Awareness of physicians in Jordan about the treatment of high blood pressure according to the seventh report of the Joint National Committee (JNC VII)

Adaptation, implementation, and evaluation of the HEARTS technical package in primary health care settings in Jordan to improve the management of hypertension: a pilot study

The majority of patients with hypertension in Jordan have uncontrolled blood pressure. This study aimed to adapt and implement the hypertension management protocol (a module in the HEARTS technical package) in health care centers in Jordan and evaluate its effectiveness on hypertension management and control. The hypertension management protocol was adapted and implemented in six health centers followed by training of the healthcare staff on the adapted protocol. Patients above 18 years old who attended health centers during the study period were recruited consecutively. The blood pressure of 852 patients was monitored over 4 months, using an individual patient treatment card. At the baseline visit, the proportion of patients with uncontrolled blood pressure was 71.5%. After 4 months of the implementation of the protocol, the proportion of patients with uncontrolled blood pressure decreased to 29.1%. Of all studied characteristics, age was the only significant predictor of achieving blood pressure control. Patients aged ≤50 had a higher rate of controlled blood pressure readings after 4 months of implementation of the protocol compared to patients older than 60 years (OR = 1.98, 95% CI: 1.07, 3.67; P value = 0.028). In conclusion, the implementation of the HEARTS hypertension management protocol has successfully achieved better control of the blood pressure of the enrolled patients after 4 months of implementation. To achieve better control of hypertension in the general population, integrating evidence-based strategies for hypertension control that are listed in the HEART technical package into routine care is strongly recommended.

The capacity of primary health care centers in Jordan to manage hypertension: areas for improvement

The assessment of the capacity of Primary Health Care (PHC) settings for the management of hypertension is essential to identify areas for improving management outcomes. This study aimed to assess the capacity of PHC centers in Jordan to manage hypertension including the assessment of human resources, equipment, and infrastructure. All comprehensive PHC centers located in Irbid and Mafraq governorates in north of Jordan (n = 23) were assessed. An assessment tool from HEARTS Technical Package was adapted and used for assessment. All centers have general practitioners and half of the centers (n = 11, 47.8%) had at least one family doctor working full time. In only one center, all doctors, nurses, and other health workers were trained on the management of hypertension. All centers, except one, had at least one functional automatic blood pressure measuring devices (BPMDs). Almost two thirds of centers (43.5%) had no measuring tapes. ECG machines were present in all centers except two. One third (n = 8, 34.8%) of centers had no functional glucometers. The majority of health centres carry out the laboratory investigations. Educational materials on physical activity, hypertension, and diabetes were seen in four (17.4%) centers only. Necessary medications were always available in the majority of health centers. In conclusion, this assessment revealed many areas for improvement in human resources, equipment, infrastructures, and other resources, such as developing an updated guideline/protocol of hypertension management, training the PHC staff on these guidelines, providing PHC centers with the necessary equipment, and establishing e-registry to improve documentation of data.

Awareness of Physicians in Yemen Toward High Blood Pressure Management According to the Eighth Joint National Committee (JNC 8) Guideline

Background

Hypertension is a common public health problem that impacts more than one-third of the world population. Awareness of physicians towards the guidelines of high blood pressure management is an essential step to reduce the consequences of high blood pressure.

Objective

This study was aimed to assess the awareness of physicians towards high blood pressure treatment according to the recent report of the Joint National Committee (JNC8) guideline.

Methods

A self-administered questionnaire was distributed to 400 physicians during the period from February to April 2017. Physicians were recruited from public and private hospitals as well as clinics. A validated questionnaire that incorporated the changes seen in JNC 8, as well as the specific modality of hypertension management based on other guidelines, was administered to the participating physicians.

Results

Three hundred and eighty-nine physicians completed the questionnaire; with all the interviewed physicians have ever heard about JNC 8. The practice of general practitioners (GPs) was significantly deviated from the recommended guideline of blood pressure management as compared to consultants, specialists, and residents. Additionally, certain variations were found among consultants, specialists, and residents with slight superiority of consultants towards most aspects.

Conclusion

The finding of this study highlights an inadequate knowledge of GPs in Yemen towards high blood pressure management guidelines. The findings of this study emphasize the necessity for continuous medical education programs that are specially designed to target GPs. Continued update of medical curricula in Yemeni universities is also needed.

Doctors' Knowledge of Hypertension Guidelines Recommendations Reflected in Their Practice

Aim

To evaluate doctors' knowledge, attitude, and practices and predictors of adherence to Malaysian hypertension guidelines (CPG 2008).

Methods

Twenty-six doctors involved in hypertension management at Penang General Hospital were enrolled in a cross-sectional study. Doctors' knowledge and attitudes towards guidelines were evaluated through a self-administered questionnaire. Their practices were evaluated by noting their prescriptions written to 520 established hypertensive outpatients (20 prescriptions/doctor). SPSS 17 was used for data analysis.

