The aim of this study was to examine the degree of control of blood pressure with respect to individuals on anti-hypertensive drug therapy attending a Health Centre for repeat prescription. Despite their being on anti-hypertensive drug therapy, only 35% of the individuals were found to be normotensive, 27% were in the borderline range whereas 38% were found to be hypertensive. The relatively high prevalence of poorly controlled patients suffering from high blood pressure is partly a reflection of the degree of non-compliance by patients to prescribed drug regimens although this is difficult to either qualify or quantify. Education of the patient vis-à-vis his medical condition and its treatment is of great importance as is regular monitoring and effective control of raised blood pressure by the family physician.peer-reviewe

Cacciottolo, Joseph M.

Galea, Wilfred

English

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'l Maltese Medic al Journal 48 Volume 1 Issue II 1989 ,. ~:" , ..!! . J ' , .~ f! t<~ f Effectiveness of Blood Pressure ~-. Control in a Small Community Wilfred Galea and Joseph M. Cacciottolo ABSTRACT The aim of this study was to examine the degree of control of blood pressure with respect to individuals on anti-hypertensive drug therapy attending a Health Centre for repeat prescription. Despite their being on anti·hypertensive drug therapy, only 35% of the individuals were found to be normotensive, 27%were in the borderline range whereas 38% were found to be hypertensive. The relatively high prevalence of poorly controlled patients suffering from high blood pressure is partly a reflection of the degree of non-compliance by patients to prescribed drug regimens although this is difficult to either qualify or quantify. Education of the patient vis·a-vis his medical condition and its treatment is of great importance as is regular monitoring and effective control of raised blood pressure by the family physician. INTRODUCTION The prevalence of hypertension among the Maltese population is high I. In comparison with other Mediterranean European count­ries the mean levels of both the systolic and diastolic blood pressures for the adult Maltese population are among the highest2. Although the awareness of high blood pressure is rather low (50% of all Maltese hypertensives) the use of drugs in the treatment of raised blood pressure is very widespread. Availability of treatment with all classes of hypotensive agents is facil­itated by the Department of Health in that such medications are available free-of· charge irrespective of the recipient's finan­cial means. In 1988 hypertension was by far the commonest condition for which applic­ation for supply of free-of-charge drugs was made:l . Blood pressure control by drug therapy depends on several factors, among them the appropriate medication at the right dosage and the patient's behavior in terms of compliance with prescribed medication. The magnitude of non-compliance with anti· hypertensive medication is often great4 and consequently itis a barrier for obtaining full benefit of therapy. This paper seeks to address the degree of blood pressure control in a small mixed urban/ rural community and suggests non­compliance to prescribed treatment as a major reason for inadequate control. METHOD The study was designed to investigate the degree of control of blood pressure in a defined group of persons known to suffer from hypertension. The prescribing habits with respect to individuals attending a particular Health Centre for repeat prescrip­tion of anti-hypertensive medication were studied while possible existing relationships between blood pressure levels and modalities of treatment at a community, rather than at an individual level were analysed. A period of four weeks was chosen at random on the assumption that persons who are entitled to free medication for high blood pressure, have of necessity to attend the Health Centre every four weeks for repeat prescriptions. The period chosen was from the 12 September to the 8 October 1988 and the subsequent week was utilised in order to follow up defaulters. The field work was carried out at the Health Centre in Rabat, Malta. All patients from the Rabat area making us of the facility offered by the Department of Health to obtain free medication aimed at lowering blood pressure, directly from the Health Centre, were enrolled into the study. This involved a total of 183 individuals; 81 males and 102 females. The overall response rate following the second recall was 89%. pressure was being monitored. The individ­uals were also asked about any other chronic intercurrent disorders. A casual blood pressure measurement