Factors associated with blood pressure control among patients attending the outpatient clinic of a South African district hospital

Blood pressure control in hypertensive patients attending a rural community health centre in Gauteng Province, South Africa: A cross-sectional study

Background

Hypertension is a major cause of morbidity and mortality and its control has important clinical and socio-economic benefits to the family and community. Unfortunately, the extent of blood pressure (BP) control and its potential predictors in hypertensive patients in many rural communities in low-resource settings are largely unknown. This study assessed the extent of uncontrolled BP and its predictors amongst hypertensive patients accessing primary health care in a rural community in South Africa.

Methods

This cross-sectional study included 422 randomly selected hypertensive patients. Demographic and clinical data were collected using structured face-to-face questionnaire supplemented by respondents’ clinical records.

Results

Obesity plus overweight (n = 286, 67.8%) and diabetes (n = 228, 54.0%) were the most common comorbidities. Treatment adherence was achieved in only 36.3% and BP was controlled to target in 50.2% of the respondents. Significant predictors of uncontrolled BP were poor treatment adherence (odds ratio [OR] = 15.88, 95% confidence interval [CI] = 8.96, 28.14, p < 0.001), obesity compared with normal weight and overweight (OR = 3.75, 95% CI = 2.17, 6.46, p < 0.001) and being a diabetic (OR = 2.83, 95% CI = 1.74, 4.61, p < 0.001).

Conclusion

Poor adherence to treatment was the major predictor of uncontrolled BP. The increase in uncontrolled BP in the presence of diabetes and/or obesity as risk predictors, indicates the need for appropriate behaviour change/interventions and management of these conditions in line with the health belief model (HBM). We also propose the use of Community-Based Physical and Electronic Reminding and Tracking System (CB-PERTS) to address poor treatment adherence.

Lifestyle advice, processes of care and glycaemic control amongst patients with type 2 diabetes in a South African primary care facility

BACKGROUND

The influence of processes of diabetes care on glycaemic control is understudied in primary health care (PHC).

AIM

To explore the influence of lifestyle advice, drug regimen and other processes of care on glycaemic control.

SETTING

Johan Heyns Community Health Centre, Vanderbijlpark, South Africa.

METHODS

In a cross-sectional study involving 200 participants with type-2 diabetes, we collected information on sociodemography, comorbidity, processes of diabetes care, drug regimen and receipt of lifestyle advice. Anthropometric measures and glycosylated haemoglobin (HbA1c) were also determined.

RESULTS

Participants' mean age was 57.8 years and most were black people (88%), females (63%), overweight or obese (94.5%), had diabetes for 10 years (67.9%) and hypertension as comorbidity (98%). Most participants received lifestyle advice on one of diet, exercise and weight control (67%) and had their blood pressure (BP) checked (93%) in the preceding 12 months. However, 2% had any of HbA1c, weight, waist circumference or body mass index checked. Glycaemic control (HbA1c 7%) was achieved in only 24.5% of participants. Exclusive insulin or oral drug was prescribed in 5% and 62% of participants, respectively. Compared to insulin monotherapy, participants on combined metformin and insulin or metformin, sulphonylurea and insulin were less likely to have glycaemic control. Comorbid congestive cardiac failure (CCF) significantly increased the likelihood of glycaemic control.

CONCLUSION

There is substantial shortcomings in the implementation of key processes of diabetes care and glycaemic control. Strategies are needed to prompt and compel healthcare providers to implement evidence-based diabetes guidelines during clinic visits in South African PHC.

Blood pressure control and burden of treatment in South African primary healthcare: A cross-sectional study

Background

Poor blood pressure (BP) control has been associated with high burden of treatment (BOT) in several settings. It is not known whether this relationship holds true for South African primary care.

Aim

The aim of this study was to assess BOT and determine its relationship with BP control amongst patients with hypertension in a large community health centre, south of Johannesburg.

Setting

The setting of this study was carried out in the OPD of Johan Heyns Community Health Center.

Methods

A cross-sectional study involving 239 patients with hypertension was carried out. Information on sociodemography and BP readings in the last 3 months were extracted from patient medical records. A researcher-administered treatment burden questionnaire was also used to collect information on participants’ perceptions of BOT relating to medication regimen, navigating the healthcare system and life style changes and/or social and/or financial issues. Total BOT (TBOT) was determined as the sum of the scores in the three components and categorised as 1–45 = low, 46–90 = moderate and 91–140 = high. Analysis included descriptive statistics and test of association.

Results

Most participants were white (54.2%), > 55 years (52.9%), female (60.1%), married (56.3%), had grade 12 or more education (71.9%) and had no comorbidity (56.7%). The mean duration of hypertension treatment was 113.8 months and most participants were uncontrolled (60.1%). Most participants (75%) reported a low TBOT score, with a mean of 19.7. Amongst participants with clinical comorbidities, most (66.3%) did not consider hypertension to be more burdensome than other comorbid illnesses. There was no significant association between TBOT and BP control (p = 0.53). However, participants with a high BOT relating to medication regimen were significantly more likely to be uncontrolled (p = 0.04).

Conclusion

Total BOT is low amongst study participants and has no significant influence on BP control. However, improvements in BP control in South African primary healthcare may be hinged on interventions that address problems associated with hypertension medication regimen.

