Hypertension (HTN), a major public health problem world wide, is associated with high morbidity and mortality rates. The majority of cases are asymptomatic and, therefore, go unrecognized and untreated, leading to a high risk of coronary artery disease, heart failure, renal failure and cerebrovascular disease.1–4 The true prevalence of HTN in Saudi Arabia is unknown but according to the studies carried out in the Kingdom, HTN seems to affect about 10% of the Saudi population.5–7 In another study, the prevalence of HTN was found to be 30 % among people aged 35 years and above attending PHC centers in the Al Qassim Region.8 The high prevalence of HTN in Saudi Arabia calls for its management in primary health care (PHC) centers. Firstly, the follow up procedure for hypertensive patients does not require any sophisticated techniques. Secondly, in the more relaxed atmosphere of the PHC centers, physicians have more time for the patients than in the busy secondary and tertiary care system. Thus, it has been shown that uncontrolled HTN may be associated with the lack of attention of a PHC care physician to the patient.9
The aim of this study is to assess the quality of hypertension care in AL Asyah primary health care (PHC) center in the Al Qassim region, Saudi Arabia, through the auditing of structure, process, and outcome of hypertension care.
SUBJECT AND METHODS
AL Asyah, is small town in the Qassim region served by Al Asyah primary health care (PHC) Center. It is the only PHC in Al Asyah. It serves approximately 4628 inhabitants (4414 Saudi and 214 non Saudi ). One of the clinics in this PHC center was selected and equipped as a chronic disease clinic and started operating in October 1999. This mini-clinic cares for diabetic, hypertensive and asthmatic patients. Indicators for structures, process and outcome of hypertension care were assessed using the scoring system based on the recommendation by WHO, Quality Assurance protocol, protocol of management of chronic diseases and the sixth report of joint National committee on detection, evaluation and treatment of high blood pressure (JNCVI). Data was collected by the authors from July to September 2003. All files of hypertensive patients were reviewed using a two-part pre-designed form. Part I included the degree of availability of all essential resources for care of HTN (man power, chronic diseases register, files, ECG, blood pressure apparatus, medications, ophthalmoscope, stethoscope, weighing scale, health education materials, protocol for management of HTN, appointment system). Part II included the process and outcome measures. The processes included were: patient characteristics such as age, sex, nationality, marital status, education, and occupation. Besides relevant history such as duration, type, severity of HTN, type of treatment, referral to the hospital, there were also risk factors as diabetes, family history of HTN, smoking, hypercholesterolemia, hypertriglyceridemia. Information on regular health measurements such as blood pressure, body mass index, urine dipstick, fundus examination, creatinine, cholesterol and triglyceride levels, ECG and chest X-ray was elicited as also were health outcome measures including the degree of patient control, and creatinine level. Information on the presence of such complications as left ventricular hypertrophy, ischemic heart disease, myocardial infarction, and stroke was asked for.
A total of 201 files of hypertensive patients registered in Al Asyah PHC center were included in this study. The prevalence of hypertension among adults of 15 years and above was 7.4%. Table 1 shows the demographic characteristics of the studied group, 94.5% of whom were mostly Saudi with a mean age of 58.6 ± 13.9 years. Most of the patients were diagnosed as essential HTN (98.5%) and 87.1% of these were diagnosed at the Al Asyah PHC center. The mean duration of the HTN was 7.7 years; 48.8% had a family history of HTN and 35.3% had diabetes mellitus.
Table 2 shows that the prevalence of hypertension increased with age. Among males and females above 65 years, it was 55.4% and 57.1% respectively.
Table 3 shows that 98.5% of the patients were diagnosed as essential HTN, and most (93.5%) were Grade I HTN. Most (87.1%) were diagnosed at the PHC center. For 41.8% of the patients, the duration of hypertension since diagnosis was <5 years, for 25.9% it was 5 – 10 years and for 32.3% >10 years. The mean duration of HTN was 7.7±5.8years, mean systolic blood pressure was 139.7 mmHg and mean diastolic blood pressure was 82.4 mmHg. Nine patients (4.5%) managed by diet plus exercises only and 192 (95.5%) needed drugs. One hundred nine cases (54.2%) had regular follow up in the PHC center, 72cases (35.8%) had regular follow-ups in both (PHC and hospital).