was taken with the individual in the sitting position after a minimum period of five minutes rest5 . The individuals' right arm was used for blood pressure recording. The average ambient temperature during the field work was 23°C. RESULTS The individuals responding to the invitation to take part in the study were 73 males (45%) and 90 females (55%).Their age ranged from 19 to 82 years with a mean age of 60 years (fig. 1).42%of the individuals were in the age group 50-69 years. The mean systolic blood pressure (SBP) of the group was 149.5 mmHg (S.D. 22.9) and the mean diastolic blood pressure (DBP) was 89.2 mmHg (S.D. 9.4) . No significant differences were found between the blood presure levels of males and females. The mean blood pressures at different age groups are presented in Table 1. t, Age DiltrlbutlOD ol Simple , )j 19 - 82 yl.';.>t's f 30 60 41yrs u P 2~ m' b t 20 , 1 " , ", <" 19 20·29 30·39 40-49 SO -59 60·69 >,, 80 Age group. I- M"" [J reml" 1 f ig.1 Table 1. MEAN BLOOD PRESSURES AT DIFFERENT AGE GROUPS Age Group Under 39 40-44 45-49 50-54 Mean SBP 130.0 142.6 138.6 141.5 MeanDBP 86.5 83.7 95.7 89.5 A simple questionnaire was administered by one of us (W.G.) and information was sought about any regular medication taken and the time-period that the individual had been taking such medication. Information was also sought about the original prescriber and the method whereby their blood 55-59 60-64 65-69 70-74 Over 75 141.7 150.5 154.3 161.9 168.6 89.4 88.5 853.1 89.2 87.0 Wilrred Galea M.D. Family Physician, Rabat Health Centre, Malta. Joseph M. Cacciottolo M.D., M.R.C.P.(U.K.), M.R.C.S., Consultant Physician, St. Luke's Hospital, Malta. Maltese l\lcdic,ll Jourllal 49 Volullle I Issue 11 19H9 Blood pressure was classified as follows: for monitoring of risk factors for cardio­normotensive (under 140/ 90 mmHg), border­ vascular diseases in Malta (MONICA) mayCCNTRCt.- CFH'YPEfll"ENSlCN line hypertensive (SBP 140 to 160 and/ or % only be made with caution because our DBP of 90 mmHg to 95 mmHg) and study population was composed solely of hypertensive (160/ 95 mmHg and over). individuals on anti-hypertensive drug Overall, 35% were found to be normotensive, therapy. Whereas in the MONICA popul­27'K, were in the borderline range while 38% ation the rise of both the systolic and the were found to be hypertensive despite their diastolic blood pressure over the years was being on therapy specifically designed to generally steady, in our study there was noCui -off 140/90 C ui -oil 160/95 Cui -oft 140/90 Cui·off 160/95 lower their blood pressure. Again there were . 	 ·FE MAlE S· significant rise in the blood pressures overMAL E S ·· ······ no significant differences in this respect bet­	 the years (figures 4 and 5). Despite the manyI0 	 fig. 2Uncontrolled • w ell .COn1rOlled J ween males and females (fig. 2). differences between our study population and the MONICA population (amongst All individuals studied were on anti­ them the design and age-structure but not ~ hypertensive drug therapy: 26'Po of individ­ the method of taking blood pressure) the uals were on one anti-hypertensive agent, prevalence rates of blood pressures underT.,., n='" .f ,.":,, " mri." '" '" ]51% were on two different agents, 20% were ~ adequate control are practically identical on three different agents whilst 3% were on M ~an number of tab lets (around 35%) (fig. 2).per p ~rson pcr cl ay four agents (figure 3). The mean blood pressure levels were also classified by the . u , P " III • ~ o ' number of agents used (Tables 2 and 3). ., 30 it] Systollc Blood Pr"9sure Variation with Ag,, : ~ Comparison with Data from MONICA Projec t (Malta) t 20 Figure 2. Control of blood pressure consid­Tering different cut-off points as criteria for ::: t'6'::: >" • - • / ./ 0control. >', Number of Uoble t s pe. day fig.3 , ". fTable 2. Mea n SBP and mean DBP by 	 u "" - //.~/ Q-""'--./" to' ~ !=~-"'--._/different drugs prescribed. '" '" L.Table 3. Mean SBP and mean DBP by 120 ­number of different anti-hypertensive DISCUSSION  Age Ran&"s [ •. M"aJI Sy.l. BP . - MONICA F EMALE:Sagents prescribed. It is a general trend that a large variety of fig.4Cognizance was also taken ofthe medication chronic disorders are being managed by prescribed for reasons other than hyper­ family physicians. Indeed, hypertension is tension (figure 3). The mean number of probably one of the commonest chronic tablets prescribed per person per day was disorders managed in family medical tv ~~:~O!~s:~o=:t=r~:~:~::~~~~c~~r~:~ (Malta) 5.25. No attempt was made to compare the practice6• In this respect the Maltese family treatment prescribed to the treatment physician is aided by the health service toO I actually taken (i.e. compliance) as this facility whereby most generic anti-hyper­would have been beyond our means to tensive drugs are available to the patient "· ·~·~~~:----.