi Arabia Khalid S. Al-Gelban1, Mohd. Yunus Khan1, Yahia M. Al-Khaldi2, Ahmed AR Mahfouz1, Ismail Abdelmoneim1, Asim Daffalla1, Ossama A. Mostafa1, Hasan S. Al-Amri3 1 Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha 2General Directorate of Health Affairs, Aseer Region, 3Department of Medicine, Section of Psychiatry, College of Medicine, King Khalid University, Abha, Saudi Arabia ABSTRACT Although there has been significant progress in the management of hypertension, rates for control of this chronic disease in the Kingdom of Saudi Arabia (KSA) has been shown to be very low. This study was aimed to assess the knowledge of primary health care (PHC) physicians and the extent of their adherence to the recommendations of clinical practice guidelines concerning care of hypertensive patients. The assessment was made in the Aseer region of KSA using a modified version of the World Health Organization “Physician Inquiry Questionnaire.” Only 5.6% of the participants measured blood pressure (BP) with the patient in sitting and other postures. Variable sphygmomanometer cuff sizes for different patients were used by 56.5% of the participants, while 74.8% correctly recorded the diastolic BP at Koratkoff sound, phase-5. Among non-diabetics, the correct diagnosis of systolic and diastolic hypertension was reported by 76.7% and 81.4% respectively, of the PHC physicians. Among diabetics, the correct diagnosis of systolic and diastolic hypertension was reported by 36% and 17.1% of the PHC physicians, respectively. Most physicians inquired about cardiovascular risk factors. Several important items of patients’ clinical examination were not completely covered by physicians, e.g., fundus examination (75.2%). PHC physicians missed a few investigations and laboratory tests, e.g., ECG (87.9%), serum creatinine (88.2%) and lipid profile (89.8%). Less than one-fifth of the physicians correctly chose the thiazide diuretics as the preferred initial anti-hypertensive agent (19.9%). Almost two-thirds of the physicians (65.2%) emphasized the importance of BP self-measurement, 89.8% encouraged patients to use a reminder system while 96.3% motivated patients for BP control. Measures for lifestyle modification included weight reduction (98.8%), sodium restriction (97.5%), physical exercise (96.3%) and behavioral improvement (87.6%). Our study suggests that continuing medical education and training courses on guidelines for hypertension management should be arranged for PHC physicians in Aseer. Correspondence to: Dr. Mohd. Yunus Khan Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha, Saudi Arabia E-mail: mmkhandr@gmail.com Introduction and Aim of the Study Worldwide estimates for number of cases of hypertension may be as much as 1 billion individuals. Approximately 7.1 million deaths per year may be attributable to hypertension. The World Health Organization (WHO) reported that high blood pressure (BP) is responsible for [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal 942 62% of cerebrovascular disease (CVD) and 49% of ischemic heart disease. In addition, high BP is the number one attributable risk factor for death throughout the world. It is second only to diabetes as the most common antecedent for end-stage renal disease. Undiagnosed, untreated, and uncontrolled hypertension clearly places a substantial strain on the health-care delivery system.1,2 Hypertension is an increasingly important medical and public health issue. The prevalence of hypertension increases with advancing age to the point where more than half of the people 60–69 years of age and approximately threefourths of those 70 years of age and older are affected.3 The Framingham Heart Study reported that the lifetime risk of hypertension is approximately 90% for men and women who were non-hypertensive at 55 or 65 years and survived to the age of 80–85 years.4 In the Kingdom of Saudi Arabia (KSA), with preventive medicine practices, the incidence and prevalence of infectious diseases are becoming progressively less common. However, the dramatic changes in lifestyle and food consumption patterns have led to the growing magnitude of hypertension as a public health problem. Several research works have indicated that the prevalence of hypertension and its related clinical events and complications (e.g., myocardial infarction and stroke) appear to be increasing.5,6 The prevalence of hypertension in KSA is about 10%, with one-third of the cases being not well controlled.7 Hypertension not only can be easily diagnosed but also its control can be achieved with simple and well-tolerated medication regimens that would consequently lower its related morbidity and mortality.8 Primary health care (PHC) centers play a major role in providing suitable health care for hypertensive patients.9 