Table 4 shows the results of the completed process. All the items of the process showed high percentages of coverage, except the examination of the fundus (29.4%).
Table 5 shows the results of health outcome measures. Serum urea and creatinine level were normal in most patients, while serum cholesterol and triglyceride levels were high in 39.8 % and 9.0% respectively. Moreover, most of the patients were obese or overweight (53.7% and 31.3% respectively). ECG, chest X-ray and fundus examination showed variable levels of abnormality. The patients’ compliance to appointment was good (95.5%).
Care of hypertensive patients by the primary health care (PHC) team should be appropriate, achievable and relevant. Auditing the structure, process, and outcome of care is extremely important.10 All essential resources for hypertension care are available in Al Asyah PHC center unlike in the Al-sharif study which found that many essential resources for hypertension care were inadequate at the primary health care centers in the Aseer region.11 In our study, the prevalence of HTN among adult males aged 15 years and over was 7.5% and among females of the same age group was 7.3%. This is higher than the results of the Al Owayyed study (0.6%), the Taffinder study (4.2%) and the Saudi Arabia family health survey (SFHS) which showed a prevalence rate of 4% for males and 7% for females.101213 The prevalence of HTN tends to increase with age.14 In this study, it was found to be 27% in males and 23.5% in females aged 45 -<65 years reaching 55.4% in males and 57.1% in females aged ≥ 65years. This is in accordance with the results of the Saks study in Estonia which found that the prevalence of HTN among patients aged 65 years and above was 63.2% and was more common among females than males.15 Also Siddiqui found that the prevalence of HTN was more common in females than males and increased with age.16 Our results are higher than those of the Al Owayyed study (23%), the Hewart study (26%) and SFHS1996.101317 These higher percentages of prevalence of HTN could be due to the fact that only 8.6% of population is aged between 45-<65 years, and 2.7% of the population is aged 65years and above.
Our study revealed that as in the Al Khaldi study, the data base information, namely demographic and HTN related data was available in all hypertensive patient files giving a mean of 89.4%.18
Sixty-two point two percent of the patients were illiterate; 51.7% of the patients were females (house wives) and 56.3% were >65 years old.
This study revealed that all items of the process of HTN care showed a higher percentage of coverage with a mean percentage of 96.7% which was higher than Al –Owayyed study.10 The mean duration of HTN in this study was 7.7 years. Approximately 98.5% of cases were diagnosed as essential HTN, which is in accordance with the result of Al- Owayyed study finding that 99% of the patients had essential HTN and 77% had it for less than 10 years10. Our study showed that 188 cases (93.5%) had Grade I HTN and 13 cases (6.5%) had Grade II HTN. This classification is in consonance with that used in the (JNCVI) report.19 This figure was higher than what was reported by Al – Owayyed (66.1%) and the Stern studies (27%) on the patients with Stage I HTN.1020 This could be due to the fact that blood pressure measurement was taken only at the start of treatment or could be the result of the use of a different definition of Stage I HTN treatment.
