|Year : 2019 | Volume
| Issue : 4 | Page : 132-136
Process of care indicators among patients treated for hypertension at a tertiary care hospital in Puducherry, South India
Jeby Jose Olickal1, Chanaveerappa Bammigatti2, Vinayagamoorthy Venugopal3, Kalaiselvi Selvaraj4, Karthickeyan Duraisamy5, Kalpita Shringarpure6, Vanitha Priya Deenathayalan5, Kedar Gautambhai Mehta7, Priya Rathi8, Manisha Chetan Khemani9, Sadhana Subramanian1, Revathi Ulaganeethi1, Palanivel Chinnakali1
1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
4 Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
5 Academy for Public Health, Kozhikode, Kerala, India
6 Department of Preventive and Social Medicine, Medical College Baroda, Vadodara, Gujarat, India
7 Department of Community Medicine, GMERS Medical College Gotri, Vadodara, Gujarat, India
8 Department of Community Medicine, Kasturba Medical College, Mangalore, Karnataka, India
9 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||19-Nov-2019|
|Date of Acceptance||05-Dec-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Palanivel Chinnakali
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research,Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Background: Routine follow-ups, laboratory tests, and fundus examination are necessary in controlling blood pressure (BP) and thus control the complications of hypertension (HTN). Hence, in this study, we aimed to determine the process of care indicators among patients with HTN who have obtained care at a tertiary care center, South India.
Methods: A hospital-based cross-sectional descriptive study was conducted among patients with HTN who were registered on or before September 2017 and were on treatment for a minimum of 1 year. Patient case records were retrospectively reviewed to identify the process indicators.
Results: A total of 385 patients with HTN were included in this study. The mean (standard deviation) age was 57.9 (9.8) years and more than half were females (51.7%). Of total, 274 (71.2% [95% confidence interval (CI) 66.5–75.5]) patients have consulted their physicians on the last two scheduled visits and 62% (95% CI 56.9–66.5) have got their BPs measured. Only one-fifth underwent retinal examination and lipid profiling. Only 77 (20% [95% CI 15.8–23.7]) of the patients achieve at least three processes of care indicators we studied. Outcome indicators showed that around one-third (36.9%) of the participants had unsatisfactory outcome indicators with respect to BP control. Care-availing outpatients have 1.2 (95% CI 1–1.4) times higher poor care indicators (not underwent last three processes of care indicators) as compared to those availing care from HTN clinic (P = 0.01).
Conclusions: We found suboptimal adherence to process of care indicators among patients with HTN availing care at a tertiary care hospital.
Keywords: Hypertension, patient outcome assessment, structured operational research and training initiative
|How to cite this article:|
Olickal JJ, Bammigatti C, Venugopal V, Selvaraj K, Duraisamy K, Shringarpure K, Deenathayalan VP, Mehta KG, Rathi P, Khemani MC, Subramanian S, Ulaganeethi R, Chinnakali P. Process of care indicators among patients treated for hypertension at a tertiary care hospital in Puducherry, South India. Int J Non-Commun Dis 2019;4:132-6
|How to cite this URL:|
Olickal JJ, Bammigatti C, Venugopal V, Selvaraj K, Duraisamy K, Shringarpure K, Deenathayalan VP, Mehta KG, Rathi P, Khemani MC, Subramanian S, Ulaganeethi R, Chinnakali P. Process of care indicators among patients treated for hypertension at a tertiary care hospital in Puducherry, South India. Int J Non-Commun Dis [serial online] 2019 [cited 2020 Mar 29];4:132-6. Available from: http://www.ijncd.org/text.asp?2019/4/4/132/274462
| Introduction|| |
Hypertension (HTN), also known as high/raised blood pressure (BP), is a global public health issue  and the third-largest factor contributing to disability-adjusted life years. Participants with HTN possess a two-fold higher risk of developing coronary artery disease, four times higher risk of congestive heart failure, and seven times higher risk of cerebrovascular diseases compared to normotensive participants. HTN, one of the primary risk factors for heart disease and stroke, is also the leading cause of death worldwide. In fact, globally, cardiovascular diseases account for 17 million deaths a year, of which complications resulting from HTN result in 9.4 million deaths every year. Overall, 26.4% or 972 million people worldwide had HTN in 2000, and it is expected to increase to 1.56 billion in 2025, a 60% increase from 2000. Nearly two-thirds of the patients with HTN live in low- and middle-income countries, resulting in significant economic burden., In India, the overall prevalence of HTN is estimated to be 29.8% or 387 million. The “rule of halves for” chronic diseases stands true for HTN as well, whereby half of those detected with high BP do not receive appropriate care and only half of those treated for high BP have their BP in control. Regular clinical monitoring and adherence to treatment are very important for proper HTN management and the prevention of long-term complications. Routine follow-ups, laboratory tests, fundus examination, and electrocardiogram are helpful in determining the effect of therapy and to identify the symptoms and complications, if any. Hence, the current study is aimed to determine the process of care indicators among patients with HTN seeking care for at least 1 year in the HTN clinic or outpatient clinic of a tertiary care institute in Puducherry, South India.
