Quality of care of hypertension in three clinical settings in Jamaica.
To determine quality of monitoring and control of hypertension in Jamaica, 756 records of patients, aged > 30 years, attending a public general clinic (PUBMC) (n = 500), a specialist hypertension clinic (SPMC) (n = 119) and a private group general clinic (PRMC) (n = 137), for more than one year, were reviewed. Duration of follow-up varied among clinics with the longest mean follow-up at PRMC (10.8 yrs) compared to 6.1 years and 4.7 years at the PUBMC and SPMC respectively. Mean age was greatest at the PUBMC (60 yrs) compared to 53 years in the SPMC and 50 years in the PRMC (p < 0.001). Sex distribution differed among clinics with 15% men in the PUBMC, 34% in the SPMC and 54% in the PRMC (p < 0.001). Over 92% of patients had blood pressure (BP) recorded at least once in the 12-month review period. Hypertension was defined as being prescribed antihypertensive medication in clinic records. By this definition 98% SPMC patients were hypertensive, compared to 87% PUBMC and 80% PRMC. Using BP < 160/95 mmHg, the PRMC control rate, 63% was significantly better than those of PUBMC (46%) and SPMC (49%) (p < 0.01). The odds ratio and 95% confidence interval for poor control (BP > 160/95 mmHg) at the PRMC was 0.57 (0.34-0.97) compared to the other two clinics after adjustments for age, clinic type, duration of follow-up and gender. Only age was a significant covariate with older patients at greater risk of poor control. Only 18% of hypertensives were controlled to BP < 140/90 mmHg with no difference among clinics. Diuretics were the commonest agent used at the PUBMC (76%) and SPMC (86%) followed by alpha-methyldopa, 41% and 27%, respectively. These agents were less commonly prescribed at the PRMC than at the other clinics (45% diuretics and 8% alpha-methyldopa, p < 0.001 for both agents compared to other clinics). PRMC used more angiotensin converting enzyme inhibitors 38%, compared to SPMC 23% and PUBMC 1% (p < 0.001). Between 9% and 15% of patients at the PUBMC and PRMC had recorded data on smoking and alcohol use compared to 69% at the SPMC. A record of body weight was found in 99% at SPMC compared to 82% at PRMC and 33% at PUBMC (p < 0.001). Surveillance for complications differed for proteinuria (PRMC 33%, PUBMC 15%, SPMC 15%) and fundoscopy (PUBMC 0%, PRMC 3%, SPMC 43%). These results show very limited adherence to recommended hypertension treatment guidelines in all three settings.
Wilks
R
R
Epidemiology Research Unit, University of the West Indies, Kingston, Jamaica.
Sargeant
L A
LA
Gulliford
M
M
Reid
M
M
Forrester
T
T
D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000209:etiology; D007563:Jamaica; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D017149:Private Sector; D017150:Public Sector; D011785:Quality Assurance, Health Care; D012307:Risk Factors
D000959:Antihypertensive Agents