Hypertension is common in diabetics and its treatment is important to prevent cardiovascular complications.21 Evidence of raised blood sugar was found in 73 cases (36.3%) and this was lower than the result of the Al-Owayyed study in which 64% of the patients had high blood sugar,10 but was higher than the result of the Al Humaidi study (30%),22 the Framingham study in which 21% of the patients with hypertension had high blood sugar.23 Only 10.4% were smokers compared to 14% and 17% in other studies.10 A family history of HTN is a risk factor of HTN; 48.8% of our samples had a family history of HTN, 12.4% had no family history and for 38.8% there was an unrecorded family history of HTN. This is in accordance with the Al Mustafa study which reported 47.7% of the hypertensive patients with a positive family history of HTN,24 but was higher than the results of the Al Owayyed study in which 18.1% of the hypertensive patients had a family history of HTN and 81.9% had a negative family history of HTN.10 High cholesterol level was found in about 40% of our sample. This was higher than the results of the Al Owayyed study (32%), Al Humaidi Study (31%),21 Framingham's heart study (30%),23 and Charles et al (15%).25 Obesity is known to be one of the most prevalent nutritional disorder in Saudi Arabia. Our study showed high percentages of overweight and obesity among hypertensive patients (31.3%) and (53.7%) respectively. This in accordance with the previous studies done by Al Turki, El Hazmi, Al Nuaim and Al Humaidi.26–29 ECG abnormality was found in 27.9% of the cases; and this is higher than the Al Owayyed study in which there was evidence of abnormal ECG in 8.7% of the patients with HTN.10 Also there were abnormal chest X-rays in 18.4% of the cases. This again in accordance with the Al Owayyed study which had 20.2% and the Levy D, et al survey in which chest X-rays gave evidence of left ventricular hypertrophy in more than 15-20% of adults with HTN.10 It was, however, less than what was reported in the Martinez study in which echocardiography indicated that 32 % of mild hypertensive patients had left ventricular hypertrophy.30 Referral of all hypertensive patients to the hospital for annual follow up in HTN or cardiology clinic is mandatory. In this study, the percentage of annual referral was 93%. In spite of this, the percentage of available data on fundus examination in hypertensive files was (27.6%). This result is in accordance with the results of the Al Owayyed study which showed that fundoscopy was done in 25% of hypertensive patients.10 Variation between the number of referrals and the availability of fundoscopy report in patient files may be attributed to poor coordination between the hospital and the PHC center. Compliance with follow-up appointments was high in our study (95.5%). This could be the result of the antihypertensive medications being prescribed to the patients from the PHC center or the hospital instead of being given to the patients through the PHC centers only in the Al Qassim region. Our study showed that blood pressure in 79.6% of the hypertensive patients was well controlled, and this was higher than the results of the Al Owayyed study of 55% and the Sterns study of 53%.10–20 Of the patients, 95.5% needed medications, while 4.5% were controlled with diet and exercises only. This agreed with the Al Owayyed study in which 5% of the patients were controlled with diet and exercises.10 Approximately 45.3% of our hypertensive patients had at least one reported complication. Ischemic heart disease was the most commonly observed complication (19.9%), followed by left ventricular hypertrophy (18.4%), stroke (2.5%), myocardial infarction (2%), nephropathy (1.5%) and retinopathy (0.5%).
This study proves that all essential resources needed for hypertension care are available. The results of process and outcome indicators however, show the need to improve the referral system and establish good continuous health education programs to encourage patients, their families and the community to observe more healthy lifestyles.
