Post Intervention data Phase III

Im p ro vin g B lo o d P re ss u re C o n tro ls i n P rim ar y C ar e S et tin g s Table 5. Results of blood pressure, sex and age in the intervention group during pre and post intervention periods INTERVENTION n=1500 Baseline Dec 2006 n=300 Post Intervention 1 May 2007 n=300 p-value p1 Post Intervention 2 June 2007 n=300 p-value p1p2 Post Intervention 3 July 2007 n=300 P value p1p3 Post Intervention 4 Aug 2007 n=300 p-value p1 p4 Gender • Male 117 39 88 29.3 0.01 112 37.3 0.73 97 32.3 0.10 99 33 0.15 • Female 183 61 212 70.7 0.01 188 62.7 0.73 203 67.7 0.23 201 67 0.15 Mean in age in years 57.95 SD 11.7 60.61 SD 11.6 0.98 57.87 SD 12.2 1.0 56.53 SD 11.8 0.91 62.72 SD 11.7 0.76 Mean SBP 139.87 SD 17.3 135.61 SD 15.7 – 133.45 SD 16.2 – 131.03 SD 15.2 – 134.34 SD 17.5 – Mean DBP 84.56 SD 8.8 82.21 SD 8.1 – 81.90 SD 7.5 – 82.09 SD 7.8 – 81.19 SD 8.1 – Percentage of controlled SBP 199 66.3 229 76.3 0.009 242 80.7 0.0001 253 84.3 0.0001 236 78.7 0.001 Percentage of controlled DBP 148 49.3 199 66.3 0.0001 208 69.3 0.0001 200 66.7 0.0001 224 74.7 0.0001 Percentage of controlled BP 132 44.0 179 59.7 0.0002 186 62.0 0.0001 0.6 182 60.7 0.0001 0.8 198 66.0 0.0001 0.27 p1 = p value baseline versus post intervention of the month p2 = p value Post 1 versus Post 2 p3 = p value Post 2 versus Post 3 p4 = p value Post 3 versus Post 4 2 67 p ro vin g B lo o d P re ss u re C o n tro ls i n P rim ar y C ar e S et tin g s Table 6. Results of blood pressure, sex and age in the control group during pre and post intervention periods CONTROL n=1500 Baseline Dec 2006 n=300 Post Intervention 1 May 2007 n=300 p-value p1 Post Intervention 2 June 2007 n=300 p-value p1p2 Post Intervention 3 July 2007 n=300 p-value p1p3 Post Intervention 4 Aug 2007 n=300 p-value p1p4 GENDER • Male 111 37 108 36 0.86 97 32.3 0.26 118 39.3 0.61 112 37.3 1.0 • Female 189 63 192 64 0.86 203 67.4 0.23 182 60.7 0.61 188 62.7 1.0 Mean in age in years 59.1 SD 12.0 58.5 SD 12.7 1.0 57.9 SD 11.5 1.0 57.5 SD 12.1 0.91 59.2 SD 11.3 1.0 Mean SBP 136.6 SD 16.4 133.8 SD 18.0 – 133.60 SD 17.5 – 137.01 SD 20.5 – 138.8 SD 17.8 – Mean DBP 82.4 SD 7.6 81.19 SD 8.6 – 81.42 SD 9.7 – 82.41 SD 9.6 – 82.38 SD 8.9 – Percentage of controlled SBP 224 74.7 230 76.7 0.63 240 80.0 0.14 218 72.7 0.64 203 67.7 0.07 Percentage of controlled DBP 203 67.7 207 69.0 0.79 216 72.0 0.29 190 63.3 0.30 199 66.3 0.79 Percentage of controlled BP 182 60.7 185 61.7 0.9 194 64.7 0.35 0.5 160 53.3 0.08 0.006 153 51.0 0.02 0.32 p1= p value baseline versus post intervention of the month p2= p value Post 1 versus Post 2 p3= p value Post 2 versus Post 3 p4= p value Post 3 versus Post 4 268 Improving Blood Pressure Controls in Primary Care Settings who had their blood pressure treated to target but the drop was not significant which again showed that the improvement made in the first intervention was sustained. In the post intervention 4, there was increased percentage of patients treated to target compare with the following month but it was not significant. Again it clearly showed that the improvement was sustained over four consecutive months after the Post intervention 1 in the clinics where interventional package has been implemented. As far as the age and sex are concerned in the intervention group, the samples between pre and post intervention were comparable as the different is not statistically significant. Looking at Table 6, it can be seen that the improvement of percentage of patient treated to target in post intervention 1 and pre intervention in control group was not significant. This trend continues till post intervention 3 when there was significant drop in percentage of patients in control group treated to target. This continues to drop in post intervention 4 but it was not significant. Figure 3. Percentage of patients whom blood pressure treated to target between male and female in both intervention and control groups 269 Improving Blood Pressure Controls in Primary Care Settings As far as the age and sex are concerned in the control group, the samples between pre and post intervention are comparable as the different was not statistically significant. Looking at Figure 3, we can see that percentage of blood pressure treated to target significantly improved among female in intervention group as opposed to male. In control group, the changes in percentage of patients treated to target between female and male are not significant. In this Figure 4, we can see that the age group less than 40 in intervention group made a significant improvement in percentage of blood pressure treated to target. Other age groups however do not show any significant changes. In control group , there is no significant changes among age groups with respect to blood pressure treated to target over four months periods. Figure 4. Percentage of patients treated to target according to age group between intervention and control groups 270 Improving Blood Pressure Controls in Primary Care Settings In this Figure 5, we can see that all districts in intervention group make steady improvement in the percentage of patients treated to target with time after intervention except for Manjung and Kerian. In Manjung, there was a drop in post 2 and post 3 then remain the same in post 4. In Kerian the drop is noticed in post 3 and remains the same in post 4. However, there was significant improvement in Perak Tengah intervention group from post 3 to Post 4. In control group, the changes in percentage of patients treated to target across district are significant.

