Summary

Objective: (1)To carry out an audit on management quality of hypertension in a Hospital Authority general out-patient clinic, (2) To identify areas of inadequacy in hypertension management for improvements in the clinic, (3) To assess improvements after implementation of change.

Design: An audit exercise on hypertension management was done in a Hospital Authority general out-patient clinic by using a modified audit protocol for hypertension management published by the Eli Lilly National Clinical Audit Centre of the Department of General Practice, University of Leicester from January to October 2005. The criteria and standards were based on that of the Eli Lilly protocol with some modifications according to the most updated evidence-based clinical guidelines. Data collection was done by reviewing medical records of the randomly chosen sample of patients. A data collection form modified from that prepared by the Eli Lilly audit protocol was used. Chi-square test was used to see the significance of changes as seen in the second cycle.

Subjects: A randomly selected sample of 360 patients each out of 5590 patients in the first and 5804 patients in the second cycle was included for the audit exercise.

Main outcome measures: The percentage of patients fulfilling the 10 criteria being assessed was calculated. The percentage of patients fulfilling each of the criteria was compared with the standard. The significance of improvement after implementation of changes in each of the criteria was calculated.

Results: 349 of the sample of patients were included for data analysis in the first cycle. In the first cycle, the rate for assessment of symptoms and signs of target organ damage (criterion 3) was far from the target standard. Only 7.4% of patients had been assessed for retinopathy and peripheral vascular disease and only about half of the patients had been assessed for angina, heart failure and renal disease. Another major deficiency was noted for criterion 7 in which just about half of the patients had their blood pressure controlled to target. It was worse in patients with diabetes or renal disease in which only 20% had their target blood pressure achieved. For criterion 8, the result was also far from the target with only 57.1% of patients appropriately referred for specialist assessment. The results for other criteria were quite satisfactory especially for assessment of risk factors in which 6 out of the 7 risk factors had achieved the target.
In the second cycle, 352 of the sample of patients were included for analysis. For most of the criteria, there was improvement in the results in the second cycle. The improvement was statistically significant for the assessment of target organ damage (criterion 3), assessment of physical inactivity (criterion 4), control of blood pressure to target for patients without diabetes mellitus and renal disease and the provision of diet advice (criterion 10). The standard of the criteria in second phase was achieved for criteria 1, 4, 5, 6 and 10. For assessment of symptoms and signs of target organ damage, standards for angina and heart failure were achieved but not for others.

Conclusion: This audit showed that there were deficiencies in the management of hypertension in the concerned clinic. With an audit exercise, significant improvement could be achieved. With the improvement in the care standard, we could expect that the complication rate of hypertensive patients could be reduced. Since the standard of some of the criteria had not yet been reached seen following the second cycle, especially assessment of some of the target organ damage and the control to target blood pressure, to repeat another round of audit with these criteria should be considered.

Keywords: Audit, hypertension management, general out-patient clinics

摘要

目的：(1)審計在醫院管理局轄下一所普通科門診的高血壓治療質素；(2)尋找治療高血壓不足之處，以便作出相應改善。(3)評估在實行改善措施後的情況。

設計：於2005年一月至十月間，在一所醫院管理局轄下普通科門診內進行。審計準則和標準是以李斯特大學全科部門 的Eli Lilly國家臨床審計中心的高血壓治療指引為藍本，再根據最新實証臨床指引作出修訂。以回顧隨機抽樣方式將病人醫療記錄抽查，採用Eli Lilly審計指引中經修訂後的表格收集資料。以Chi-square test來判斷在第二階段中變化的重要性。