Microalbuminuria and Retinopathy among Hypertensive Nondiabetic Patients at a Large Public Outpatient Clinic in Southwestern Uganda

BACKGROUND

Routine testing of microalbuminuria and retinopathy is not done among patients with high blood pressure in resource-limited settings. We determined the prevalence of microalbuminuria and retinopathy and their risk factors among hypertensive patients at a large hospital in western Uganda.

METHODS

We consecutively recruited nondiabetic patients with hypertension at the outpatients' clinic over a period of 3 months. Spot urine samples were tested for urine albumin. Direct fundoscopy was done to assess retinal vasculature and optic disc for signs of hypertensive retinopathy. Logistic regression was done with retinopathy and microalbuminuria as primary outcomes.

RESULTS

We enrolled 334 patients and, of these, 208 (62.3%) were females, with median age of 55 years (range: 25-90). The prevalence of microalbuminuria was 59.3% (95% CI: 50.1-72.2) and that of retinopathy was 66.8% (95% CI: 58.6-76.5). The independent correlates of retinopathy and microalbuminuria were systolic blood pressure (SBP) > 140 mmHg (OR = 2.76, 95% CI: 1.29-5.93) and treatment with beta-blockers (OR = 2.16, 95% CI: 1.05-4.44). Use of ACEIs was unrelated to the study outcomes.

CONCLUSION

The prevalence of retinopathy and microalbuminuria is high. Clinicians should aim for better control of blood pressure and routinely perform fundoscopy and urine albumin, especially for patients with poorly controlled blood pressure.

Serum Creatine Kinase-MB Isoenzyme Activity among Subjects with Uncomplicated Essential Hypertension: Any Sex Differences

Hypertension (high blood pressure) is a major health challenge and more women than men are affected by the condition. Complications as a result of this condition often lead to disabilities and premature death. The objective of this study was to evaluate creatine kinase-MB (CK-MB) activity in uncomplicated hypertension and to know whether sex differences exist in the activity of the enzyme. Serum creatine kinase-MB isoenzyme activity, troponin I, and lipid profile were evaluated in 140 male and 100 female Nigerians with hypertension. The control group was comprised of 100 (50 males and 50 females) normotensive subjects. Measured parameters were assayed using Selectra Pros chemistry analyzer. The means were compared between males and females using Students't-test. The mean CK-MB activity of the female hypertensive subjects was significantly higher (p < 0.001) than the males. Similarly, the mean cardiac troponin I (cTnI) of the female hypertensive subjects was significantly higher (p < 0.001) than the males. Conversely, the mean CK-MB activity of the female normotensive subjects was significantly lower (p < 0.001) than the male counterparts. There was no difference in the levels of cTnI between male and female normotensive subjects. Serum CK-MB activity was higher in female than male hypertensive subjects. In the light of these results, cardiac markers should be routinely done in the evaluation of hypertensive subjects and sex-specific consideration may be recognized in the management of these patients.

Hypertension control and care at Mulago Hospital ambulatory clinic, Kampala-Uganda

Background

Hypertension is as prevalent in many developing countries, as in the developed world and is the leading cause of cardiovascular morbidity and mortality in Africa. The control of hypertension in this resource limited setting is inadequate, a situation that translates into poorer outcomes in form of increasing incidences of stroke, heart failure, kidney failure and therefore early cardiovascular death.

Methods

This was a chart review of all the patients seen during the months of September 2012 to February 2013. We determined the level of blood pressure control, basic investigations documented as well as the choice of hypertensive treatment among patients attending a hypertension clinic in a national referral hospital, Mulago.

Results

Of the 741 patients whose charts were reviewed the median age was 60 years, Inter quartile range (IQR) was 51–71. Six hundred forty-two (86.6%) were females. Blood pressure (BP) control defined as BP lowering to at least 140/90 was seen in only 198 (26.7%) patients. Biophysical measurement documentation was very low especially for waist and hip circumference at 0.3%. Majority of patients, 476 (64.2%) had at least one documented investigation for the complications of hypertension. Only 103 (13.9%) had all investigations documented in their charts. The investigations included; complete blood count (CBC), urinalysis, renal function tests (RFTs), Chest X-Ray (CXR), echocardiography (Echo) and electrocardiography (ECG). The commonly documented investigations were RFTs (45.5%), ECG (45.2%) and Echo (44.2%). The commonly prescribed anti hypertensive medications were; Angiotensin receptor blockers (ARBs)/Angiotensin converting enzyme inhibitors (ACEI) (72.74%), calcium channel blockers (72.3%) and thiazide diuretics (68.6%). Majority of patients were receiving three anti hypertensive medications 313 (42.2%), with 149 (43.6%) of these, on an ACEI/ARB, a calcium channel blocker and a thiazide diuretic.

Conclusion

Blood pressure control is suboptimal in a tertiary clinic setting at Mulago hospital and documentation of investigations is inadequate. ARB/ACEI, Calcium channel blockers and thiazide diuretics were the commonly prescribed anti hypertensive medications. There is a great need to investigate for renal and cardiac complications as well as exploring reasons for inadequate blood pressure control and consider appropriate interventions to avert bad outcomes.