5.0 DISCUSSION

There were several limitations in the study. 1. Our interventions and control were in the same districts. The doctors and medical assistants are at times needed to cover other clinics. Even though the intervention only being done in the intervention clinic the doctors and medical assistant from the other clinic also get to know about it. 2. Duration of the illness were not taken into consideration in this study that may also affect the controlled of blood pressure. Figure 5. Percentage of patients whom blood pressure treated to target according to district both intervention and control groups 271 Improving Blood Pressure Controls in Primary Care Settings 3. There was also movement of staff during the study period, this also affect our study. One of the doctors had move from intervention clinic to control clinic, the other doctor transferred to the hospital and one resign from governments. One of the medical assistant from the intervention clinic were promoted and transferred. 4. The trained staffed in the intervention are not always available during clinic days. These maybe due to their taking leave or going for courses and being relieved by untrained staff. 5. We are not doing card auditing so we cannot assess weather staffs involved actually practiced all the interventions. Same also to the patients. As far as we know, this is the first study that attempt to look into the effectiveness of intervention in the management of patients with essential hypertension involving three districts in Perak, namely Perak Tengah, Manjung and Kerian. Knowledge of patients regarding hypertension was good. Majority of them knew why they should take medication, the need for lifelong treatment and their complication. Only 50 of the patients know what are normal blood pressure and their current status. So, at majority of our patients knows about hypertension but did not aware of their target blood pressure. From focus group discussion we found that Clinical Practice Guidelines and protocols are available but their usages are limited hence the knowledge. Paramedic had limited knowledge regarding the range of anti hypertensive that is available whereas the medical officers having problem with List A drugs. Majority of the staff also said that they are over worked. In phase 3, there were significant differences between the percentages of pre interventions blood pressure control as compare to post interventions in the intervention group. When compared between the post interventions the percentage of controlled blood pressure, it did not show significant difference. There were improvements initially but not sustained over the time. These might be due to relocation of staff causing loss of trained staff. By minimized the movements of staff and reinforced on the used of interventional package. In the control group, we found that there were significant improvement in controlled blood pressure in May and Jun but there were dropped in July and dropped further in August. Perak Tengah had shown a continuous good improvement in controlled blood pressure in the intervention clinic. In districts of Manjung, the percentage of controlled blood pressure had increased for the first month but deteriorate after that. The change of doctors and medical assistant in Klinik Kesihatan Pulau Pangkor might had contributed to this deterioration. In Klinik Kesihatan Pantai Remis, the medical officer went for maternity leave for two month. Relocation of staff had a great impact on the management of patient as the officer that replaces might not familiar with the intervention that had been implemented and there were also no proper handlings over of task before leaving the