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 priv ate group general clinic (PRMC) (n=137), for more than one year were review ed 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 5 3 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% i n the PRMC (p<0.001). Over 92% of parients had blood pressure (BP) recorded at least once in the 12-month review period Hypertension was defined as be ing prescribed antihypertensive medication in clinic records. By this defin ition 98% SPMC patients were hypertensive compared to 87% PUBMC and 80% PRM C. Using BP<160/95mmHg, the PRMC control rate, 63%, was significantly bette r 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 0.5 7 (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 c ovariate with older patients at greater risk of poor control. Only 18% of h ypertensives were controlled to BP<140/90 mmHg with no difference among cli nics. Diuretics were the commonest agent used at the PUBMC (76%) and SPMC ( 86%) followed by <alpha>-methyldopa, 41% and 27%, respectively. These agent s 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 ot her clinics). PRMC wed more angiotensin converting enzyme inhibitors 38%, c ompared 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 compa red to 82% at PRMC and 33% at PUBMC (p<0.001). Surveillance for complicatio ns differ ed for proteinuria (PRMC 33%, PUBMC 15%. SPMC 15%) and fundoscopy (PUBMC 0%, PRMC 3%, SPMC 43%). These results show very limited adherence t o recommended hypertension treatment guidelines in all three settings.