Results

Nineteen doctors (73.07%) had adequate knowledge of guidelines. Specialists and consultants had significantly better knowledge about guidelines' recommendations. Doctors were positive towards guidelines with mean attitude score of 23.15 ± 1.34 points on a 30-point scale. The median number of guidelines compliant prescriptions was 13 (range 5–20). Statistically significant correlation (r_s = 0.635, P < 0.001) was observed between doctors' knowledge and practice scores. A total of 349 (67.1%) prescriptions written were guidelines compliant. In multivariate analysis hypertension clinic (OR = 0.398, P = 0.008), left ventricular hypertrophy (OR = 0.091, P = 0.001) and heart failure (OR = 1.923, P = 0.039) were significantly associated with guidelines adherence.

Conclusion

Doctors' knowledge of guidelines is reflected in their practice. The gap between guidelines recommendations and practice was seen in the pharmacotherapy of uncomplicated hypertension and hypertension with left ventricular hypertrophy, renal disease, and diabetes mellitus.

Approach to hypertension among primary care physicians in the West Region of Cameroon: substantial room for improvement

OBJECTIVE

This study was conducted to assess the knowledge and approach of primary care physician (PCP) towards the management of hypertension in Cameroon.

METHODS

In 2012 we surveyed 77 PCPs among the 111 working in the West region of Cameroon. We used a standardized questionnaire assessing practices regarding the detection, evaluation and treatment of hypertension, and source of information about updates on hypertension.

RESULTS

Participants had a mean duration of practice of 10.1 (SD 7.6) years, and received an average of 10.5 (SD 5.8) patients daily. Most of the PCPs (80.5%, n=62) measured blood pressure (BP) for all adult patients in consultation, however, only 63.6% (n=49) used correct BP thresholds to diagnose hypertension. Sixty-seven PCPs (87.0%) ordered a minimal work-up for each newly diagnosed hypertensive patient, but only the work-up offered by 8 (10.4%) PCPs was adequate. Regarding treatment, the most commonly prescribed medications as monotherapy were loop diuretics (49.3%). Bitherapy mostly included the combination of a diuretic with other drug classes. Most of PCPs used incorrect target BP, with a general tendency of using higher target levels. PCPs received updates on hypertension management mostly through drug companies representatives (53.2%, n=41). Up to 97.4% were willing to receive continuing medical training on hypertension.

CONCLUSIONS

PCPs' knowledge and management of hypertension is poor in this region of Cameroon. Our data point to a need for continually updating the teaching curricula of medical schools with regard to the management of hypertension, and physicians in the field should receive continuing medical education.

Guidelines adherence and hypertension control at a tertiary hospital in Malaysia

RATIONALE, AIMS AND OBJECTIVES

Existing literature suggests that doctors' poor adherence with guidelines is one of the major contributing factors to suboptimal control of hypertension. This study aims to evaluate doctors' adherence with Malaysian clinical practice guideline (CPG 2008) in a tertiary care hospital, and factors associated with guideline adherence and hypertension control.

METHODS

This was a cross-sectional study conducted at Hospital Pulau Pinang, Penang, Malaysia. Prescriptions written by 26 enrolled doctors to 650 established hypertensive outpatients (25 prescriptions per enrolled doctor) were noted on visit 1 along with patients' demographic and clinical data. The noted prescriptions were classified either as compliant or non-compliant to CPG (2008). Five hundred twenty (80%) of the enrolled patients (20 patients per enrolled doctor) were followed for one more visit. Blood pressure (BP) noted on visit 2 was related to the prescription written on visit 1. SPSS 16 (SPSS Inc., Chicago, IL, USA) was used for data analysis.

RESULTS

Three hundred forty-nine (67.1%) patients received guidelines compliant pharmacotherapy. In multivariate analysis, hypertension clinic had significant negative association with guidelines adherence. Two hundred sixty-five patients (51%) were at goal BP on visit 2. In multivariate analysis, angiotensin-converting enzyme inhibitors and guidelines adherence had significant positive, while renal disease, diabetes mellitus and diabetic clinic had significant negative association with hypertension control.

CONCLUSIONS

An overall fair level of adherence with guidelines and better control of hypertension was observed. Guidelines compliant practices resulted in better control of hypertension. The gaps between what guidelines recommend and clinical practice were especially seen in the pharmacotherapy of uncomplicated hypertension and hypertension with diabetes mellitus and renal disease.

Comparison of two methods of teaching hypertension in under graduate medical students: "planned lecture" versus "cooperative learning"

Background

The direct and indirect negative impacts of hypertension on mortality and morbidity and the deficiencies in physicians’ knowledge on its management prompted us to search for new methods of training this item.

Objectives

In this study, 2 methods of teaching—planned lecture and cooperation—were compared in instructing hypertension to medical students.