對象：分別在第一階段的5590位和在第二階段的5804位病人中，以隨機抽樣方式為360位病人進行審核。

測量內容：計算符合10項準則病人的百分比。以標準來比較符合個別每一項準則病人的百分比。計算經過實行改善措施後，每一項準則的改善程度。

結果：在分析第一階段的349位病人資料，目標器官損害病 徵（第3項準則）的評估比率遠低於標準。視網膜病變和外周血管疾病方面，只有7.4%的病人得到評估；心絞痛，心臟衰竭和腎病方面，約半數病人得到評估。第7項準則亦有重要不足，只有約半數病人的血壓控制能夠達標，而糖尿病或腎病病人的情況更差，只有20%達標。第8項準則的結果亦遠離目標，只有57.1%的病人被適當地轉介予專科醫生評估。而其他結果均令人滿意，尤其是危險因素的評估，七個危險因素中有六個達標。
在第二期階段，分析了352位病人的資料。大部分準則的結果得以改善。目標器官損害的評估（第3項準則），運動不積極的評估（第4項準則），非糖尿病和腎病病人的血壓控制及營養意見提供（第10項準則）各方面，都有顯著改善，在第二期階段中，第1，4，5，6和10項準則都達到標準。在評估目標器官損害病徵方面，只有心絞痛和心臟衰竭的標準達到。

結論：本審計顯示有關診所在高血壓治療有許多不足之處。審計可達致顯著的改善。在照顧上經過改善後，可預見高血壓病人併發症的病發率會得以降低。但由於部份準則的標準仍未能達到，尤其是在部份目標器官損害的評估和目標血壓的控制，再次進行審計是值得考慮的。

主要詞彙：審計、高血壓治療、普通科診所

---

Introduction

Audit is the process of critically and systematically assessing our own professional activities with a commitment to improving personal performance and, ultimately, the quality and/or cost-effectiveness of patient care. (Fraser, 1982)

There is growing evidence that participation in audit, allied to appropriate implementation strategies, does have a considerable potential for promoting changes in professional behaviour leading to improved outcomes for patients.

Worldwide prevalence estimates that there may be as much as 1 billion individuals having hypertension and approximately 7.1 million deaths per year may be attributable to hypertension.² The relationship between blood pressure and risk of cardiovascular disease events is continuous, consistent and independent of other risk factors. The higher the blood pressure, the greater the chance of myocardial infarction, heart failure, stroke and kidney disease.^3-5 There is also increased risk of peripheral vascular disease and retinopathy in hypertensive patients.⁶

The Framingham Heart Study showed that hypertension is an important risk factor for heart diseases and cerebrovascular disease. These diseases are the second and third commonest causes of death in Hong Kong respectively. Hypertension itself accounted for more than 8000 hospital admissions in 2000. A community study in Hong Kong found that about 1 in 10 men and 1 in 9 women had blood pressure of 140-159/90-94mmHg of which the control rate was no more than 50%.⁷

Clinical trials had shown that antihypertensive therapy has been associated with 35% to 40% mean reductions in stroke incidence; 20% to 25% in myocardial infarction; and more than 50% in heart failure.⁸

Despite advances in the understanding of the pathophysiology of hypertension and advances in antihypertensive therapy during the past 3 decades, overall rates of hypertension control were overwhelmingly poor. A study in the blood pressure control in the community in the USA showed that of all the hypertensive subjects, only 29% were controlled to the target pressure (systolic < 140mmHg and diastolic < 90mmHg) and among the subjects who were receiving antihypertensive therapy (60.7% of all hypertensive subjects), only 47.8% were controlled to target.⁹ In a recent study, it was found that at the 140/90mmHg threshold, only 29% of hypertensives in the United States, 17% in Canada, and <10% in European countries had their blood pressure controlled. Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk attributable to elevated blood pressure compared with that in North America.¹⁰ In Hong Kong, the controlled rate was no more than 50%.¹¹

Clinical evidence has reinforced recommendations that certain lifestyle modifications can lower blood pressure, enhance antihypertensive efficacy and decrease cardiovascular risk.^12-15 Hence advice on lifestyle modifications should be provided to all people with hypertension or borderline normal blood pressure.