1. Al Khashman AS. Screening for hypertension. Assessing the knowledge, attitudes and practice of primary health care physicians in Riyadh, Saudi Arabia Saudi Med J. 2001;22(12):1096–100
2. Yamani MH, Massie B M. Hypertension, myocardial ischemia and sudden death Curr Opin Cardiol. 1994;9:542–50
3. Petrovitch H, Curb JD, Bloom–Marcus E. Isolated systolic hypertension and risk of stroke in Japanese- American men Stroke. 1995;26:25–9
4. Alberto Z, John C, Kijuo A. Guidelines for management of mild hypertension; memorandum from a WHO/ ISH meeting J Hypertens. 1993;11:905–18
5. Ahead AFM, Mohmoud ME. The prevalence of hypertension in Saudi Arabia Saudi Med Journal. 1922;6:548–51
6. Al-Nozha M, Al-Shabrawy MA, Karar A Arterial hypertension in Saudi Arabia. Proceedings of the 5th
scientific Session. 1994 Riyadh Saudi Heart Association
7. Abolfotooh MA, Abu-Zeif HAH, Abdelaziz M, Alakija W, Mahfouz AA, Bassuni WA. Prevalence of hypertension in south-western Saudi Arabia East Mediterranean Health Journal. 1996;2:211–8
8. Kalantan KA, Mohamed AG, Al-Taweel AA, Abdul Ghani HM. Hypertension among attendants of primary health care centers in Al-Qassim region, Saudi Arabia Saudi Med J. 2001;22(11):960–3
9. Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe uncontrolled hypertension in an inner-city minority population N Engl J Med. 1992;327:776–81
10. Al Owayyed A. Hypertension care in Family and Community Medicine Department: An audit of process and outcome Saudi Medical J. 1996;17(1):18–25
11. Al-Sharif Al, Al-Khaldi YM. Resource availability for care of hypertensives at primary health settings in Southwestern Saudi Arabia Saudi Med J. 2003;24(5):466–71
12. Taffinder AP, Taffinder GA. An audit of hypertension in General practices The Practitioner. 1984;228:595–8
13. Koja T A, Farid S M Saudi Arabia Family Health Survey 1996: Principal Report. 2000 Riyadh Ministry of Health
14. Whelton PK. Epidemiology of hypertension Lancet. 1994;344:101–6
15. Saks K, Kolk H, Soots A, Takker U, Vask M. Prevalence of cardiovascular disorders among the elderly in primary care in Estonia Scand J Prim Health Care. 2003;21(2):106–9
16. Siddiqui S, Obeide DO, Karim A, Al-khalifa I. Prevalence of hypertension in patients attending Al-Kharj Military Hospital Saudi Med J. 2000;21(6):558–60
17. Stewart T. Treatment of hypertension BMJ. 1985;291:1908
18. Al-Khaldi YM, Khan MY. Impact of a mini-clinic on diabetic care at a primary health care center in southern Saudi Arabia Saudi Med J. 2002;23(1):51–5
19. Elzubier AG. Hypertension in Diabetics registered in primary health care center in Makkah district, Saudi Arabia Journal of Family & Community Medicine. 2000;7(3):23–8
20. Stern DH. Management of hypertension in twelve Oxfordshire General Practice J of the Royal College of General practitioner. 1986;36:549–51
21. Akbar DH. Is hypertension common in hospitalized type 2 diabetic patients? Saudi Med J. 2001;22(2):139–41
22. Al-Humaidi MA. Probability of coronary artery disease among patient attending primary health care centers (PHCCs) in Southwest Saudi Arabia Ethn Dis. 2000;10(3):350–6
23. Kennel WB. Contribution of the Framingham study to prevention Cardiology. Bishop Lecture J Amer Coll Cardiol. 1990;15:206–11
24. 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
25. Eaton CB, Feldman HA, Assaf AR, Mephillips JB, Jhme AB, Lasater TM. Prevalence of hypertension, dyslipidemia and dyslipidemic hypertension The Journal of Family Practice. 1994;38:17–23
26. Al Turky Y A. The prevalence of overweight and obesity amongst hypertensive and diabetic adult patients in primary health care Saudi Med J. 2000;21(4):340–3
27. EL Hazmi MAF, Warsy AS. Prevalence of obesity in Saudi population Annals of Saudi Medicine. 1997;17:302–6
28. Al–Nuaim AR. High prevalence of metabolic risk factor for cardiovascular disease among Saudi population aged 30-64 years Int J Cardiol. 1997;62:227–35
29. Al Humaidi MA. Obesity and associated risk of coronary artery disease among patient of primary health care center, in Abha, Saudi Arabia Journal of Family & Community Medicine. 2000;7(1):25–30
30. Martinez MA, Sancho T, Armada E, Rubio JM, Anton GL, Torre A, et alVascular Risk Working Group. Monitorizacion Ampulatoria de la Presion Arterial. (MAPA) – Madrid. Prevalence of left ventricular hypertrophy in patients with mild hypertension in primary care: impact of echocardiography on cardiovascular risk stratification Am J Hypertens. 2003;16(7):556–63