--.-_____.t----investigate and validate. free-of charge. 	 P m H. :·t~·=· Fig. 3 Number of different drugs prescribed Comparisons between our study population 8. to patients in the study population. and the randomly selected population used " Ai" R .. ng,,~ I .- M" aJI DJ..,.!. BP 0 - MONICA MALES . ' MONlCA FEMAL£S ] Table 2: ANY DRUG TYPE fig.S No. of n 	 means STANDARD DEVIATION As an outcome of our study, a major cause Drugs Systolic Diastolic Systolic Diastolic for concern must be the relatively high proportion of persons with high blood 1 18.00 144.83 87.27 18.9:i 9.45 	 pressure who are inadequately controlled 2 	 50.00 149.18 88.50 22.55 9.45 despite their ostensibly being on anti­hypertensive drug therapy. Only 35'71, could:3 45.00 145.49 89.02 25.20 9.97 be considered as having their blood pressure 4 :iO.OO 154.67 91.80 21.02 9.01 under adequate control. One ofthe principal 5 14.00 157.57 88.07 23.18 8.67 	 reasons for this lack of control is poor 6 	 6.00 151.67 90.83 24.83 8.59 compliance to treatment on the part of the patient. The magnitude of non-compliance with Table 3: ANTIHYPERTENSIVE DRUGS ONLY 	 anti-hypertensive therapy is often large and 30 to 80% of patients on anti-hyertensive agents fail to take their medication asNo. of n 	 means STANDARD DEVIATION prescribed'. Compliance is also such aDrugs 	 Systolic Diastolic Systolic Diastolic complex phenomenon, that it cannot be expressed unambiguously by simple rates or1 43.00 26'!l, 152.14 88.74 21.21 9.59 percentages. 2 83.00 51% 146.75 89.34 21.09 9.35 3 	 33.00 20% 150.67 88.52 27.42 8.96 Non-compliance is notoriously difficult to measure and interviews are considered4 4.00 2% 168.75 95.50 30.65 13.20 unreliable because people tend to over­-Maltese Medical.lourllal 52 volulllc I IsslIC II Imm estimate their compliance8 In addition, pill counting and urine analysis may not be reliable and practical methods for detection. However the reasons for non-compliance are well known. Often there are no subjective symptoms of hypertension, the presence of which would remind the individual of the need to take the medication as prescribed. Indeed, several anti­hypertensive agents may actually com­plicate the life-style of the individual through their side-effects. It is possible that fear of hypotension may also be a cause for non-compliance. Such fear may also be a reason for inadequate medication on the part of the prescriber as at times treatment is scaled down when normotension is achieved. The fact that low blood pressure has been positively correl­ated with prolonged life-expectancy should be acted upon effectivelyH 11) The more complicated the treatment regimen the greater is the risk of poor compliance to it. Factors which have been negatively correlated with compliance are the number of different drugs prescribed ", the actual number of tablets to be taken per day and the number of times that the individual needs to remember to take the medication '2. A further complication is that at times the individual has to take medications for other disorders other than raised blood pressure. One of the factors which also affects compliance to treatment is patient education regarding the disease itself and its treat­ment. This is especially so when the disease is chronic and req uires long term monitoring and treatment. Here the relationship between the individual and his doctor is of great importance. Education of the patient is important both with regard to the nature of the disorder as well as the possible complications of the disorder should this be inadequately treated. However knowledge of one's own treatment regimen seems to be more important than general knowledge about hypertension. Education of the individual is much more effective the better the doctor-patient relationship is in terms of continuity-of-care and trust between doctor and patient. Care of blood pressure not only includes the judicious prescription of medicaments but also the prescription of certain life-style changes such as the maintenance of ideal body-weight, salt-intake reduction and adequate physical exercise ''' . As with other chronic conditions, drug therapy must be as simple as possible without compromising effectiveness while the possibility of deleterious side effects should always be kept in mind. The treatment regimen must be as uncom· plicated as possible and ideally the less the number of tablets prescribed the better l4. This could be achieved by using long-acting or sustained-release