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Physicians' approach to the management of hypertension in a developing community
International
Journal
of Cardiology
51 (1995)
193-197
Physicians’ approach to the management of hypertension in a developing community * Joel 0-B. Olubodun’ Dept of Medicine,
Obafemi
Awolowo
College of Health Sciences, Ogun State PMB 2001, Shagamu, Nigeria
Received
23 January
1995; accepted
University
Teaching
Hospital,
6 June 1995
Abstract General physicians’
(GP) approach
to the management
of hypertension
was assessed by a standard questionnaire.
Each of the 42 physiciansstudiedseeabout 42 patientsin a clinic day. Over half do not usually measurethe blood pressure (BP) of all new patients. A third do not investigate before starting therapy. Over half commence drug therapy with less than three BP readings, while over two thirds do so from appropriate
BP levels. Over 70% employ sedatives
in treatment(50%asthe only initial therapy); 45%employ parenteraldrugsfrom a diastolicBP of 110nnnHg. Over 40%do not educatetheir patientson the implicationsof hypertensionandthe needfor regulartreatmentandfollow-up, but mostgive follow-up appointments.Patientsare requestedto stop therapy onceBP is normalisedby 25.9%of GPs. Thesepracticeswerenot significantlyinfluencedby yearsof experienceor by beinga GP in a teachinghospitalsystem (P > 0.1 and P > 0.5, respectively). The study suggests that physician recognition and management of hypertension is still inadequateand this might in part be related to a generalheavy patient load. In addition, continuedmedical education is essential for physicians for the purpose of improving our management skills. Keywords:
General
physician;
Hypertension;
Management;
Treatment;
Compliance;
Education;
Developing
com-
munity
1. Introduction Hypertension is known to be one of the most common cardiovascular diseasesin our adult population [l]. Recent reports suggestit might in fact be the most common 121.Except for the prevalence *An
abstract
of this work
was presented
at the 6th Intema-
tional Interdisciplinary Conference on Hypertension in Blacks, Salvador,
Bahia, Brazil, l-5 August 1991. address: Dept of Medicine/Nephrology, University of Newcastle Upon Tyne, Ward 4, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN, UK.
‘Present
0167-5273/95/$09.50 0 1995 Elsevier SSDI 0167-5273(95)02409-P
Science
Ireland
Ltd. All rights
cited for various occupational and social groups, the prevalence for our population is not known. Most of our detected hypertensives present late [3] and comply poorly with therapy and clinic appointment [4], with a resultant high morbidity and mortality [5]. Even in parts of developed communities, it is observed that half of hypertensives might not be detected, half of the detected are untreated and half of the treated are uncontrolled (the rule of halves) [6], and in general, blood pressure detection and management appear quite inadequate [7]. Studies carried out among some reserved
194
J.O.B.
Olubodun
/International
hypertensives suggest that physicians might be partly to blame with regard to the poor detection and drug compliance in hypertension [4,8]. To identify the cause(s) of ineffective management of hypertension, three aspects need to be closely examined: The management of the disease by the physician - is he/she rendering effective management?; the receiver of the management (the patient) - is he/she cooperating and complying with the management?; the agent(s) used in treatment - is it readily available to the patient and, if so, is it effective? This study tries to examine the first aspect. Following a study suggesting that ignorance is the major reason for poor drug compliance in our environment [4], this study was carried out to assess and evaluate the approach of general physicians (GPs) to the management of hypertension. It is believed this will help in a further understanding of the complex problems of poor drug compliance and blood pressure control in our hypertensives. 2. Materials
and methods
A questionnaire aimed at obtaining information directly from GPs regarding their approach to the management of hypertension was designed for this study. GPs were chosen because they occupy a key position in the management of hypertension. They have the first contact with most patients and, if they fail to make the diagnosis early, their patients may escape diagnosis until a stage of complication. All the GPs in two university health centres and one Polytechnic health centre, the general outpatient and staff clinics of two teaching hospitals and randomly selected private hospitals in two of the states in Nigeria were studied. Letters were written to the physicians informing them of the study and urging them to complete the questionnaire while the bearer waited. The questionnaire was comprised of structured questions covering the following themes: sex, number of years in practice and medical degrees, diagnostic approach, including the level of diastolic blood pressure at which treatment is usually instituted, drugs usually first prescribed, levels at which parenteral drugs are employed, information on health education and follow-up programmes
Journal
of Cardiology
51 (1995)
193-197
and the average number of patients attended to on a weekly basis. The questions were intended to find out the usual approach of physicians to the management of hypertension, rather than whatever they know the books or standard teachings require. Therefore, to reduce the likelihood of withholding such vital information, names were not required on the questionnaire. Self-reported (habitual) practice as well as self-administered questionnaires have been reported to be reliable [9]. Mean values were calculated + S.E.M. while chi-squared test was used to assess the difference between proportional values. 3. Results This is a pilot study of 42 GPs consisting of 22 males and 20 females. They consisted of 28 GPs in government-owned hospitals, health centres of higher institutions and privately owned hospitals and 14 in general outpatient departments of teaching hospitals. Three of the physicians approached could not complete the questionnaire. They have been qualified and been in medical practice for 1 to 27 years (mean 9.7 f 1.0). They have their clinics on a daily basis with a patient load of 60 to 800 per week (mean 207.5 f 29.9 per clinic week; 41.5 per clinic day). However, 2 very senior physicians who head their units do more of administrative work and therefore see an average of 10 and 20 patients per week, respectively. Twenty two GPs (52.4%) do not usually measure the blood pressure of most of their new patients. This practice is not influenced by years of experience in medical practice (P > 0.1). Fig. 1 shows the diastolic blood pressure (DBP) level at which the practitioners diagnose hypertension and institute therapy, i.e., below these levels, they will not treat. Over two-thirds start drug treatment at appropriate BP levels, while less than a third do so prematurely. 12% and 43% begin treatment after the first and second blood pressure readings, respectively, while only 38% do so after taking three readings. 31% begin treatment the same day of detecting what is considered a high blood pressure. Similarly, 31% do not investigate hypertensives before instituting therapy. With regards to drug therapy, 50% of the practi-
J.O. B. Olubodun
/ International
Journal
of Cardiology
51 (1995)
195
193-197
loo-
80 -
n >130
>llO Diastolic
blood
pressure
Diastolic
blood
pressure
at which partnteral
NR drug given
Fig. 1. The level of diastolic blood pressure at which the physicians diagnose and institute therapy for hypertension.