In Hong Kong, a significant proportion of patients with hypertension are managed in the Hospital Authority general out-patient clinics (GOPCs). According to the Survey on Disease Surveillance at GOPCs in February 2001, about 26% of patients had hypertension as the first diagnosis. As a result good care of hypertensive patients in these clinics is especially important if we want to minimize the potential complications of hypertension. During his practice in the GOPC, the first author has observed that quite a lot of patients had their blood pressure much higher than the target pressure seen during consecutive consultations without any adjustment of anti-hypertensive drug regimen. Most of these cases had no contraindications to adjustment of drug regimen. The situation was even worse in diabetic patients in that the target blood pressure is advised to be even lower (130/80). Moreover, the author thought that with the availability of the most updated international guidelines for hypertension management for some time already, it should be a good time to audit our own practice based on those guidelines. So the author decided to carry out an audit of the management of hypertension in his clinic in order to improve the management and assure the quality of care provided.

Objectives

(1)	To carry out an audit on management quality of hypertension in a Hospital Authority general out-patient clinic.
(2)	To identify areas of inadequacy in hypertension management for improvements in the clinic.
(3)	To assess improvements after implementation of change.

The audit cycle
1)	Choose a topic and planning The principal author noticed that a significant number of hypertensive patients did not have possible complications assessed and their blood pressure were above the target blood pressure. Therefore, it was decided that an audit of the management of hypertension with an aim to improving patient care was needed.
2)	Set criteria and standards The following criteria were adopted from the audit protocol published by the Eli Lilly National Clinical Audit Centre of the Department of General Practice, University of Leicester in 19951 with some modifications according to the most updated evidence-based clinical guidelines.6, 17 Although the Eli Lilly audit protocol was published 10 years ago, most of the criteria were based on research evidence and some of the evidence could still be applied to present-day practice. However, with more evidence-based guidelines published, some modifications according to those guidelines must be made for the present audit.
A)	The "Must do" criteria:
Criterion 1
	Patients who have been diagnosed as hypertensive have been recorded in a practice hypertension register. It is widely accepted that a register is the cornerstone for systematic care.
Criterion 2
	The records show that in patients without target organ damage, the blood pressure has been measured at least twice on each of at least two separate occasions prior to commencement of drug therapy. Modification was based on JNC 7 report6 which suggested that measurement of blood pressure on 2 separate occasions was enough for the diagnosis of hypertension. Eli Lilly protocol recommended 3 separate occasions.
Criterion 3
	The records show that within three consultations after diagnosis, the following symptoms and signs of target organ damage have been sought: retinopathy, left ventricular hypertrophy, angina, stroke, heart failure, peripheral vascular disease and renal disease. For known hypertensive cases referred from other clinics for follow up, the same assessment should be done as for new cases diagnosed in our clinic unless target organ damage had been excluded by the referring doctor. There is good evidence that patients with target organ damage have a higher morbidity and mortality, which can be reduced by appropriate treatment. It had been believed that the incidence of peripheral vascular disease was low in Chinese but a local epidemiological study published in 1999 showed that there was an increasing incidence of peripheral vascular disease in Hong Kong and most of the patients presented late with advanced ischaemia.16 As the time available for consultation in GOPC is very short, it is more reasonable to allow the symptoms and signs of target organ damage to be sought in one of the three consultations following confirmation of the diagnosis instead of at the first one consultation.
Criterion 4
	The records show that an assessment has been made of the risk factors for cardiovascular and cerebrovascular disease and that if necessary, appropriate advice and treatment has been given: smoking habit, body mass index, diabetes mellitus, serum cholesterol, excessive alcohol intake, physical inactivity and family history of premature coronary artery disease. There is good evidence that additional cardiovascular risk factors have a substantial impact on morbidity and mortality from hypertension. Modification of these risk factors improves outcome.
Criterion 5
	The records show that the mean pre-treatment blood pressure level was at least greater than 140mmHg (systolic) and/or 90mmHg (diastolic).6, 18 According to JNC 7 report, with blood pressure persistently higher than 140/90mmHg, we could start drug treatment even without evidence of target organ damage or presence of other risk factors since hypertension alone is a significant risk factor for cardiovascular and cerebrovascular complications.The original Eli Lilly protocol criterion was: The records show that the mean pre-treatment blood pressure level was at least a diastolic 95mmHg or greater and/or a systolic of 160mmHg or greater, or a diastolic of 90-95mmHg in the presence of other cardiovascular risk factors, and/or target organ damage.
