Implementation of national guidelines, incorporated within structured diabetes and hypertension records at primary level care in Cape Town, South Africa: a randomised controlled trial.
OBJECTIVE
Many clinical management guidelines for chronic diseases have been published, but they have not been put into practice by busy clinicians at primary care levels. This study evaluates the implementation of national guidelines incorporated within a structured diabetes and hypertension clinical record (SR) in Cape Town in a randomised controlled trial (RCT).


METHODS
Eighteen public sector community health centres (CHC) were randomly selected and allocated as intervention or control CHC. At each clinic, 25 patients with diabetes and 35 patients with hypertension were enrolled at baseline. Questionnaires were completed, blood samples were collected, blood pressure (BP) and anthropometric measures were taken and patient records were audited. SR with clinical guideline prompts were introduced at the intervention clinics after training doctors in their use and suggestions to incorporate them in regular patient records. Contact was maintained during the year of intervention with the clinic staff. A follow-up survey was conducted 1 year later to assess BP and HbA1c, and the patient records were examined to ascertain the extent of use of the SR in the intervention clinics. In-depth interviews were conducted with doctors and nurses to record their response to the intervention.


RESULTS
The intervention evaluated in this RCT had no impact on either diabetes or hypertension control. In the intervention clinics, less than 60% of the patient folders contained the SR and when present was seldom used. Although the staff were well disposed to the research team, their workload prohibited them from undertaking a true evaluation of the SR, and overall they did not perceive the SR as supporting their current process of patient care.


CONCLUSIONS
No benefit to diabetes of hypertension care by introducing and availability of the staff in the use of the SR was shown in this RCT. The process measures suggest that the SR was not widely used by the healthcare provided in the primary care clinics.
Department of Medicine, Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa; Chronic Diseases of Lifestyle Unit, Medical Research Council, Tygerberg, South Africa; krisela.steyn@uct.ac.za.
Krisela
K
Steyn
Carl
C
Lombard
Nomonde
N
Gwebushe
Jean M
JM
Fourie
Katherine
K
Everett-Murphy
Merrick
M
Zwarenstein
Naomi S
NS
Levitt
D003920:Diabetes Mellitus / Q000628:therapy*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods / Q000592:standards*; D016730:Program Development; D013019:South Africa
clinical guidelines; diabetes; hypertension; implementation; primary care