Yan Lily D, Chirwa Cindy, Chi Benjamin H, Bosomprah Samuel, Sindano Ntazana, Mwanza Moses, Musatwe Dennis, Mulenga Mary, Chilengi Roma
Primary Care and Health Systems Department, Center for Infectious Disease Research Zambia, Lusaka, Zambia.
Stanford University School of Medicine, Stanford, CA, USA.
BMC Health Serv Res. 2017 Feb 3;17(1):111. doi: 10.1186/s12913-017-2063-0.
Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure.
Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content.
From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1-100%), but decreased to 62.1% (range: 0-100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance.
Our findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes.
ClinicalTrials.gov, Identifier NCT01942278 . Date of Registration: September 2013.
发展中国家需要改善初级卫生保健，以有效应对不断增加的高血压负担。我们的目标是使用过程和结果指标评估赞比亚农村初级保健诊所的高血压管理情况，以评估高血压的筛查、监测、治疗和控制。
通过指导和评估实现更好的健康结果（BHOMA）是一项在赞比亚46家农村诊所进行的为期5年的改善临床服务提供的随机阶梯楔形试验。临床数据作为常规患者护理的一部分，从电子病历系统中收集，并根据高血压相关指标（筛查（血压测量）、管理（记录诊断、体格检查或尿液分析）、治疗（正在用药）和控制）随时间审查各诊所的表现。定量数据用于制定定性深入访谈指南，对一半（20家）诊所的医疗服务提供者进行比例抽样访谈。对定性数据进行迭代分析以获取主题内容。
2011年1月至2014年12月，纳入了年龄≥25岁、进行过血压测量的成年人到46家初级保健诊所的318380次就诊。生命体征筛查时的血压测量最初总体较高，为89.1%（范围：70.1 - 100%），但在干预开始后48个月降至62.1%（范围：0 - 100%）。大多数高血压患者仅到诊所就诊一次（57.8%）。在9022名至少两次就诊且血压升高的患者中，只有49.3%的病历记录了高血压诊断。高血压监测的过程指标低于10%，且未随时间改善。在深入访谈中，抗高血压药物短缺很常见，20家诊所中有15家报告氢氯噻嗪 - 阿米洛利缺货。高血压管理的主要挑战包括：1）设备和人员短缺；2）医疗服务提供者认为在正式管理前需要多次就诊；3）药物缺货，导致处方不当；4）患者就诊出勤率低。
我们的研究结果表明，赞比亚初级卫生设施在高血压诊断和管理方面存在众多障碍。未来的工作应侧重于在资源匮乏的环境中制定和验证绩效指标，以便定期和系统地审查数据，改善患者治疗效果。
ClinicalTrials.gov，标识符NCT01942278。注册日期：2013年9月。
