Audit of Hypertension Care in a Primary Health Care Center in Abha City, Saudi Arabia

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1 Med. J. Cairo Univ., Vol. 80, No. 2, December: 53-60, Audit of Hypertension Care in a Primary Health Care Center in Abha City, Saudi Arabia MOHAMMAD M. MOGBEL, SBFM, ABFM, JBFM and ABDULLAH A. KHAWAJI, SBFM, CABFM The Department of Family Medicine, Ministry of Health, Kingdom of Saudi Arabia Abstract Objectives: To evaluate structure, process and outcome of hypertension care in a primary health care center (PHCC). Methodology: This study was based on the information provided in the files of all hypertensive patients (n=218), who attended Al-Manhal PHCC during the period from 1/1/2011 to 31/12/2011. The structure of hypertension care was assessed by two checklists. The process of hypertension care was assessed by two checklists. The outcome indicators were undertaken according to the Quality Assurance in Primary Health Care Manual. The last blood pressure reading during the year 2011 was taken. The patient was labeled as controlled if his blood pressure was <140/90mmHg or uncontrolled if it was equal to or more than 140/90mmHg. Results: The main risk factors for hypertension were diabetes (42.7%) and obesity (78.5%). Check-list of the structure resources score was 32 (out of 47), while the mean score for process evaluation for hypertensive patients was 34 (out of 50). The annual general physical examination was almost completely ignored by physicians, referral to specialists was done for 11.5%, while health education was offered for almost all patients. Most routine investigations were requested to be performed at the secondary health care level, with high proportion of no feedback. Control of systolic blood pressure reached 37.2% while that for diastolic blood pressure was 47.2%. Incidence of systemic complications was generally low. Conclusions: Main risk factors for hypertension include diabetes and obesity. Primary health care physicians are not trained on proper registration and documentation of medical records. The primary health care centre lacks a standardized protocol for management of hypertension. The health care team does not include a dietitian, social workers or a physician qualified to carry out fundoscopy. The primary health care process needs improvement. The general physical examination of hypertensive patients is rarely done. The design of medical records for follow-up of patients contains several problems. The success rates for control of blood pressure of hypertensive patients are low. All these negative findings should be dealt with accordingly. Moreover, audit studies should be performed at several primary health care centers caring for other chronic diseases. Correspondence to: Dr. Mohammad M. Mogbel, The Department of Family Medicine, Ministry of Health, Kingdom of Saudi Arabia Key Words: Hypertension Primary health care Audit. Introduction HYPERTENSION is the presence of a blood pressure (BP) elevation to a level that places patients at increased risk for target organ damage, and patient is labeled to have hypertension if systolic B.P of 140mmHg or greater or diastolic pressure of 90mmHg or greater [1,2]. It remains a significant but treatable public health problem in most populations worldwide [3]. High blood pressure is associated with excess morbidity and mortality, regardless of what cut-off values are used in definition [4]. Hypertension affects approximately one billion individuals worldwide and its prevalence varies widely worldwide [5]. In the United States of America, hypertension affects 50 million Americans, and its prevalence is 8%-18% of adults (blood pressure above 160mmHg systolic and/or 95mmHg diastolic) [1,4,6]. Prevalence in North America was 27.6% and in Europe was 44.2% [7]. Its prevalence among Saudis aged 18 years and above was found to be 20.4% for systolic and 25.9% for diastolic hypertension. It is generally accepted that well organized care can improve the outcome of hypertensive patients, in detecting complications early and probably in their prevention [4]. In clinical trials, 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 HF [8]. It is estimated that in patients with stage 1 hypertension (systolic BP, mmHg and/or diastolic BP, 90-99mmHg) and additional cardiovascular risk factors, achieving a sustained 12-mm Hg decrease in systolic BP for 10 years will prevent 1 death for every 11 patients treated. In the presence 53