However, Siddiqui et al indicated that control of hypertension at these PHC centers falls short of the recommended goals.10 In hypertension, accurate BP readings and correct interpretation of the obtained values are of great importance to epidemiology as well as to diagnosis, treatment and research.11,12 Although Al-Gelban KS, Khan MY, Al-Khaldi YM, et al a large number of guidelines and recommendations describing how BP is measured are available, research shows that health care providers frequently do not comply with these guidelines.13,14 This leads to possible mistakes in the diagnosis and treatment of hypertension.12 The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. Lowering BP to targets that are <140/90 mmHg is associated with a decrease in complications such as CVD. In patients with diabetes or renal disease, the BP goal is <130/80 mmHg.15,16 Adoption of healthy lifestyles is critical for the prevention of high BP, and is an indispensable part of the management of those with hypertension. Major lifestyle modifications shown to lower BP include weight reduction in those individuals who are overweight or obese,17 adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan,18 which is rich in potassium and calcium,19 dietary sodium reduction,20 physical activity,21 and avoidance of alcohol consumption.22 These lifestyle modifications were shown to reduce BP, enhance efficacy of antihypertensive drugs, and decrease cardiovascular risk. Combination of two (or more) lifestyle modifications can achieve even better results.19 Lowering BP with several classes of drugs will reduce the complications of hypertension.23-25 The thiazide-type diuretics have been the basis of antihypertensive therapy26 that should be used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes.2 Although there has been a significant progress in the management of hypertension in KSA, rates for control of this chronic disease has proved to be very low. Family physicians’ awareness of hypertension practice guidelines in KSA has not been assessed before. Hence, this study was performed to assess the knowledge of PHC physicians and the extent of their adherence with the recommendations of clinical practice guidelines concerning care of hypertensive patients. [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal Primary health care physicians and hypertension management guidelines Table 1. Personal characteristics of the study sample (n = 322). Characteristics No. % Age (in years) <30 15 4.7 31–50 252 78.3 >50 55 17.1 Gender Male 260 80.7 Female 62 27.3 Highest qualification MBBS 288 89.4 Postgraduate degrees 34 10.6 Nationality Saudi 6 1.9 Non-Saudi 316 98.1 Arab 179 55.6 Asian 121 37.6 European or Western 16 4.9 Subjects and Methods This study was conducted during the period from November 2006 to January 2007 following a cross-sectional design on all physicians working at PHC centers within the Aseer Region of KSA. The Aseer Region occupies a part of Southwest of KSA with a total population of 1.6 million inhabitants and a total area that exceeds 81,000 km2.27 All PHC physicians were assessed using a modified version of the WHO “Physician Inquiry Questionnaire.”28 It was used to collect data 943 concerning the demographic characteristics of physicians, BP measurement, handling of patients in the clinic, attitudes toward hypertension control, diagnostic procedures, and therapeutic procedures. The physicians’ responses were assessed according to the guidelines of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).2 Participants were assured about the confidentiality of any provided data through a covering letter. The questionnaire was distributed to all PHC physicians working in the Aseer region (n = 345). Technical supervisors in all sectors (16 sectors) supervised data collection and returned the responses to the General Directorate of Health Affairs within a maximum of one week. A total of 322 correct responses were received (93.3% response rate). Data of the completed questionnaire were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 15. Results Table 1 shows that most participants were nonSaudi (98.1%), males (80.7%), aged 31–50 years (78.3%), and their highest qualification was MBBS (89.4%). Table 2 shows that 5.6% of the participants measured BP with the patient sitting in addition to other postures (e.g., standing). Table 2. Blood pressure measurement and diagnosis of hypertension (n=322). Variables No. Patient’s position during measurement Sitting position only1 304 Sitting and sometimes other positions2 18 Cuff size of sphygmomanometer One size for all patients1 140 Variable sizes for different patients2 182 Diastolic blood pressure is recorded at Krotokoff sound phase 41 81 Krotokoff sound phase 52 241 Diagnosis of