Materials and Methods

This study was designed to be a prospective analysis of the efficacy of 2 models of cooperation and planned lecture teaching of hypertension. The medical students, in the second term of the 2010 academic year who were introduced to the nephrology ward for their internal medicine course, were randomly assigned to 2 groups to be taught hypertension by 2 models of cooperation and planned lecture to compare their advantages and disadvantages. In their final exam 2 questions concerning the management of hypertension were asked with regard to evaluating the long-term impact of the models on learning. Data were analyzed by paired t-test to compare pre- and post-test in each group, and independent t-test was used to compare the average and standard deviation scores between groups.

Results

Fifty-one students participated in the study. The total number of students in the lecture (group 1) and cooperation (group 2) methods was 28 and 23, respectively. By independent t-test, differences in test scores indicated a similar achievement of the 2 methods for the endpoint of basic knowledge (P = 0.253). But, the cooperation method was more successful in transferring abilities, primarily in the areas of workup and treatment (P < 0.05).

Conclusions

The study findings show that both methods can set in the optimal training for hypertension to students but that the cooperative method is more effective for deduction analysis.

Carotid intima-media thickness is associated with cognitive deficiency in hypertensive patients with elevated central systolic blood pressure

Background

The role of hypertension in the loss of cognitive function is controversial. Relationships between hypertension and increases in cerebral vascular resistance, diffused lesions and multiple lacunar infarcts of the white matter are well known. Thus, the objectives of this study were: to evaluate the relationship between hypertension and cognitive dysfunction (CD), identify risk factors and determine the association between early markers of vascular disease and CD in hypertensive individuals.

Methods

Two hundred individuals aged between 40 and 80 years old were evaluated in this cross-sectional prospective study. Fifty participants were controls (CT). The remaining 150 hypertensive patients were subdivided into two groups, those with CD (HCD) and those without CD (HNCD). All participants underwent clinical evaluations and biochemical blood tests were performed. CD was investigated using the Mini Mental State Examination (MMSE) following the guidelines for its use in Brazil. The impact of hypertension on the arterial bed was assessed by identifying and measuring changes in the intima-media thickness (IMT) by vascular ultrasonography of the carotid arteries and analyses of the central blood pressure and Augmentation Index by applanation tonometry of the radial artery.

Results

There were no significant differences in the total cholesterol, high-density lipoprotein cholesterol and triglycerides plasma concentrations between the three groups. The serum creatinine and estimated glomerular filtration rate were within normal ranges for all three groups. A significantly lower MMSE score was recorded for the HCD Group compared to the HNCD and CT Groups (p-value < 0.05).

The IMT was significantly different between the HNCD and HCD Groups (p-value = 0.0124). A significant difference in the IMT was also observed between hypertensive patients and the CT Group (p-value < 0.0001). Age, low-density cholesterol, high-density cholesterol, triglycerides and IMT increased the Odds Ratio for cognitive dysfunction.

The central systolic pressure was significantly higher in the HCD and HNCD Groups compared to CT Group (p-value < 0.0001).

Conclusions

Hypertensive patients with CD have changes in the vascular morphology characterized by an increased carotid IMT, enhanced atherosclerotic lipid profile and impaired hemodynamic functional manifested by elevated central systolic blood pressure.

Piloting the development of a cost-effective evidence-informed clinical pathway: managing hypertension in Jordanian primary care

OBJECTIVES

The UK's National Institute for Health and Clinical Excellence (NICE) and the Jordan office of the Medicines Transparency Alliance embarked on a pilot project to design an evidence-based guideline for cost-effective pharmacological treatment of essential hypertension in Jordan. The project's objectives were to directly address a major health problem for Jordan by producing a guideline; and to delineate the strengths and weaknesses of Jordan's healthcare process to allow similar future efforts to be planned more efficiently.

METHODS

The pilot spanned a period of approximately 8 months. Activities were overseen by local technical and guideline development teams, as well as experts from NICE. NICE's hypertension guidelines and economic model were used as a starting point. Parameters in the economic model were adjusted according to input and feedback from local experts with regards to Jordanian physician and patient practices, resource costs, and quality of life estimates. The results of the economic model were integrated with the updated available clinical trial literature.

RESULTS

The outputs of the economic model were used to inform recommendations, in the form of a clinical algorithm. A report of the process and the strengths and weaknesses observed was developed, and recommendations for improvements were made.

CONCLUSIONS

The pilot represented the start of what is intended to be a healthcare process change for the country of Jordan. Issues emerged which can inform strategies to ensure a more cohesive and comprehensive approach to the cost-effective use of appropriate drugs in managing chronic disease in Jordan and countries operating in a similarly resource-constrained environment. Furthermore, our pilot highlights how richer countries with relevant experience in evidence-informed healthcare policy making can assist others in strengthening their decision-making methods and processes.