2 54 Audit of Hypertension Care in a Primary Health Care Center of CVD or target-organ damage, only 9 patients would require this BP reduction to prevent a death [9,10]. The hypertension clinics aim to maximize the early detection among high risk groups in the community, to minimize complications, to interfere with the patient's life as little as possible, to rationalize the use of anti-hypertensive drugs and to correct other cardiovascular risk factors (e.g. smoking and other adverse lifestyle characteristic) [11]. Saudi primary health care teams are doing their best to care for their hypertensive patients. However, going through the health centers records, it can be seen that all the cases recorded are adults above middle age and that these cases are far less than the expected number of hypertensives [11]. Ahmed and El-Awad reported that 77% of hypertensive patients in southern Saudi Arabia were compliant with their medications and 34% needed more than one drug to control their blood pressure [10]. Clinical audit is the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient. It involves looking at what is done in a way that allows to see how things might be done better, making appropriate changes and then looking again to assess improvements in clinical practice. Clinical audit can provide a feedback, allowing to assess the clinical practice and its impact on patient care against our expectations and those of our profession [4]. So, the aim of this study is to evaluate structure, process and outcome of hypertension care in a primary health care center. Material and Methods Following a simple random sample, Al-Manhal Primary health Care Center (PHCC) has been selected among all primary health care centers in Abha City of Aseer Region. The PHCC lies in Al- Manhal neighborhood, covering nine areas, serving a population of 14,169, most of whom are Saudis. Review of the files of all hypertensive patients (n=218) who visited the Hypertension Clinic in Al-Manhal PHCC from 1/1/2011 to 31/12/2011. The structure of hypertension care was assessed by two checklists derived from Abdullah I. Al- Sharrif and Yahia M. Al-Khaldi study [12]. The first checklist was for the essential items of care (13 items), and the second one was for the less essential items (22 items). The checklist on the essential items of care was scored on three-point scale of: 2 (if the item was available all the time), 1 (if the item was available sometimes), and 0 (if not available). Checklist of the less essential items of care was scored on two point scale, 1 (if such item was available) and 0 (if not available). The total score of all items of the structure of hypertension care ranged from 0 to 47. The structure of care was considered good if total score is more than 80% of total score (i.e., >37 score); fair if between 60% and 80% (i.e., score); or poor if less than 60% (i.e., <28 score). The process of hypertension care was assessed by two checklists that were modified from the study of Khattab et al. [13]. The first checklist was that for the essential items of care (20 items), and the second one was for the less essential items (10 items). Checklist on the essential items of care was scored on two points scale: 2 (if the item was available all the time), and 0 (if not available). The checklist for the less essential items of care was scored on two point scale, 1 (if such item was available) and 0 (if not available). The total score of all items of the process of hypertension care ranged from 0 to 50. The process of care was considered good if total score is more than 80% of total score (i.e., >40 score); fair if between 60% and 80% (i.e., score); or poor if less than 60% (i.e., <30 score). The outcome indicators were undertaken according to the Quality Assurance in Primary Health Care Manual [11]. The achievements in the process and outcome indicators in the past 12-month period were assessed by reviewing hypertensive patients medical records in Al-Manhal PHCC. The last blood pressure reading during 2011 was taken. A patient was labeled as controlled if his/her BP readings were <140/90mmHg or uncontrolled if equal to or more than 140/90mmHg. Patients who did not show up during the last six months of the study period were excluded from the study. Results Table (1) shows that 76.6% of patients aged years, while 16.5% aged 70 years or more. Female patients were more than males (52.3% vs. 47.7%, respectively). Most patients were Saudis (89%) and married (82.1%). According to the records, about one third of patients were illiterate (31.7%), while 5.5% attained primary level of education, 1.4% attained intermediate level, 4.6% attained the secondary level while 9.2% were university graduates. However, the educational