Criterion 6
	The records show that the patient has been reviewed at regular intervals not exceeding 6 months. There is good evidence to show that failure of follow up is common, and is associated with poor outcome. Regular follow up is mandatory. Most guidelines state a follow up interval of at least 3 to 6 months. Although the optimal interval for follow up was uncertain, it should never exceed 6 months even in the most well controlled patient. The follow up interval needs to be individualized.
Criterion 7
	The records show that the hypertension is well controlled, the average of the last three recorded diastolic pressure readings being 90mmHg (diastolic) or below, and 140mmHg (systolic) or below for non-diabetes. For patients with diabetes or renal disease, the blood pressure goal is equal or less than 80mmHg (diastolic) and 130mmHg (systolic).6, 19, 20 Based on JNC 7 report, there was strong evidence that the complication rate could be much reduced if the patient's blood pressure was controlled to target. The original Eli Lilly audit protocol only required the average blood pressure controlled to 160/90mmHg or below.
Criterion 8
	The records show that a patient with refractory hypertension and/or suspected secondary hypertension has been referred for specialist advice.
B)	The "Should do" criteria
Criteria 9
	The records show that at least annually there is an assessment of side effects caused by antihypertensive drugs. Hypertension is generally a condition without symptoms. However there are often side effects arising from drug treatment. It is important to ascertain the presence or absence of these side effects.
Criteria 10
	The records show that at least annually the patient has been given advice about dietary salt restriction and DASH (Dietary Approaches to Stop Hypertension) diet advice.6, 13 DASH diet advice is added in addition to salt restriction. There was research evidence that by consuming a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat (DASH diet), the blood pressure could be reduced.
The "standard" Ideally the "standard" should be set at 100%. However this would be impossible in practice for most criteria for various reasons. In this audit, the standard for criterion 1 was set at 100%. Since registers are a vital necessity for managing hypertension in general practice and with the help of computers in daily practice, this criterion should be easily achieved. The standard for criteria 2-6 and 8 was set at 90%.The standard for these "must do" criteria (Criteria 2-6 and 8) is set at 90% since these criteria are the most important parameters in hypertension management and to maintain a high standard is the "cornerstone" in the prevention of hypertension related morbidity and mortality. However, since this was the first audit for hypertension management in our clinic, to set the standard at a higher level such as 95% might be a bit hard and difficult to achieve. For criterion 7, the standard was set at 70%. The standard for criterion 7 is based on the Hypertension quality indicators in the new General Medical Service Contract (2005) set in England. The contract set a standard of 70% of patients with blood pressure controlled to target in a clinic as good quality indicator. Although the proportion of patients with their target blood pressure achieved is also important to minimize the complications caused by hypertension, most study showed that the target blood pressure is controlled in only about 50% and some with even lower, so our standard is set at 70% in the first audit of hypertension management in the clinic. The "should do" criteria 9-10 was set at 80% since the clinical importance of fulfilling the "should do" criteria was relatively less than that of the "must do" criteria.
3)	First phase data collection and analysis
Data collection method and sampling frame: This audit was done in a Hospital Authority general out-patient Clinic. In January 2005, a list of 5590 patients with hypertension coded by ICPC code and had been followed-up in our clinic from past one year was generated from the clinical management system (CMS). The list of patients was numbered according to alphabetical order. A sample size of 360 was calculated by an on-line computer programme called The Survey System. The sample size was calculated so that it would be 95% sure (confident) that the results obtained from the sample would be within 5% of the results we would have obtained for our whole population if we had chosen to collect data on them all. A random list of 360 numbers from 1 to 5590 was then generated by using an on-line computer programme called Research Randomizer. The patients were then selected according to the list of random numbers. These 2 programmes were chosen in the audit because both of them were user friendly. Data were then collected by reviewing the medical records of all selected patients by using a data collection form modified from that prepared by the Eli Lilly audit protocol. 349 of the sample of patients were included for data analysis with 11 rejected because they were followed up in other clinics. The average age of patients was 66.1 years old. There were 142 female and 207 male patients. The result of the first cycle is summarized in Table 1.
4)	First phase evaluation
