Home About us Current issue Ahead of Print Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 1233 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

Table of Contents   
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 941-948
Adherence of primary health care physicians to hypertension management guidelines in the Aseer region of Saudi Arabia


1 Department of Family and Community Medicine, College of Medicine, King Khalid University, Saudi Arabia
2 General Directorate of Health Affairs, Aseer Region, Saudi Arabia
3 Department of Medicine, Section of Psychiatry, College of Medicine, King Khalid University, Abha, Saudi Arabia

Click here for correspondence address and email

Date of Web Publication6-Sep-2011
 

   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.

How to cite this article:
Al-Gelban KS, Khan M, Al-Khaldi YM, Mahfouz AA, Abdelmoneim I, Daffalla A, Mostafa OA, Al-Amri HS. Adherence of primary health care physicians to hypertension management guidelines in the Aseer region of Saudi Arabia. Saudi J Kidney Dis Transpl 2011;22:941-8

How to cite this URL:
Al-Gelban KS, Khan M, Al-Khaldi YM, Mahfouz AA, Abdelmoneim I, Daffalla A, Mostafa OA, Al-Amri HS. Adherence of primary health care physicians to hypertension management guidelines in the Aseer region of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Jun 27];22:941-8. Available from: https://www.sjkdt.org/text.asp?2011/22/5/941/84393

   Introduction and Aim of the Study Top


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 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 three- fourths 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 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],[24],[25] The thiazide- type diuretics have been the basis of antihypertensive therapy [26] 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.


   Subjects and Methods Top


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 km 2 . [27] ]

All PHC physicians were assessed using a modified version of the WHO "Physician Inquiry Questionnaire." [28] It was used to collect data 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 Top


[Table 1] shows that most participants were non- Saudi (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). 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 in [Figure 1].
Figure 1: Percentage of correct responses from PHC physicians with regard to definition of systolic and diastolic hypertension among non-diabetic and diabetic patients.

Click here to view
Table 1: Personal characteristics of the study sample (n = 322).

Click here to view
Table 2: Blood pressure measurement and diagnosis of hypertension (n=322).

Click here to view


[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 (88.2%), and lipid profile (89.8%).
Table 3: Patient evaluation and management (n = 322).

Click here to view


[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 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%).
Figure 2: Preferred initial anti-hypertensive agents by the study subjects.

Click here to view
Table 4: Measures adopted by physicians to improve hypertension control (n = 322).

Click here to view



   Discussion Top


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 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 non- diabetics 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 two- thirds 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 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 self- measurement 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 out-of- 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 examination, 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.


   Recommendations Top


Continuing medical education and training courses on guidelines for hypertension management should be arranged for PHC physicians in Aseer.

 
   References Top

1.World Health Report 2002: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization. 2002.  Back to cited text no. 1
    
2.JNC7. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. U.S. Department Of Health And Human Services, National Institutes of Health National Heart, Lung, and Blood Institute National High Blood Pressure Education Program NIH Publication No. 04- 5230. August 2004.  Back to cited text no. 2
    
3.Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988- 1991. Hypertension 1995;25:305- 13.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle aged women and men: The Framingham Heart Study. JAMA 2002;287:1003- 10.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Al- Shammari SA, Ali M, Al- Shammari A, al-Maatouq M, Tennier A, Armstrong K. Blood lipid concentrations and other cardiovascular risk factors among Saudis. Fam Pract 1994;11: 153- 8.  Back to cited text no. 5
    
6.Al- Nozha MM, Ali MS, Osman AK. Arterial Hypertension in Saudi Arabia. Ann Saudi Med 1997;17(2):170- 4.  Back to cited text no. 6
    
7.Wahid Saeed AA, al Shammary FJ, Khoja TA, Hashim TJ, Anokute CC, Khan SB. Prevalence of hypertension and socio- demographic characteristics of adult hypertensives in Riyadh City, Saudi Arabia. J Hum Hypertens 1996;10(9): 583- 7.  Back to cited text no. 7
    
8.Perez- Stable EJ, Salazar R. Issues in achieving compliance with antihypertensive treatment in the Latino population. Clin Cornerstone 2004;6 (3):49- 64.  Back to cited text no. 8
    
9.Al- Mustafa BA, Abulrahi HA. The role of primary health care centers in managing hypertension. How far are they involved? Saudi Med J 2003;24(5):460- 5.  Back to cited text no. 9
    
10.Siddiqui S, Ogbeide DO, Karim A, Al- Khalifa I. Hypertension control in a community health centre at Riyadh, Saudi Arabia. Saudi Med J 2001;22(1):49- 52.  Back to cited text no. 10
    
11.O'Brien E, Asmar R, Beilin L, et al. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21:821- 48.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Houweling ST, Kleefstra N, Lutgers HL, Groenier KH, Meyboom- de Jong B, Bilo HJ. Pitfalls in blood pressure measurement in daily practice. Fam Pract 2006;23:20- 7.  Back to cited text no. 12
    