3 Mohammad M. Mogbel & A bdullah A. Khawaji 55 level of almost half of the patients (47.7%) was unspecified. More than one third of patients were housewives (37.2%), while 18.3% were retired and 14.2% were unemployed or dependent. Less than one third of patients were employed (29.4%). Table (2) shows that most patients were diagnosed within the past 5 years (45.4%) or 6-10 years (20.6%). On diagnosis, hypertension was mostly classified as stage one (50.5%). However, the severity of hypertension in about one fifth of records (20.6%) was not specified. Family history of hypertension was documented in one third of the patients (33.9%). Management of hypertension was mainly by beta blockers (35.3%) or ACE inhibitors (15.1%). Very few patients received calcium channel blockers (4.6%) and diuretics (3.7%). Combination therapy was applied in 33%, while no drug management was used with 8.3% of patients. Table (3) shows that diabetes comorbidity was present in 42.7% of cases. Patients with normal weight constituted 6.8%, while the majority were either overweight or obese. Only 3.2% of patients were smokers. Hypercholesterolemia and hypertriglyceridemia were documented in 6.9% of patients. However, more than one third of requests for levels of serum cholesterol and triglycerides were not fulfilled (38% and 42.2%, respectively). Concerning structure, Tables (4,5) reveal the absence of some important resources (e.g., availability of protocol for diagnosis and treatment of hypertension, health education materials and programs), and the lack of a dieticians, social workers or physician to carry out fundoscopy. Table (6) shows that the grades for process evaluation of hypertensive patients were poor in more than one third of patients (37.6%), fair in 40.4% and good (22%). The mean of scores was 34.0±7.3. Table (7) shows that most patients were generally categorized by their physician as compliant as regard medication, diet and appointment, as the prevalence rates of poor compliance were low (9.6%, 10.6 and 9.2%, respectively). Total number of visits during 2011 was less than 6 in about two thirds of patients (66%). Table (8) shows that general physical examination was not performed by the primary health care physician in almost all patients (98.6%). A total of 11.5% of patients were referred to the secondary health care level facility. On the other hand, health education was done to almost all patients (98.2%). Table (9) shows that CBC and serum electrolytes were not requested for almost all patients (98.1% and 97.7%, respectively). Fasting blood glucose was requested for all patients. However, no feedback was received in 37.6% of them. Serum creatinine was raised in 7.3% of patients and was very high in 1.8% of cases. However, in 40.8% of cases there was no feedback for the requested test. Proteinuria was present in 9.6% of cases. Serum uric acid was high in 9.6% of cases, while 36.2% of patients did not have feedback for their requests. Chest X-ray was not requested for most patients (98.6%) since it has been omitted as a routine investigation for hypertensive patients. ECG and fundoscopy were requested for all patients. However, there was no feedback in 38.5% of patients. Table (10) shows that systolic blood pressure control was achieved only in about one third of patients (37.2%) while diastolic blood pressure was controlled in less than one half of patients (47.2%). Control of systolic blood pressure did not differ significantly between males and female, while control of diastolic blood pressure was significantly better among females than males (p=0.032). Table (11) shows that 5% of hypertensive patients developed cardiac complications, 1.4% developed renal complications while 1.8% had central nervous system complications. Table (1): Characteristics of hypertensive patients (n=218). Patients characteristics No. % Age Groups: < Sex: Male Female Nationality: Saudi Non Saudi Marital Status: Married Single Widow Unspecified Educational Status: Illiterate Primary 12 Intermediate Secondary University Unspecified Occupation: Housewife Employed Retired Unemployed/Dependent Unspecified 2 0.9