Deficiencies in care/service in the first cycle: After the first phase data analysis, the result was presented to all clinic doctors and all agreed that there were deficiencies in the care of our hypertensive patients. Firstly, the rate for assessment of symptoms and signs of target organ damage (criterion 3) was far from the target standard. Only 7.4% of patients had been assessed for retinopathy and peripheral vascular disease and only about half of the patients had been assessed for angina, heart failure and renal disease. Another major deficiency was for criterion 7 in which just about half of the patients had their blood pressure controlled to target and it was even worse in patients with diabetes or renal disease in which only 20% had their target achieved. For criterion 8, the result was also far from the target with only 57.1% of patients appropriately referred for specialist assessment. The results for other criteria were quite satisfactory especially for the assessment of risk factors in which 6 out of the 7 risk factors had been assessed and were better than the target. Explanations for the deficiencies: The causes for our deficiencies were discussed among the doctors during clinic meetings. We concluded that the major reason for the poor result in the assessment of symptoms and signs of target organ damage was the short consultation time. We had on average only about 7.5 minutes for each consultation and many patients had other complaints other than their blood pressure during the hypertension follow up. As a result, some doctors would only ask for those symptoms and signs which they thought were more important such as angina and heart failure. The assessment of renal disease and left ventricular hypertrophy would need further investigations and thus needed more time and so sometimes the doctors resisted to ask. For other target organ damage like stroke, retinopathy, peripheral vascular disease, they thought that these were less common and more difficult to assess and so they usually did the assessment only when the patients had complaint of symptoms related to the organ damage. For the target blood pressure, all knew what the target blood pressure for the patients was but some doctors did not realize the importance of tight blood pressure control. They thought that blood pressure mildly above the target blood pressure was already satisfactory enough. Some of them were reluctant to adjust the drug regimen as making adjustment required extra time to explain to patients. For the criterion about referral to specialist, they thought that the number of cases with suspected secondary hypertension was relatively small and the result might not be reliable. They thought that the results should be better if a guideline for referring was available. For criterion about diet advice, some doctors did not know what DASH diet was. Some doctors sometimes gave verbal advice without making a note in the record, and thought that the result might not reflect the true picture.
5)	Implementing change and intervention
How changes were agreed and implemented: The identification of the deficiencies led to a series of measures to try to improve the situation. First, a copy of the latest hypertension management guideline prepared by the Hospital Authority in 2004 was given to all doctors for reference. The important points of the guideline were explained. They were also advised to look through the JNC VII report for the most updated guidelines for hypertension management. A review article of management of secondary hypertension was also given. Meeting was then held to share suggestions to help improve the standard of care and the following changes were made: Templates for management of both new and old cases of hypertension and diabetes mellitus were made so that most of the important points for hypertension management were covered in the templates and this could save them time in typing. A list of the audit criteria was posted up next to the computer in every consultation room to remind the doctors the criteria for good hypertension management. A review of management of our hypertensive patients after the implementation of intervention was carried out every now and then; those colleagues who complied poorly with the guidelines would be given support and had their difficulties discussed. Whenever there were new doctors joining the clinic, orientation sessions on the audit exercise would be arranged for them. All nurses were reminded to do the initial assessment of all new hypertensive cases in our clinic. During the initial assessment, basic assessments including the BMI and some of the risk factors for cardiovascular and cerebrovascular complications were assessed and recorded in the CMS system.
6)	Second phase data collection and analysis
For the second phase data collection in September 2005, a list of 5804 patients with hypertension coded by ICPC code and who had been followed up in our clinic from March to August 2005 was generated from the CMS system. A sample size of 360 was included for audit so that it would be 95% confident that the results obtained from the sample would be within 5% of the results we would have obtained for our whole population if we had chosen to collect data on them all. The selected patients were randomly sampled as in the first cycle. Data was then collected by the same method as in the first cycle. The first cycle patients sample was not used for second cycle assessment because for some of the criteria (criteria 2,3,5), we would need to have newly diagnosed hypertensive patients or new cases referred to us for follow up, to be included in the sample. 352 of the sample of patients were included for analysis with 8 rejected because they were followed up in other clinics. The average age of patients was 65.6 years old. There were 145 female and 207 male patients. There were 31 new cases in the sample and 13 of the new cases were diagnosed to have hypertension in our clinic. The results of the second cycle are summarized in Tables 2 and 3.