hypertension among non-diabetics ≥ 140 mmHg2 247 ≥ 90 mmHg2 262 Diagnosis of hypertension among diabetics ≥ 130 mmHg2 116 ≥ 80 mmHg2 55 1 Not consistent with JNC7, 2Consistent with JNC7 % 94.4 5.6 43.5 56.5 25.2 74.8 76.7 81.4 36.0 17.1 [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal 944 Al-Gelban KS, Khan MY, Al-Khaldi YM, et al Figure 1. Percentage of correct responses from PHC physicians with regard to definition of systolic and diastolic hypertension among non-diabetic and diabetic patients. The use of variable cuff sizes for different patients was practiced by 56.5% of the participants. Almost three-fourths of the participants (74.8%) correctly recorded the diastolic pressure at Koratkoff sound, phase-5. Among non-diabetics, the correct diagnosis of systolic hypertension was reported by 76.7% of the physicians, while diastolic hypertension was correctly reported by 81.4%. Among diabetics, the correct diagnosis of systolic hypertension was reported by 36% of the physicians while diastolic hypertension was correctly reported only by 17.1%, as shown Table 3. Patient evaluation and management (n = 322). Variables Inquiry about cardiovascular risk factors Alcohol intake Physical inactivity Life stressors Smoking Diabetes Family history of hypertension Clinical examination Fundus examination Auscultation of lungs Examination of abdomen BMI assessment Cardiovascular examination Investigations and laboratory tests ECG Serum creatinine Lipid profile Urine analysis in Figure 1. Table 3 shows that most physicians inquired about cardiovascular risk factors. The least inquired about by the physician was alcohol intake by the hypertensive patient (88.8%). Several important items of patients’ clinical examination were not completely covered by the physicians, e.g., fundus examination (75.2%), auscultation of lungs (85.7%), abdominal examination (86.3%), and body mass index assessment (90.1%). Some physicians missed few investigations and laboratory tests, e.g., ECG (87.9%), serum creatinine No. % 286 299 313 319 320 321 88.8 92.9 97.2 99.1 99.4 99.7 242 276 278 290 313 75.2 85.7 86.3 90.1 97.2 283 284 289 308 87.9 88.2 89.8 95.7 [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal Primary health care physicians and hypertension management guidelines 945 Table 4. Measures adopted by physicians to improve hypertension control (n = 322). Variables No. % Preferred initial anti-hypertensive agent Beta-blocking agents1 152 47.2 Thiazide-type diuretics2 64 19.9 Angiotensin-converting enzyme inhibitors1 57 17.7 Calcium channel blockers1 42 13.0 Methyl dopa1 7 2.2 Applied measures to improve hypertension control Recommending blood pressure self-measurement 210 65.2 Encouraging patients to use a reminder system 289 89.8 Motivating patients for their blood pressure control 310 96.3 Inducing lifestyle modification: Weight reduction 318 98.8 Sodium restriction 314 97.5 Physical exercise 310 96.3 Behavioral improvement3 279 86.6 1 Not consistent with JNC7, 2Consistent with JNC7, Examples of behavioral improvement: decreasing watching television, playing video games, or spending time online. (88.2%), and lipid profile (89.8%). Table 4 shows that less than one-fifth of the physicians correctly chose the thiazide diuretics as the preferred initial anti-hypertensive agent (19.9%), as shown in Figure 2. Almost twothirds of the physicians (65.2%) emphasized the importance of BP self-measurement, 89.8% encouraged patients to use a reminder system while 96.3% motivated patients for BP control. Measures for lifestyle modification included weight reduction (98.8%), sodium restriction (97.5%), physical exercise (96.3%), and behavioral improvement (87.6%). Discussion The prevention and management of hypertension are major public health challenges. If the rise in BP with age could be prevented or diminished, much of hypertension-related cardiovascular and renal disease and stroke might be prevented.29 The present study indicated that PHC physiccians did not fully adhere to all hypertension guidelines. Only 5.6% of the participants measured the BP with the patient in sitting and other postures. The JNC7 stated that measurement of Antihypertensive Agents Antihypertensive Agents 19.9% 80.1% Thiazide diuretic Other agents Figure 2. Preferred initial anti-hypertensive agents by the study subjects. [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal 946 BP in the standing position is indicated periodically, especially in those at risk for postural hypotension, prior to commencement of drug therapy or adding a new drug, and in those who report symptoms consistent with reduced BP upon standing.2 The use of variable cuff sizes for different patients was performed only by about half of the physicians (56.5%). The JNC7 stated that an appropriately sized