BACKGROUND Hypertension is a common cardiovascular risk factor - PDF document

BACKGROUND  Hypertension is a common cardiovascular risk factor worldwide BLOOD PRESSURE CONTROL IN  While treatment of hypertension has been shown to prevent cardiovascular diseases and to extend and enhance life, HYPERTENSIVE PATIENTS ENROLLED IN A hypertension remains inadequately managed everywhere RURAL OUTPATIENT SETTING  Lack of data, limited national resources, and the lack of prediction models in certain populations contribute to the major challenges of primary and secondary prevention in patients who are at risk or have hypertension.  A critical component of hypertension management is to Nathalie Dougé facilitate sustained access of affected individuals to effective May 8, 2014 clinical services. GE/NMF International Medical Scholars, Kenya OBJECTIVES METHODS  To determine the prevalence of patients with hypertension  A retrospective chart review was conducted of all medical enrolled at a rural medical outpatient clinic outpatient files at the Yala Sub-County Hospital  Among the hypertensive patients, determine the prevalence  Non-pregnant patients aged 18 years and over identified with rate of those with adequately controlled blood pressure a diagnosis of hypertension met the inclusion criteria for the study  To identify characteristics of hypertensive patients that may be associated with blood pressure control  Upon thorough review of each chart, patients not previously or actively followed* in the medical outpatient clinic or those with missing data of interest were excluded from the study

YALA SUB-COUNTY HOSPITAL’S SELECTION OF STUDY POPULATION MEDICAL RECORDS OFFICE Filed and reviewed medical outpatient charts (n=709) Patients with diagnosis of hypertension (n=227) Patients Excluded (n=88) Missing age 15 • Missing BP recordings 23 • ≤ 1 documented outpatient • clinic visit * 49 Patients included in data entry (n=139) Patients Excluded (n=88) Incorrect data entry 3 • Patients included in data analysis (n=136) OUTCOMES ANALYSIS  Primary Outcome  All statistical analyses were conducted via Microsoft  Optimal blood pressure control as defined by the Joint National Excel software Committee (JNC) 7 hypertension guidelines  For patients >50 years of age, SBP <140 mmHg and DBP  Chi-squared tests and t-tests were performed to <90mmHg assess for bivariate associations between specific  In patient with hypertension and diabetes or renal disease, characteristics of the study population (i.e. BP goal is <130/80 comorbidities and mean age, respectively) and blood pressure control  Secondary Outcome  Correlation between specified variables (i.e. sex, age, number of clinic visits, etc.) and blood pressure control in hypertensive patients OVERALL PREVALENCE OF RESULTS HYPERTENSIVE PATIENTS Pa Patients tients d diagnos agnosed wi d with hypertens ension on Total M tal Medical O dical Outpatient F tpatient Files, N s, N=709 100 Non-hypertensive patients Hypertensive patients 90 80 70 60 32% 50 40 30 20 68% 10 0 2010 2011 2012 2013 2014