Results and statistical analysis

For most of the criteria, there was improvement in the results in the second cycle. The standard of the criteria in the second phase was achieved for criteria 1, 4, 5, 6, 10. For the assessment of symptoms and signs of target organ damage, the standard for angina, and for heart failure was achieved but not for others.

Chi-square test was used to test the significance of the changes made in the second cycle. The result was calculated by using the SPSS computer programme. The result is shown in Table 4. There was no statistically significant difference in the proportion of patients of different sex in the two audit cycles. There was statistical significant improvement for all points in criterion 3 only if the new cases were compared. The old cases were not used for comparison only for criterion 3 because the criterion required the assessment of symptoms and signs of target organ damage within three consultations after the diagnosis or who were followed up in our clinic and so we could not do anything to improve the standard of criterion 3 for the old cases. Even if the assessment was done in subsequent follow ups, the criterion would not be counted as fulfilled. The result for assessment of physical inactivity and provision of diet advice also showed significantly improved. The proportion of patients with target blood pressure reached was also shown to be statistically improved for patients without diabetes and renal disease. Although for those patients with diabetes and renal disease, the improvement was not statistically significant, improvement was shown. Unfortunately, the standard for target controlled blood pressure for all patients was not reached. There was also little improvement shown for criterion 8 but it was statistically insignificant. There was only slight decrease in the proportion of patients who fulfilled the criteria 2, 6 and 9 but all of them were statistically insignificant.

Discussion

In general, improvement was shown in most of the criteria in this audit. The improvement was impressive for the assessment of symptoms and signs of target organ damage only if new cases were compared. However, the result for the assessment of retinopathy, left ventricular hypertrophy, stroke and peripheral vascular disease was still far from the standard. The result for assessment of damage of these target organs which required a relatively longer time for doing physical examination and so with a limitation of consultation time available assessment were more difficult and so assessment were easily missed and not done.

For criteria 2 and 5, there was no obvious change in second phase and this could be explained by the small number (13) of newly diagnosed hypertension cases in the sample. Since we could improve the standard of criteria 2 and 5 of our newly diagnosed patients only and the number of new cases was relatively very small compared to the whole sample, the results could not tell us even if there was any definite improvement.

For criterion 7, the proportion of patients with blood pressure controlled to target blood pressure in our first cycle was shown to be quite low especially for patients with diabetes or renal disease but the proportion was better than the proportion in other studies.^9,10 The results after intervention were shown to be much better in the second cycle although the target standard of 70% could not be reached. One of the possible reasons that the standard could not be reached was that the implementation period was only half year and most patients had only one to two follow ups during the period. As a result, even if the latest blood pressure fulfilled the criteria after adjustment of drug regimen and modification of lifestyles, the average of the blood pressure of the last three consultations might not reach the target.