cuff (cuff bladder encircling at least 80% of the patient’s arm) should be used to ensure accuracy.2 This study showed that correct definition of hypertension was quite deficient among many PHC physicians. One-fourth of the participants did not know that the diastolic pressure is being recorded at phase-5 Koratkoff sound. Moreover, the diagnosis of systolic hypertension among nondiabetics was not correctly stated by one-fourth of the participants, while diastolic hypertension was incorrectly reported by almost one-fifth of the PHC physicians. The definition of hypertension among diabetics was worse; systolic hypertension was incorrectly defined by almost twothirds of the PHC physicians, while diastolic hypertension was incorrectly defined by more than four-fifths of the PHC physicians. A similar finding was reported by Ernest, who noted that one-fifth of the private physicians and PHC physicians (20.6%) incorrectly diagnose hypertension.30 With regard to the assessment of hypertensive patients, the present study showed that the great majority of PHC physicians inquired about cardiovascular risk factors. The least inquired about was alcohol intake by the hypertensive patient. The omission of inquiring about alcohol intake by some physicians may be due to the fact that the Saudi community is highly religious and conservative, which absolutely forbids the intake of any alcoholic beverages. However, several other important items of patients’ clinical examination and investigations were missed by some PHC physicians. These findings are in agreement with those reported by Ernest in Pretoria, South Africa, who noted that most general practitioners do not fully adhere to the hypertension guidelines suggested Al-Gelban KS, Khan MY, Al-Khaldi YM, et al by the JNC VI.30 With regard to the management of hypertensive patients, the present study showed that the preferred single initial anti-hypertensive agent (i.e., thiazide diuretics) was overlooked by most PHC physicians. Psaty et al emphasized that despite the various benefits of diuretics, they remain under-utilized.26 Ernest reported that in spite of the fact that diuretics are superior in the prevention of cardiovascular morbidity and mortality associated with hypertension, nearly 40% of the physicians preferred to prescribe other anti-hypertensive drugs, which suggests that diuretics still remain underused in the treatment of hypertension.30 Moreover, studies on the prescribing patterns of health care physicians revealed that most physicians lack detailed knowledge of hypertension guidelines and tend to prescribe more expensive drugs without evidence of efficacy.31 With regard to the specific measures to improve hypertension control, the present study revealed that one-third of the PHC physicians do not emphasize the importance of BP selfmeasurement while most of them encourage patients to use a reminder system and motivate patients for BP control. The great majority of PHC physicians apply different measures adopted to induce lifestyle modification, including weight reduction (98.8%), sodium restriction (97.5%), physical exercise (96.3%), and behavioral improvement (87.6%). The JNC7 stated that self-monitoring of BP at home and work is a practical approach to assess differences between office and out-of-office BP prior to consideration of ambulatory blood pressure monitoring (ABPM). For those whose outof-office BP is consistently <130/80 mmHg despite an elevated office BP, and who lack evidence of target organ disease, 24-hour monitoring or drug therapy can be avoided.2 Based on the JNC7 guidelines, the present study concluded that many PHC physicians in the Aseer region lack the necessary knowledge to define and to correctly diagnose hypertension, especially among diabetic patients. Most PHC physicians do not adhere to the guidelines of hypertension management. Fundus examina- [Downloaded free from http://www.sjkdt.org on Thursday, September 15, 2011, IP: 67.72.98.26] || Click here to download free Android application for this journal Primary health care physicians and hypertension management guidelines tion, auscultation of lungs, and ECG tracing are most frequently missed. Most PHC physicians do not duly consider the importance of thiazide diuretics as the basis of initial antihypertensive therapy, either alone or in combination with one of the other classes of drugs. 9. 10. Recommendations Continuing medical education and training courses on guidelines for hypertension management should be arranged for PHC physicians in Aseer. 11. 12. References 1. 2. 3. 4. 5. 6. 7. 8. World Health Report 2002: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization. 2002. JNC7. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 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