Table 1 . General characteristics of study population by gender based on blood pressure control and overall, n=136 Hypertensive Patients with Well ‐ Hypertensive Patients with OVERALL PREVALENCE OF HYPERTENSIVE PATIENTS controlled BP RESULTS Uncontrolled BP Overall Characteristics Men Women p ‐ value Men Women p ‐ value Men Women p ‐ value WITH ADEQUATELY CONTROLLED BLOOD PRESSURE* Total, n (%) 13 (31) 29 (69) 29 (31) 65 (69) 42 (31) 94 (69) Mean age, years (SD) 66 (8) 57 (11) 0.01 t 63 (14) 62 (13) 0.59 64 (12) 60 (12) 0.10 Age in years, n (%) 0.22 0.34 0.16 <50 0 (0) 7 (24) 5 (17) 13 (20) 5 (12) 20 (21) 50 ‐ 59 5 (38) 9 (31) 4 (14) 13 (20) 9 (21) 22 (23) Study P Stu Population, N=13 N=136 60 ‐ 69 3 (23) 7 (24) 9 (31) 21 (32) 12 (29) 28 (30) 70 ‐ 79 5 (38) 6 (21) 10 (34) 11 (17) 15 (36) 17 (18) ≥ 80 0 (0) 0 (0) 1 (3) 7 (11) 1 (2) 7 (7) Comorbidity, n (%) 0.003 0.30 0.39 none 3 (23) 22 (76) 19 (66) 31 (48) 22 (52) 53 (56) diabetes 3 (23) 5 (17) 8 (28) 22 (34) 11 (26) 27 (29) heart disease* 2 (15) 2 (7) 0 (0) 4 (6) 2 (5) 6 (6) stroke 2 (15) 0 (0) 1 (3) 1 (2) 3 (7) 1 (1) 31% other** 3 (23) 0 (0) 1 (3) 7 (11) 4 (10) 7 (7) # of BP medications 0.33 0.53 0.51 Controlled, N=42 prescribed, n (%) 0 1 (8) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) Uncontrolled, N=94 1 2 (15) 9 (30) 5 (17) 6 (9) 7 (17) 15 (16) 2 9 (69) 19 (63) 15 (52) 38 (58) 24 (57) 57 (61) ≥ 3 1 (8) 1 (3) 9 (31) 21 (32) 10 (24) 22 (23) Mean # of clinic visits 69% (SD) 9 (11) 8 (8) 0.87 t 7 (7) 8 (7) 0.63 t 8 (8) 8 (7) 0.79 Mean systolic BP, mm Hg (SD) 128 (8) 124 (11) 0.25 t 171 (23) 164 (22) 0.11 158 (28) 151 (27) 0.18 Mean diastolic BP, mm Hg (SD) 75 (7) 74 (7) 0.76 t 86 (14) 89 (13) 0.32 83 (13) 84 (13) 0.47 Status of follow ‐ up care, n (%) 0.55 0.38 0.25 current 9 (69) 17 (57) 13 (45) 32 (49) 22 (52) 49 (52) past due 2 (15) 9 (30) 6 (21) 19 (29) 8 (19) 28 (30) lost to follow ‐ up 2 (15) 3 (10) 10 (34) 14 (22) 12 (29) 17 (18) RESULTS DISCUSSION/RECOMMENDATIONS  Evaluating patients with documented hypertension:  Mean age of hypertensive patients (p-value t = 0.40) 1. Assess lifestyle and identify other cardiovascular  Adequately controlled= 60  Poorly controlled= 62 risk factors or concomitant disorders that may  Majority of both adequately controlled and poorly controlled affect prognosis and guide treatment hypertensive patients, 60% and 53% respectively, have no 2. Search for identifiable causes of high BP comorbidities (p-value=0.40)* 3. Assess for the presence or absence of target organ  19% of hypertensive patients with adequately controlled BP also had diabetes vs. 31% of hypertensive patients with poorly damage and CVD controlled BP (p-value=0.19)  Majority of hypertensive patients were on 2 or more antihypertensive medications  62% of well-controlled hypertensive patients vs. 48% of poorly controlled hypertensive patients (p-value=0.16)

DISCUSSION/RECOMMENDATIONS  New hypertension guidelines released by JNC 8 in December 2013  BP <150/90 mm Hg for patients 60 years or older without diabetes or chronic kidney disease (CKD)  BP <140/90 mm Hg for patients 18-59 years of age without major comorbidities, 60 years or older with diabetes and/or CKD LIMITATIONS TAKE HOME POINTS  Small sample size  Hypertension remains one of the most important preventable contributors to disease and death.  Recall bias secondary to relying on accuracy of written record of individuals  At Yala Sub-County Hospital, almost 1/3 of all patients in the medical outpatient clinic have documented hypertension  Limited capability of statistical analyses  Out of those with hypertension, only about 1/3 are adequately  Cannot determine directionality of associations (i.e. cause controlled and effect)  There are hypertension guidelines to help physicians manage  Difficult to control bias and confounders hypertensive patients  No randomization, no blinding ACKNOWLEDGEMENTS THANK YOU  Dr. Oginga – site mentor  Members of the Yala Sub-County Hospital workforce  Dr. Owiti – academic mentor  GE/NMF