preparations in adeq­uate dosages. The use ofcombined agents in one tablet may also be a useful step in this direction (e.g. a beta-blocking drug together with a diuretic or a calcium channel blocking agent). An aim of this study has been to evaluate the need for more effective control of blood pressure at the community level; clearly such a need exists. In order that treatment for high blood pressure be more effective, certain measures have to be taken, irrespec­tive of whether health care is delivered through a Health Centre or through the patient's chosen physician. Monitoring and control of blood pressure must be both effective and efficient without inducing excessive anxiety. No hard and fast rules can be set with regard to the frequency of monitoring as this is often dictated by the degree ofcontrol itself. What is certain is that the incidence of all cardiovascular events is reduced even if mildly raised blood pressure is actively treated and controlled'5. ACKNOWLEDGEMENTS While the Department of Health, Malta, kindly allowed us to use the facilites at the Rabat Health Centre for field work, views expressed in this paper are those of the authors alone. We thank Mr. Paul Galea BA, for his help with computer handling of the data and we are also grateful to the staff of the Rabat Health Centre for their valuable cooperation. REFERENCES 1. 	Cacciottolo, JM. Epidemiology of blood pressure and hypertension in the adult Maltese community. Maltese. Med. J. 1988, 1.1.12. 2. 	WHO MONICA Project. Geographical variation in major risk-factors of coron­ary heart disease in men and women aged 35-64 years. Wld. hIt. statist. Quart. 1988, 41, 115. 3. 	Office of the Administrator, St. Luke's Hospital. Malta, unpublished data. 4. 	 Polk, BF, Compliance with treatment of high blood pressure. Silverberg DS, Viskoper R (eds.) Hypertension Control in the community. John Libbey Co. Ltd. London 1985 p244. 5. 	 Rose G., Blackburn, H, Gillum, RF. Prineas RJ. Cardiovascular Survey Methods. WHO, Geneva 1982. p82. 6. 	 McWhinney J, An Introduction to Family Medicine, Oxf. University Press 1981, p51. 7. 	 Hypertension, Coronary Heart Disease and Aterioscerosis:- Therapy and pre­vention with Calcium antagonists. Exerpta Medica. Elsevier Science Publishers, 1987, p17. 8. 	 Enlund, H. Drug use and patient compliance in hypertension care in Eastern Finland. PhD. dissertation. University of Kuopio, Kuopio, Finland 1982, p68. 9. 	Kannel WB, Wolf PA, Verter J, Mc Namara -PM. Epidemiologic assess­ment of the role of blood pressure in stroke. The Framingham Study. JAMA 1970,214,301-310. 10. Shapiro MF, Korda H, Robins J. Diagnosis and treatment of low blood pressure in a Canadian Community. Can. Med. Assoc. 1982, 126:918-920. 11. 	Hamblin D, Wells FO, EllisS. A study of the compliance to prescribed treatment on anti-hypertensive therapy. J . Clin. Pharm. 1979,4: 41-49. 12. 	Gatley, MS. To be taken as directed . J. Roy.Coll.Gen.Pract. 1968,16:39-44. 13. 	Prevention of Coronary Heart Disease. Report of a WHO expert committee. Technical report series 678. WHO Geneva 1982, p25. 14. 	Gross F, Pisa Z, StrasserT, Zanchetti A. Management of Arterial Hypertension. WHO Geneva 1984, pp 40-53. 15. 	MRC Working Party. Med.Res.Comm. trial of treatment of mild hypertension: Principal Results 1985, BMJ 291. 97. Correction Please note MMJ Winter issue 1988/ 89 page 17. Distribution Categories should read 2a MALES, 2b FEMALES. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

A study of the compliance to prescribed treatment on anti-hypertensive therapy.

An Introduction to Family Medicine,

Cardiovascular Survey Methods.

Compliance with treatment of high blood pressure.

Diagnosis and treatment of low blood pressure in a Canadian Community.

Drug use and patient compliance in hypertension care in Eastern Finland.

Epidemiologic assess ment of the role of blood pressure in stroke. The Framingham Study.

Epidemiology of blood pressure and hypertension in the adult Maltese community.

Geographical variation in major risk-factors of coron ary heart disease in men and women aged 35-64 years.

Heart Disease and Aterioscerosis:- Therapy and pre vention with Calcium antagonists. Exerpta Medica.

Management of Arterial Hypertension.

Prevention of Coronary Heart Disease. Report of a WHO expert committee. Technical report series 678. WHO Geneva

To be taken as directed .

trial of treatment of mild hypertension: Principal Results

Effectiveness of blood pressure control in a small community

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Effectiveness of blood pressure control in a small community

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