13.Beevers G, Lip GY, O'Brien E. Blood pressure measurement. Part I. Sphygmomanometry: Factors common in all techniques. BMJ 2001;322: 981- 5.  Back to cited text no. 13
    
14.McVicker JT. Blood pressure measurement-does anyone do it right? An assessment of the reliability of equipment in use and the measurement techniques of clinicians. J Fam Plann Reprod Health Care 2001;27:163- 4.  Back to cited text no. 14
[PUBMED]    
15.American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care 2003;26(suppl 1):S80- 2.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.National Kidney Foundation Guideline. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39(suppl 2):S1- 246.  Back to cited text no. 16
    
17.He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long- term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544- 9.  Back to cited text no. 17
[PUBMED]  [FULLTEXT]  
18.Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH- Sodium Collaborative Research Group. N Engl J Med 2001;344:3- 10.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.Vollmer WM, Sacks FM, Ard J, et al. Effects of diet and sodium intake on blood pressure: Sub- group analysis of the DASH- sodium trial. Ann Intern Med 2001;135:1019- 28.  Back to cited text no. 19
[PUBMED]  [FULLTEXT]  
20.Chobanian AV, Hill M. National Heart, Lung, and Blood Institute Workshop on Sodium and Blood Pressure: A critical review of current scientific evidence. Hypertension 2000;35:858- 63.  Back to cited text no. 20
[PUBMED]  [FULLTEXT]  
21.Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2000;35:838- 43.  Back to cited text no. 21
[PUBMED]  [FULLTEXT]  
22.Xin X, He J, Frontini MG, et al. Effects of alcohol reduction on blood pressure: A meta- analysis of randomized controlled trials. Hypertension 2001;38:1112- 7.  Back to cited text no. 22
[PUBMED]  [FULLTEXT]  
23.Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): A randomized trial against atenolol. Lancet 2002;359:995- 1003.  Back to cited text no. 23
    
24.Black HR, Elliott WJ, Grandits G, et al. Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints (CONVINCE) trial. JAMA 2003;289:2073- 82.  Back to cited text no. 24
[PUBMED]  [FULLTEXT]  
25.Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin converting- enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 2003;348:583- 92.  Back to cited text no. 25
[PUBMED]  [FULLTEXT]  
26.Psaty BM, Manolio TA, Smith NL, et al. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: The Cardiovascular Health Study. Arch Intern Med 2002;162:2325- 32.  Back to cited text no. 26
[PUBMED]  [FULLTEXT]  
27.Provinces of Saudi Arabia. http://www.absoluteastronomy.com/topics/Provinces_of_Saudi_Arabia.  Back to cited text no. 27
    
28.World Health Organization. Annex 1: Protocol for the Hypertension Management Audit Project. Assessing Hypertension Control and Management. Strasser T, Wilhelmsen L. WHO Regional Publications, 1991; European Series No. 47, pp. 143- 65.  Back to cited text no. 28
    
29.Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: Clinical and public health advisory from The National High Blood Pressure Education Program. JAMA 2002;288 :1882- 8.  Back to cited text no. 29
[PUBMED]  [FULLTEXT]  
30.Ernest S. Hypertension guideline adherence of private practitioners and primary health care physicians in Pretoria. SA Fam Pract 2005;47 (3):51- 4.  Back to cited text no. 30
    
31.Huse DM, Roht LH, Alpert JS, Hartz SC. Physicians' knowledge, attitudes and practice of pharmacologic treatment of hypertension. Ann Pharmacother 2001;35:1173- 9.  Back to cited text no. 31
[PUBMED]  [FULLTEXT]  

Top
Correspondence Address:
Mohd. Yunus Khan
Department of Family and Community Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 21912023

Rights and PermissionsRights and Permissions


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Characteristics of Saudi patients with congestive heart failure and adherence to management guidelines in a tertiary hospital in Riyadh
Alqahtani, M. and Alanazi, T. and Binsalih, S. and Aljohani, N. and Alshammari, M. and Ashagag, A. and Abdullah, M. and Buabbas, S. and Abdulbaqi, M.
Annals of Saudi Medicine. 2012; 32(6): 583-587
[Pubmed]
2 (In)accuracy of blood pressure measurement in 14 Italian hospitals
Manzoli, L. and Simonetti, V. and DæErrico, M.M. and De Vito, C. and Flacco, M.E. and Forni, C. and La Torre, G. and Liguori, G. and Messina, G. and Mezzetti, A. and Panella, M. and Pizzi, C. and Siliquini, R. and Villari, P. and Cicolini, G.
Journal of Hypertension. 2012; 30(10): 1955-1960
[Pubmed]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction and...
   Subjects and Methods
   Results
   Discussion
   Recommendations
    References
    Article Figures
    Article Tables
 

 Article Access Statistics
    Viewed5784    
    Printed118    
    Emailed0    
    PDF Downloaded765    
    Comments [Add]    
    Cited by others 2    

Recommend this journal