Implementation of national guidelines, incorporated within structured diabetes and hypertension records at primary level care in Cape Town, South Africa: a randomised controlled trial

Abstract

Background and objectivesMany clinical management guidelines for chronic diseases have been published, but they have not been put into practice by busy clinicians at primary care levels. This study evaluates the implementation of national guidelines incorporated within a structured diabetes and hypertension clinical record (SR) in Cape Town in a randomised controlled trial (RCT).MethodsEighteen public sector community health centres (CHC) were randomly selected and allocated as intervention or control CHC. At each clinic, 25 patients with diabetes and 35 patients with hypertension were enrolled at baseline. Questionnaires were completed, blood samples were collected, blood pressure (BP) and anthropometric measures were taken and patient records were audited. SR with clinical guideline prompts were introduced at the intervention clinics after training doctors in their use and suggestions to incorporate them in regular patient records. Contact was maintained during the year of intervention with the clinic staff. A follow-up survey was conducted 1 year later to assess BP and HbA1c, and the patient records were examined to ascertain the extent of use of the SR in the intervention clinics. In-depth interviews were conducted with doctors and nurses to record their response to the intervention.ResultsThe intervention evaluated in this RCT had no impact on either diabetes or hypertension control. In the intervention clinics, less than 60% of the patient folders contained the SR and when present was seldom used. Although the staff were well disposed to the research team, their workload prohibited them from undertaking a true evaluation of the SR, and overall they did not perceive the SR as supporting their current process of patient care.ConclusionsNo benefit to diabetes of hypertension care by introducing and availability of the staff in the use of the SR was shown in this RCT. The process measures suggest that the SR was not widely used by the healthcare provided in the primary care clinics.

Poor control and management of type 2 diabetes mellitus at an under-resourced South African Hospital: is it a case of clinical inertia?

“…23 In a local study, an intervention using the national guidelines was implemented in 18 public sector community health clinics and the outcome showed no benefit to diabetic care, with poor glycaemia control and 64.1% of the patients having an HbA1c level of ≥ 7%. 24 The results obtained from our present study suggest poor glycaemia control. The entity of clinical inertia can be used to explain this outcome.…”

Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria

“…However, monthly doctor's appointments were considered necessary for patient retention in care and because alternative drug supply systems were not available. Similar barriers have also been reported by other studies from SSA [4,24,26]. We included patients attending a single private primary healthcare clinic in our study.…”

“…Most other prospective studies from SSA describing CVD prevention care programs also report high loss-to-follow-up rates, the majority over 50% at 1 year of follow-up [20][21][22][23][24][25]. Studies reporting higher patient retention provided free care [15,26]. Second, the insurance program provided resources for quality improvement.…”

“…Studies from high-income countries examining blood pressure control in black populations, in whom blood pressure control is more difficult to achieve than in Caucasian populations, reported lower control rates than observed in our study, ranging from 14 to 59% [46][47][48][49] in treated hypertension patients. In addition, several prospective studies from SSA evaluated CVD prevention care [15,16,[20][21][22][23][24][25][26]50]. Most studies focused on treatment outcomes only, without reporting process outcomes or systematically collected data on health system-related barriers to guideline implementation.…”

Evidence-based guideline implementation in low and middle income countries: lessons for mental health care

“…Different professionals, organisations and health workers were involved in this processHealthcare professional prescribing practices for asthma and COPDThe guidelines and accompanying implementation strategies led to a statistically significant reduction in poly-pharmacy (multiple prescriptions) in comparison to the control condition. There were no statistically significant differences in the prescription of generic and essential drugs, average prescription cost and wastage cost, or prescription of antibiotics between the intervention and control groupsSteyn et al [40]South AfricaPhysical health (diabetes mellitus and hypertension)Cluster randomised controlled trialLow -moderate risk of bias CPG A structured record which incorporated the national guidelines for the management of patients with type 2Diabetes mellitus or hypertension or both conditions Setting and participants 18 randomly selected public sector primary healthcare clinics known as Community Health Centres (CHCs) in Cape Town in 1999 and 2000. 9 clinics were randomised to deliver the intervention and 9 to control.…”