For criterion 4 about assessment of risk factors, the result in the first cycle was already quite satisfactory but there was still some improvement in the second phase. The target standard was reached for all risk factors in second phase. One of the reasons for the good result was that some of the risk factors such as smoking habit, body mass index, alcohol intake were assessed by our nurses during the initial assessment and almost all our patients had their initial assessment done already. Also, the criteria for the assessment of the risk factors included all cases with the assessment of the risk factors was carried out any time after diagnosis; and most of our patients had been followed up for a relatively long period. This increased the chance of the different risk factors becoming assessed in any one of the consultations.

For criterion 5, the target was easily achieved since nearly all old guidelines suggested to start anti-hypertensive treatment at a higher blood pressure level.

For criterion 6, most of our patients were followed up in our clinic every 4 to 12 weeks and even for those who defaulted, seldom default follow up for more than 6 months. Moreover, our clinic had a call-back system for those defaulted booking cases and so the standard was easily reached.

The number of cases with suspected secondary hypertension was relatively low. Patient with refractory hypertension could usually be managed in the general out-patient clinic with different groups of anti-hypertensive being available. Moreover, some patients already had investigations done to exclude secondary hypertension. Consequently, the validity of the result obtained would be low and did not allow us to draw a statistically meaningful conclusion.

For criterion 9, the proportion of patients with side-effects assessed was not improved and this might be partially explained by the difficulty in making a template for the assessment of drugs side-effects as there were so many possible side-effects with various different anti- hypertensives. With the limit of consultation time, and some patients did not complain of any symptom of side-effects, some doctors would sometimes assume there was no side-effects especially because patients had also been taking the same drug(s) for years and did not ask or make any assessment. Nevertheless, the principal author had observed that assessment of side-effects such as electrolyte-disturbance caused by diuretics and angiotensin-converting enzyme inhibitors in which a blood test was required, was quite often missed. As a result, possible intervention of our practice which could help to achieve a better result should be sought.

For criterion 10, the proportion of patients having diet advice given was significantly improved as this criterion was relatively easy to follow.

Limitations

There were some limitations in this audit. First, the audit used different sample group of patients in the two cycles. As a result, the age distribution of patients in the two cycles might be quite different even though the samples were randomly selected and the calculated average age was similar in both cycles. The difference might be an important confounding factor in this audit exercise. Some cases were excluded because they were followed up in other clinics. Also, about 64% of the sampled patients in both the first and the second cycles of the study were diagnosed to have hypertension by other doctors before they came to us and followed up in our clinic for hypertension management. As a result, we could not assess whether or not they fulfilled the criteria 2 and 5. The final number of patients included for comparison was thus reduced and this might have caused increased error in the results. Moreover, the audit was done by reviewing the consultation notes only and we could not be sure whether what the doctors had actually done as what was recorded on the consultation notes especially when they were using the templates for recording consultation notes or copying some of the notes from previous consultations. On the other hand, some doctors might have managed their patients according to the criteria but they did not use the template and had not recorded down all the clinical information because of the time limitation. Finally, the duration of the intervention phase might not be long enough for some of the criteria to achieve the standard although improvement could be shown.

Conclusion

This audit showed that there were some deficiencies in the managekment of hypertension in our clinic. However, with an audit exercise, significant improvement could be achieved. With the improvement in the care standard, we could expect that the complication rate of our hypertensive patients could be reduced. Since the standard of some of the criteria had not yet been reached, especially the assessment of some of the target organ damage and the control to target blood pressure, to repeat an audit with these criteria should be considered.

Key messages

1. Good care of hypertensive patients is important if we want to minimize the potential complications of hypertension.
2. In a public general out-patient clinic, some deficiencies in the management of hypertension were found.
3. With an audit exercise, significant improvement could be achieved. With the improvement in the care standard, we could expect that the complication rate of hypertensive patients could be reduced.

---

---

References