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 special hypertension clinic (SPMC) (n=119) and a private group general clinic (PRMC) (n=137), for more than one year, were reviewed. Duration of follow-up varied among clinics with the longest mean follow-up at PRMC (10.8 years) 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 53 years in the SPMC and 50 years in the PRMC (p < 0.001). Sex distribution differed among clinics with 15 percent men in the PUBMC, 34 percent in the SPMC and 54 percent in the PRMC (p < 0.001). Over 92 percent of patients had blood pressure (BP) recorded at least once in the 12-month review period. Hypertension was defined as being prescribed antihypertensive medication in clinic records. By this definition 98 percent SPMC patients were hypertensive, compared to 87 percent PUBMC and 80 percent PRMC. Using BP < 160 / 95mmHg, the PRMC was 0.57 (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 covariate with older patients at greater risk of poor control. Only 18 percent of hypertensives were controlled to BP < 140 / 90mmHg with no difference among clinics. Diuretics were the commonest agent used at the PUBMC (76 percent) and SPMC (86 percent) followed by a-methyldopa, 41 percent and 27 percent, respectively. These agents were less commonly prescribed at the PRMC than at the other clinics (45 percent diuretics and 8 percent a-methyldopa, p < 0.001 for both agents compared to other clinics). PRMC used more angiotensin converting enzyme inhibitors 38 percent, compared to SPMC 23 percent and PUBMC 1 percent (p < 0.001). Between 9 percent and 15 percent of patients at the PUBMC and PRMC had recorded data on smoking and alcohol use compared to 69 percent at the SPMC. A record of body weight was found in 99 percent at SPMC compared to 82 percent at PRMC and 33 percent at PUBMC (p < 0.001). Surveillance for complications differed for proteinuria (PRMC 33 percent, PUBMC 15 percent, SPMC 15 percent) and fundoscopy (PUBMC 0 percent, PRMC 3 percent, SPMC 43 percent). These results show very limited adherence to recommended hypertension treatment guidelines in all three settings.

Stroke in Trinidad and Tobago: burden of illness and risk factors / Los accidentes cerebrovasculares en Trinidad y Tabago: carga de la enfermedad y factores de riesgo

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12 month period. All subjects were admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1.105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9.478 bed days per annum. The hospital admission fatality rate was 29 por cien. Among surviving patients, 437 (56 percentage) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95 percentage CI: 83 to 145) per 100.000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 to 186). Among patients with first strokes, 348/531 (66 percentage) reported physician-diagnosed hypertension, but only 226 (65 percentage) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifiable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies

En este estudio se describe la carga que imponen los accidentes cerebrovasculares sobre los servicios hospitalarios de una comunidad caribeña. Las instituciones examinadas fueron los dos hospitales generales de mayor importancia en Trinidad y el período de observación fue de 12 meses. Todos los sujetos fueron ingresados al hospital con un diagnóstico clínico de accidente cerebrovascular agudo. Las variables medidas fueron las tasas de ingreso al hospital, estancia hospitalaria, tasas de letalidad, discapacidad al egreso y los factores de riesgo de accidente cerebrovascular. Se ingresó a 1 105 casos con diagnóstico de accidente cerebrovascular. La estancia mediana fue de 4 días, con un recorrido intercuartílico de 2 a 9, y los accidentes cerebrovasculares ocuparon alrededor de 9 478 días-cama al año. La tasa de letalidad para los casos ingresados fue de 29%. De los pacientes que sobrevivieron, 437 (56%) sufrieron de alguna discapacidad grave al egreso. Las tasas de ingreso estandarizadas por edad en pacientes de 35 a 64 años con un primer accidente cerebrovascular fueron de 114 (IC95%: 83 a 145) por 100 000 habitantes en hombres trinitarios de ascendencia africana y de 144 (109 a 179) en hombres trinitarios de ascendencia india oriental. Las tasas correspondientes en mujeres fueron de 115 (84 a 146) y 152 (118 a 186). De los pacientes con un primer accidente cerebrovascular, 348/531 (66%) declararon tener hipertensión diagnosticada por un médico, pero solamente 226 (65%) de ellos indicaron estar tomando antihipertensivos cuando ingresaron. En Trinidad y Tabago los accidentes cerebrovasculares se asocian con una tasa elevada de letalidad y con discapacidades graves en los supervivientes. Se notificaron factores de riesgo modificables en la mayoría de los casos de accidente cerebrovascular y es necesario idear buenas intervenciones de tipo preventivo.

Medical practitioners views on the management of hypertension in Trinidad and Tobago

We surveyed 161 medical practitioners in Trinidad and Tobago (124 reporting private sector practice and 37 describing government health centre practice) for their views on blood pressure (BP) management. 96 percent of the respondents agreed that BP should be measured on all adults seen and 90 percent agreed that diastolic pressure should be recorded as the disappearance of sounds. There was disagreement over the level of diastolic BP at which drug treatment should be initiated: 63 percent would treat diastolic BP less than 100 mm Hg, but 35 percent would only treat diastolic BP of 110 mm Hg or higher. In private practice 31 percent preferred angiotensin converting enzyme (ACE) inhibitors as treatment for an African Caribbean man with diastolic BP 110 mm Hg, but in public clinics 41 percent preferred thiazide diuretics. ACE inhibitors wre most often preferred as treatment for an Indo-Caribbean man with diabetes and diastolic BP 110 mm Hg in both public and private practice. Doctors considered that non-compliance (66 percent), lack of education (34 percent) and unhealthy lifestyles (25 percent) were important obstacles to BP control. In private practice doctors considered patients' financial constraint to be an obstacle (58 percent), whereas in the public sector limited availablity of drugs (57 percent) was felt to be more important. Less costly and possibly, more appropriate drugs were used in public clinics.