4 56 Audit of Hypertension Care in a Primary Health Care Center Table (2): Characteristics of disease. Table (3): Risk factors for hypertension. Characteristics No. % Risk factors No. % Duration of hypertension: Diabetes comorbidity: 1-5 years Positive years Negative years Body mass index: >15 years Normal weight Overweight Severity of disease on diagnosis: Mild obesity Stage 1 ( /90-99mmHg) Moderate obesity Stage 2 (160+/100+mmHg) 63 Missing data Morbid obesity Smoking status: Family history of hypertension: Smoker Positive Non-smoker Negative Missing data Cholesterol: <=200 (normal) Management: (borderline) Beta blockers >=240 (high) ACE inhibitors Requested but no feedback Calcium channel blockers Triglycerides: Diuretics <=200 (normal) Combination drug therapy (borderline) (more than one drug) >=250 (high) No drug (diet and exercise) Requested but no feedback Table (4): Check-list of the structure (resources) of hypertensive patients care at Al-Manhal PHCC during 1425 (Essential). S.No Description Scale Availability of hypertension mini-clinic. 2 Availability of physician. 3 Attending of hypertension training course by one of the physician at PHCC. 4 Availability of a well trained nurse for hypertensive clinic. 5 Availability of well-equipped laboratory for basic investigations - Ability to do FBS by gluco-stick. 6 - Ability to do CBC. 7 - Ability to do urinalysis. 8 Presence of an open access to hospital with the required laboratory, radiology and ECG facilities. 9 Availability of appointment system for hypertensive patients. 10 Presence of recall system for defaulter hypertensive patients. 11 Availability of special files for hypertensive patients. 12 Availability of special register for hypertensive patients. 13 Availability of protocol for diagnosis and treatment of hypertension. 14 Health education means and materials, Presence of drug refill card. 15 Health education means and materials, Presence of Booklets 16 Health education means and materials, Presence of Pamphlets 17 Health education means and materials, Presence of Videotapes 18 Presence of Health education programs 19 Presence of Diuretics 20 Presence of Beta-blockers 21 Presence of ACE inhibitor 22 Presence of Ca antagonist Total 32

5 Mohammad M. Mogbel & A bdullah A. Khawaji 57 Table (5): Check-list of the structure (resources) of hypertensive care at Al-Manhal PHCC during 1425 (Less essential). S.No Description 1 Presence of dieticians at PHCC 2 Presence of social worker at PHCC 3 Presence of a physician to carry out fundoscopy Scale 1 0 Total 0 Table (6): Results of process evaluation for hypertensive patients (maximum score = 50). Process score grades No. % Poor (less than 30) Fair (30-40) Good (more than 40) Mean score (mean±sd) 34.0±7.3 Table (7): Compliance of patients. Items of compliance No. % Medication: Good Fair Poor Unspecified Diet: Good Fair Poor Unspecified Appointment: Good Fair Poor Unspecified Number of visits: < Table (8): General examination, referral and health education. No. % General physical examination: Done Not done Referral to a specialist: Done Not done Health education: Done Not done Table (9): Investigations for follow-up of hypertensive patients. No. % CBC: Not done Done Serum Electrolytes: Sent and done Not requested Fasting blood glucose (mg/dl): Requested and done Requested but no feedback Creatinine (mg/dl): <1.3 (normal) (raised) >2 (very high) Requested but no feedback Urine analysis for proteinuria: Positive Negative Uric acid: <=7 (normal) >7(high) Not requested Requested but no feedback Chest X-ray: Requested and done Not requested ECG: Requested and done Requested but no feedback Fundoscopy: Requested and done Requested but no feedback Table (10): Blood pressure control of hypertensive patients. Blood pressure control Males (n=104) Females (n=114) Total (n=218) No. % No. % No. % p value Systolic blood pressure: Controlled Not controlled Diastolic blood pressure: Controlled Not controlled Table (11): Systemic complications attributed to hypertension. Complications No. % Cardiac: Yes No Renal: Yes No Central nervous system: Yes No Eye: Yes No Unspecified