| Methods|| |
We conducted a hospital-based, cross-sectional, analytical study among patients with HTN who have registered and are under treatment for a minimum of 1 year in the department of medicine of a tertiary care center in Puducherry, India, which provides healthcare to people from the union territory and also its neighboring districts of Tamil Nadu and Andhra Pradesh state.
The 2500-bed tertiary care center serves free of cost for the poor. The department of medicine is one of the largest clinical departments in the institute in terms of the number of patient care services, undergraduate and postgraduate teaching, and faculty strength. For HTN patients on care, routine tests such as renal function tests (RFTs), lipid profile, blood glucose tests for diabetes, retinal fundus examination, and electrocardiography (ECG) were offered at no cost.
All individuals with HTN who were registered on or before September 2017 and were on treatment for at least 1 year in the department of medicine were included in the study. Assuming the proportion of patients who measured BP at every visit as 50%, absolute precision of 5% and 95% confidence level, the calculated sample size was 384.
Every second patient (systematic random sampling) attending the HTN clinic/outpatient clinic was approached until the required sample size was achieved. Patients were interviewed using a questionnaire based on sociodemographic details and comorbid conditions when they come to a HTN clinic. The case records of patients were retrospectively reviewed for the process indicators for a period of 1 year. The process indicators were extracted either from the laboratory reports attached to patients' case records or from the physician notes entered in the case record.
We considered the care process to be “ideal” when a patient has undergone at least three processes of the following care indicators as per the schedule:
- Consulted the treating physician on the last two consecutive due dates
- BP measured during the last two consecutive visits
- Renal functions test performed in the last 6 months
- Lipid profile performed in the last 6 months
- Retinal fundus examined in the last 1 year
- ECG recorded in the last 1 year.
We considered BP as unsatisfactory if the systolic BP ≥140 or diastolic BP ≥90 and renal functions as unsatisfactory when serum urea >40 mg/dL and serum creatinine >1.2 mg/dL. Similarly, lipid profiles were considered unsatisfactory if total cholesterol >180 mg/dL and triglyceride >150 mg/dL.
The study protocol was reviewed and approved by the Institutional Ethics Committee. Informed written consent was obtained from all the participants, just before the interview, in their local language after explaining the purpose of the study. Information collected in the semi-structured questionnaire were entered in EpiCollect5 (mobile application) and analyzed using Stata software (version 12.0, StataCorp LLC, Texas, USA). Categorical variables such as gender, occupation, and residence were summarized as percentage. The continuous variable, age, was summarized as mean (standard deviation [SD]). The process of care indicators was summarized as percentages with 95% confidence interval (CI). Factors associated with poor process of care indicators (not undergone at least three of the criteria) were assessed using the Chi-square test and unadjusted prevalence ratios with 95% CI. To assess the independent association, we performed multivariable regression analysis (log-binomial model) and adjusted prevalence ratios with 95% CIs were calculated.
| Results|| |
A total of 385 patients with HTN were included in this study. The mean (SD) age of all the participants was 57.9 (9.8) years and nearly half of them were above 60 years (46.8%). More than half of the participants were females (51.7%). Almost three-fourth of the participants was from the rural areas (71.7%) and was daily wage earners (69%). Almost all of them were below the poverty line (95.6%). Diabetes mellitus was the most common comorbidity accounting to 27.5%. A total of 285 (74%) patients were availing care from the HTN clinic, and around 139 (35.1%) patients were receiving care for more than 5 years [Table 1].