Fig. 3. Diastolic blood pressure levels at which parenteral antihypertensives are usually instituted. NR, no response.
tioners first treat their new hypertensives with sedatives only, on the presumption of a background anxiety, while 21.4% treat with both sedatives and anti-hypertensives, and the remaining 28.6% treat with anti-hypertensives alone (Fig. 2). 45.2% institute parenteral anti-hypertensives from DBP of 110 mmHg, as against 38% who do so from DBP of 130 mmHg (Fig. 3). Diazepam (for presumable anxiety), thiazide diuretics, methyl dopa and intravenous hydrallazine were the drugs mostly employed. Overall, 24 (57.1%) usually give their patients a limited form of health
education regarding the need for regular and indefinite treatment and follow-up while 18 (42.9%) do not usually do so. The 24 consisted of 10 (71.4%) of the 14 who practice in the teaching hospital system and 14 (50%) of the 28 practicing outside the teaching hospital. This difference is, however, not statistically significant (P > 0.05). Therefore, being a general physician in a teaching hospital system does not appear synonymous with better practice in terms of appropriate patient education. This practice is also not related to years of medical practice (P > 0.1). However, most of the physicians give patients follow-up appointments and ask about drug regularity. 25.9% request their hypertensive patients to stop drug therapy when blood pressure returns to normal. 4. Discussion
lnltlal
treatment
coven
Fig. 2. The initial therapy usually instituted by the physicians. Anti-HT, anti-hypertensive.
Most of the GPs studied do not usually measure the blood pressure of all their new patients. ‘Unfortunately’ or rather ‘fortunately’, hypertension is only diagnosed by measuring the blood pressure. However, it is quite significant that these physicians each attend to an average of 42 patients each clinic. With such heavy patient load, it is impracticable for physicians to measure the blood pressure of all patients. Ways of dealing with this problem include increased involvement of nurses
196
J.O.B.
Ohbodun
/International
Journal
in blood pressure measurement and a ‘spaced out’ appointment system as previously advocated [lo]. The management of hypertension appears to pose a great problem worldwide, as some studies in the western world also indicate that 75% of men and 58% of women were not receiving satisfactory treatment [6] and that only 49% of American hypertensives might be on treatment with only 21% controlled [I 11. The study further indicates that hypertension is sometimes diagnosed and treatment started at inappropriate blood pressure levels. This practice appears to be independent of years of experience. A practice based on the World Health Organisation criteria for diagnosing and starting treatment for hypertension remains standard teaching in medical schools and should be maintained as standard practice. The ‘routine’ use of sedatives in hypertension is unjustified. The reason for employing intravenous therapy from DBP of 110 mmHg is unknown. This is probably based on a misconception of the cutoff point for severe hypertension. The use of parenteral anti-hypertensives should be strictly reserved for hypertensive crises (encephalopathy, malignant). Cerebrovascular events increase at diastolic pressures below 80-90 mmHg in longstanding hypertensives [ 121 as a result of readjustment of cerebral autoregulation [ 131. Three recently reported cases illustrate this [14]. Caution should therefore be exercised in lowering blood pressure. Though the tradition is not to discontinue therapy in hypertensives, recent evidence suggests that this may be reviewed, though carefully and with follow-up, in those who have had a good control for some years [ 151. It is appreciated that the investigation of hypertension might be hindered in some centres as a result of limited facilities coupled with the ‘pay-asit-is-done’ system of health care in our hospitals. This is unaffordable to most patients, in a setting where the individual is largely responsible for health care costs. Despite this, however, affordable tests should be done where indicated. Poor drug compliance in our patients was observed to be mostly due to ignorance and only secondarily due to economic reasons, and the former appeared to be a result of failure of proper education [4]. The
of Cardiology
51 (1995)
193-197