6 58 Audit of Hypertension Care in a Primary Health Care Center Discussion The present study showed that more than 93% of patients aged above 40 years. Scheltens et al. [14] stated that hypertension and its complications are a major cause of morbidity and mortality in the elderly. Mitchell et al. [15] stated that although absolute risk of death associated with raised BP increases with age, the benefits of treatment are greater in older patients. The present study showed that the proportion of female hypertensive patients attending the primary health clinic was higher than that for the male patients (52.3% vs. 47.7%, respectively). This finding is in agreement with that reported by Al-Owayyed [4], who noted that approximately 65% of his hypertensive patients attending the Riyadh Armed Forces Hospital Family and Community Medicine Department were females. This finding can be explained by the fact that females usually make more frequent visits to the clinic, so giving more opportunity to check their blood pressure. This study showed that Saudi patients constitute the majority of attending hypertensive patients (89%). This reflects the strictly adopted national Saudi policy of gradually reducing reliance on non-saudis and the proper selection of healthy employed foreigners through conducting preemployment thorough medical examination. Moreover, according to the Saudi bylaws, not all non- Saudis have the right to benefit from hypertension follow-up. Those who can benefit from primary health care are mainly those persons who serve at governmental institutions. Most patients were married (82.1%). This finding is understandable since the majority of patients aged more than 40 years. However, by revising the patients records, the marital status of 3.2% was unspecified. Similarly, the educational status of almost half of patients (47.7%) was not specified. This finding reflects the lack of awareness of the caring physician toward some of the identification data of the patient, assuming that fulfilling these data is a waste of his effort and precious time. As regard characteristics of hypertension, the duration of disease was within 10 years in two thirds of patients attending for follow-up. Half of patients were categorized as stage (1) according to their blood pressure at diagnosis. However, the severity of one fifth of patients (20.6%) was not specified in their records. A positive family history for hypertension was present in one third of patients. In 8 patients the family history for hypertension was not specified. Patients were treated mainly with beta blockers (35.3%) or ACE inhibitors (15.1%). Calcium channel blockers and diuretics were administered to 4.6% and 3.7%, respectively. Combination therapy was applied in 33%, while no drug management was used with 8.3% of patients. Al-Owayyed [4] reported that 18% of his patients had a positive family history for hypertension. Diuretics were administered to 10.1% while beta blockers were used by 25% of hypertensive patients, and 5% of patients received no drug treatment. However, in the British study of Chan et al. [16], 32% of patients were using diuretics, 24% were using beta blockers, while 4% of patients received no treatment. This wide variation in the use of drugs for management of hypertension can be explained by the lack of a universal and standardized protocol of management for hypertension. As regard risk factors for hypertension, the present study showed that only 6.8% of hypertensive patients had the desirable range of body mass index. Moreover, diabetes constituted a common risk factor for hypertension among these patients (42.7%). Both hypercholesterolemia and hypertriglyceridemia were documented in 6.9% of patients. Only 3.2% of patients were smokers. Al-Owayyed [4] reported more prevalent risk factors among his series of hypertensive patients than that identified in the present study. He stated that 64% of the hypertensive patients attending the Riyadh Armed Forces Hospital Family and Community Medicine Department were diabetic. Only 20% had the desirable body mass index, more than 30% had hypercholesterolemia while 36% had hypertriglyceridemia. Moreover, he explained the low reported prevalence for smoking by the fact that primary health care physicians are frequently reluctant to ask a lady or an old man about smoking, as smoking is not an acceptable social practice in the Saudi Arabian culture, especially among ladies. Regarding structure, the present study revealed the complete absence of a dietitian, a social worker or a physician who can carry out ophthalmoscopy. There was no written management protocol for hypertension for the physicians to use in diagnosis and treatment of attending hypertensive patients. Moreover, none of the primary health care physicians attended any training courses about hypertension or the proper handling of medical records. Health education efforts are limited to direct inter-