|Table 1: Sociodemographic details of 385 patients with hypertension managed at a tertiary care institute in Puducherry, South India, during 2017 and 2018 (n=385)|
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Evaluation of process indicators revealed that 70% (95% CI 66.5–75.5) of them consulted their physician on the last two consecutive due dates and BP was measured for 62% (95% CI 56.9–66.5) of the patients. Only one-fifth underwent retinal examination and lipid profiling. Only 20% (95% CI 15.8–23.7) of the patients achieve at least three processes of care indicators, and none of the participants received were able to receive all six essential process of care indicators for HTN [Table 2].
|Table 2: Process of care indicators of 385 patients with hypertension managed at a tertiary care institute in Puducherry, South India, during 2017 and 2018 (n=385)|
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Outcome indicators showed that around one-third (36.9%) of the participants had unsatisfactory outcome indicators with respect to BP control. Unsatisfactory outcome measures for RFT and lipid profile were observed in 10.2% and 14.7% of patients, respectively [Table 3].
|Table 3: Outcome indicators of 385 patients with hypertension managed at a tertiary care institute in Puducherry, South India, during 2017 and 2018 (n=385)|
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Multivariable analysis showed that patients availing care from the outpatient department (OPD) had 1.2 (95% CI 1–1.4) times higher poor process of care indicators as compared to those availing care from the HTN clinic (P = 0.01) [Table 4].
|Table 4: Association of process of care indicators with sociodemographic factors of 385 patients with hypertension managed at a tertiary care institute in Puducherry, South India, during 2017 and 2018 (n=385)|
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| Discussion|| |
The current study aims to find the process of care indicators among patients on care for HTN at a tertiary care hospital for effective HTN management. The adherence to physician visit was found to be 71.2%, which is greater than that reported in the studies from Lebanon  (52.6%), America, (44.2%), and Netherlands  (27%). This difference is because all the participants in this study are receiving free care and medications, whereas the other study participants had to pay for the treatment. Some studies have reported varying adherence ranging from 56% to 90.6%.,
The present study reported 62% regularity in BP measurement. Studies conducted in other noncommunicable diseases (NCDs) observed similar findings., Uncontrolled levels of BP was reported among 36.9% of the participants, which is similar to the study from Northwest Ethiopia. About half of the participants in this study had their RFTs in the last year. The HTN clinic of the care center was run only on Tuesday afternoons, and therefore, all the patients were not getting adequate time for laboratory investigations. This may be one of the reasons for poor process of care regarding the RFT. Similarly, around 20% of the participants performed lipid profile and retinal fundus examinations and around 11% recorded ECG as per the recommendation. We observed that the participants are travelling long distance to avail care and that can lead to poor process of care indicators. Of those who performed RFT, around 10% reported high levels of serum urea and creatinine and the finding is also supported by the study done in Bangladesh. Lipid profile test results showed that around 15% of the participants had unsatisfactory levels of total cholesterol and triglycerides and these observations were not comparable with a study conducted at a primary care center in South India.
The current study showed that the place of availing care is significantly associated with the process of care indicators. The number of patients attending the HTN clinic is much less compared to general outpatient clinics and the patients are getting a better care from the specialty clinics. In addition, as the clinic is running in the afternoon, patients may feel easy to attend an afternoon clinic than morning outpatient clinics. This might be the reasons for better process of care indicators in the HTN clinic compared to outpatient clinic. A study from Nigeria also shows that patients attending the NCD clinic had at least a better medication adherence than those attending the outpatient clinic. The present study also found that the sociodemographic characteristics are not significantly associated with the poor process of care indicators. Asch et al. reported a better process of care indicators among early adulthood patients (age <50 years) and among males.
| Conclusions|| |
We found suboptimal adherence to process of care indicators among patients with HTN availing care at a tertiary care hospital. Our data indicate that there is a scope of improvement in follow-ups of patients with HTN to identify the early signs of target organ damage and prevent mortality due to cardiovascular diseases. We suggest hospital administration could make appropriate arrangements to collect the samples of HTN patients for laboratory investigations at OPD coordinating with NCD clinic and laboratory division.
This research was supported through an operational research course that was jointly developed and run by Academy for Public Health, Kozhikode, Kerala, India; Malabar Cancer Center, Thalassery, Kerala, India with the support of the Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, France. This course is under the umbrella of the World Health Organization-TDR Structured Operational Research and Training Initiative programme for capacity building in low- and middle-income countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]