7 Mohammad M. Mogbel & A bdullah A. Khawaji 59 views through counseling sessions between the physician and the patient. Some health education materials (e.g., videotapes) were completely lacking. Regarding process, analysis of the patients records in the present study showed that referral of patients to the secondary health care level for conducting laboratory tests as a part of the routine annual check-up was not optimal. More than one third of patients referred to the secondary health care level to conduct serum cholesterol and triglycerides did not provide any feed back. The main reasons for that lack of feed-back were identified as patients did not like to go to the crowdy secondary health care hospital, and the laboratory was frequently short of the necessary reagents. The present study showed that, as indicated by the patients records, most patients were generally categorized by their physician as compliant as regard medication, diet and appointment, as the prevalence rates of poor compliance were low (9.6%, 10.6 and 9.2%, respectively). However, by revising their follow-up data, it has been proved very clearly that compliant patients' blood pressure readings, body weight as well as number and dates of their visits do not reflect any degree of compliance. General physical examination was largely neglected by the physician. Even those patients who are complicated by systemic diseases (e.g., diabetes) were not physically examined, while 11.5% of patients were referred to the secondary health care level facility. Health education was offered to almost all patients. Moreover, the mean score for process evaluation (out of 50) was The proportions of those attaining poor or fair was relatively high (37.6% and 40.4%, respectively). Al-Owayyed [4] reported a referral rate to specialists of 12.7%. The present study revealed several bottle-necks obstructing and impeding the free flow within the referral system between the primary and secondary health care levels. Apart from CBC and urinary examination for proteins (which are performed at the primary health care level), all routine investigations (including ECG) suffer from major shortage. Reasons for this critical problem include: unavailability of the necessary supplies at the primary health care facility (e.g., ECG papers), unavailability of reagents at the laboratory of the secondary health facility (e.g., triglycerides), busy schedule of specialists (e.g., ophthalmologist) leading to unacceptable waiting time by the patient, patient s non-compliance to go to the secondary health care facility. These bottle necks identified within the present study was similarly reported by Hooker et al. [14], who noted that the low response rate of participants to the individual practice reports and referrals suggest that most primary health care physicians do not consider systematic patient care to be a priority. Several studies of, amongst others, Grimshaw [17] and Feder [18] recommended a training intervention for physicians that will use social influence, personal feedback and the transfer of knowledge and skills to modify clinical behavior. Regarding outcome, the present study showed that systolic blood pressure control was achieved only in about one third of patients (37.2%) while diastolic blood pressure was controlled in less than one half of patients (47.2%). This finding is less than that stated by Al-Owayyed [4], who reported that more than 55% of the hypertensive patients at the Riyadh Armed Forces Hospital Family and Community Medicine Department had their blood pressure controlled. This is comparable to 53% in the Stern s study [19], 51 % in the Kekki study [20] and 50% in the Chan s study [21]. However, a higher level of control (74%) was reported in the study of Chan et al. [16]. Hooker et al. [14] noted that control of hypertension is never optimal. They stated the 'rule of halves' for hypertension, which states that 'half the people with high blood pressure are not known, half of those known are not treated ("rule 2") and half of those treated are not controlled. Consequently, only one in eight of the hypertensive population is receiving optimal treatment. Systemic complications were diagnosed among hypertensive patients in the present study, i.e., 5% cardiac, 1.4% renal, 1.8% CNS and 2.8% retinal. The low prevalence of systemic complications may emphasize the importance of follow-up of hypertensive patients as a strategy to control BP and minimize complications. However, Al-Owayyed [4] warned that this finding does not reflect the real state, because patients who suffer from complications usually bypass the primary health care facility and are more seen at the secondary and tertiary care levels, e.g., nephrology or cardiology units. In conclusion, the main risk factors for hypertension include diabetes and obesity. Primary health care physicians are not trained on proper registration and documentation of medical records. The PHCC lacks a standardized protocol for management of hypertension. The health care team does

8 60 Audit of Hypertension Care in a Primary Health Care Center not include a dietitian, social workers or a physician qualified to carry out fundoscopy. The primary health care process needs improvement. The physician s judgment concerning compliance of patients is purely subjective and lacks much objectivity and standards of judgment. The general physical examination of hypertensive patients is usually ignored by the primary health care physicians. The success rates for control of blood pressure of hypertensive patients are low. It is recommended that the above mentioned negative findings should be dealt with accordingly. Moreover, audit studies should be performed at several primary health care centers caring for other chronic diseases, e.g., diabetes, chronic obstructive lung diseases, etc. References 1- AHYA S.N., FLOOD K. and PARANJOTHI S.: The Washington Manual of Medical Therapeutics. 30th Edition, Lippincott Williams & Wilkins Philadelphia, 76, CHAN P.D. and JOHNSON M.T.: Treatment Guidelines for Medicine and Primary Care, First Indian Edition, Sumaiyh Distributors PVT limited New Delhi, 29, Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report. Archives of Internal Medicine, 153: , AL-OWAYYED A.: Hypertension care in a family and community medicine department: An audit of process and outcome. Saudi Medical Journal, 17 (1): 18-25, Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The seventh report. JAMA, 289, RAKEL ROBERT E.: Textbook of family practice. Sixth Edition, Philadelphia London New York, 757, WOLF-MAIER K. et al.: Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States, 289 (18): 2363, NEAL B., MACMAHON S. and CHAPMAN N.: Effects of ACE inhibitors, calcium antagonists, and other bloodpressure-lowering drugs. Lancet, 356: , OGDEN L.G., HE J., LYDICK E. and WHELTON P.K.: Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension, 35: , AHMED M.E.K. and EL-AWAD I.B.: Blood pressure control and target organ complications among hypertensive patients in southern Saudi Arabia. Eastern Mediterranean Health Journal, Vol. 7, Nos. 4/5: , AL MAZROU Y.Y. and FARAG M.K.: Quality Assurance in primary health care manual. First Edition, Riyadh, , AL-SHARIF A.I. and AL-KHALDI Y.M.: Resource availability for care of hypertensives at primary health settings in southwestern Saudi Arabia Saudi Med. J., 24 (5): , KHATTAB et al.: Audit of diabetic care in an academic family practice center in Asir Region, Saudi Arabia. Diabetic Research, 31: , SCHELTENS T., BOTS M.L., NUMANS M.E., GROBBEE D.E. and HOES A.W.: Awareness, treatment and control of hypertension: The 'rule of halves' in an era of riskbased treatment of hypertension. Journal of Human Hypertension, 21 (2): , MITCHELL E., SULLIVAN F., GRIMSHAW J.M., DON- NAN P.T. and WATT G.: Improving management of hypertension in general practice: a randomised controlled trial of feedback derived from electronic patient data. Br. J. Gen. Pract, 55 (511): , CHAN S.C., CHANDRAMANI T., CHEN T.Y., CHONG K.N., HARBAKSH S., LEE T.W., LIN H.G., SHEIKH A., TAN C.W. and TEOH L.C.: Audit of hypertension in general practice. Med. J. Malaysia, 60 (4): , GRIMSHAW J. and RUSSELL I.: Effect of clinical guidelines on medical practice: A systematic review of rigorous evaluations. Lancet, 342: , FEDER G., GRIFFITHS C., HIGHTON C. et al.: Do clinical guidelines, introduced with practice based education, improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in East London. Br. Med. J., 311: , STERN D.: Management of hypertension in twelve Oxfordshire General Practices. J. R. Coll. Gen. Pract, 36: , KEKKI P.: Assessing the adequacy of anti-hypertensive treatment in a health centre in Finland. J. R. Coll. Gen. Pract, 31: , CHAN S.C., LEE T.W., TEOH L.C., ABDULLAH Z.C., XAVIER G., SIM C.K., NG A.C., ONG I.C., BEGUM R. and LEONG C.C.: Audit on cardiovascular disease preventive care in general practice. Singapore Med. J., 49 (4): 311-5, 2008.