present study appears to support this. A few studies have pointed to physician non-compliance in taking certain simple tests to improve their patients’ compliance [ 16,171. The doctor-patient communication gap needs to be ‘bridged’ and the physician has to take the initiative. While our inadequacies might partly be related to heavy patient load and limitation of facilities, we must be mindful of the need for improving our management skills through continued education [ 16,181, which has been found to be highly effective [ 191. The establishment of small education and social worker units in our major hypertension clinics, as is done in some diabetic clinics, might partly resolve the inadequacies resulting from heavy patient load [S]. Funding is required for a larger scale study of this subject (for which a protocol has been written) among physicians involved in managing hypertension. References
ill
Akinkugbe 00. World epidemiology of hypertension in blacks. In: Hall W, Saunders E, Shulman NB, editors. Hypertension in Blacks: Epidemiology, Pathophysiology and Treatment. Chicago: Year Book Med Pub, 1985; 3-16. disease in el121 Olubodun JOB, Ambali A. Cardiovascular derly Nigerians seen in a new Teaching Hospital. Cardiol Elderly 1994; 2: 511-515. JOB, Cole TO, Falase AO, Lawal SOA. Elec[31 Olubodun trocardiographic hypertrophic patterns in hypertensive Nigerians. Int J Cardiol 1991; 30: 97-102. JOB, Falase AO, Cole TO. Drug compliance [41 Olubodun in hypertensive Nigerians with and without heart failure. Int J Cardiol 1990; 27: 229-234. from stroke and other complications 151 Anim JT. Mortality of hypertension in Accra. W Afr J Med 1984; 3: 85-90. H. 161 Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe Control of blood pressure in Scotland: the rule of halves. Br Med J 1990; 300: 981-983. and management of hy[71 Kurji KH, Hains AP. Detection pertension in general practices in North West London. Br Med J 1984; 288: 903-906. BG. Strategies to imIs1 Reichgott MJ, Simmons-Morton prove patient compliance with antihypertensive therapy. Primary Care 1983; 10: 21-27. MB, Stemberg B. Assessment of salt use at 191 Mittelmark the table: Comparison of observed and reported behaviour. Am J Pub1 Health 1985; 75: 1215-1216. 1101Olubodun JOB. Essential hypertension in a developing community: Obstacles to early detection and effective treatment. Afr Health 1991; 13: 25-26.
J.O.B.
Olubodun
/International
[l l] National High Blood Pressure Education Program Working Group Report on Primary Prevention of Hypertension. Arch Int Med 1993; 153: 186-208. [12] Beevers DG. Overtreating hypertension. Br Med J 1988; 297: 1212-1213. [13] Anonymous. Dangerous antihypertensive treatment. Br Med J 1979; ii: 228-229. [14] Olubodun JOB. Management of hypertensive crises: A call to caution. Afr Health 1992; 14: 34-35. [15] Hundson MF. How often can antihypertensive treatment be discontinued? J Hum Hypertens 1988; 2: 65-69. [16] Fletcher CN. The art of clinical communication. Med Digest 1981; 7(4): 5-11.
Journal
of Cardiology
51 (1995)
193-197
197
[17] Blackwell B, Gutmann NC. Compliance. In: Birkenhager WH, Reid JL, Bulpitt CJ, editors. Handbook of Hypertension: Epidemiology of Hypertension. Pub. Elsevier, Amsterdam 1985: 453-472. [18] Nosier N, Wood D. Management of hypertension: the problem of physician adherence. J Am Med Assoc 1976; 235: 2297. [19] Inui TS, Yourtee EL, Williamson JW. Improved outcomes in hypertension after physician tutorials: a controlled trial. Ann Int Med 1976: 84: 646-651.
Journal
of Cardiology
51 (1995)
193-197
Physicians’ approach to the management of hypertension in a developing community * Joel 0-B. Olubodun’ Dept of Medicine,
Obafemi
Awolowo
College of Health Sciences, Ogun State PMB 2001, Shagamu, Nigeria
Received
23 January
1995; accepted
University
Teaching
Hospital,
6 June 1995
Abstract General physicians’
(GP) approach
to the management
of hypertension
was assessed by a standard questionnaire.
Each of the 42 physiciansstudiedseeabout 42 patientsin a clinic day. Over half do not usually measurethe blood pressure (BP) of all new patients. A third do not investigate before starting therapy. Over half commence drug therapy with less than three BP readings, while over two thirds do so from appropriate
BP levels. Over 70% employ sedatives
in treatment(50%asthe only initial therapy); 45%employ parenteraldrugsfrom a diastolicBP of 110nnnHg. Over 40%do not educatetheir patientson the implicationsof hypertensionandthe needfor regulartreatmentandfollow-up, but mostgive follow-up appointments.Patientsare requestedto stop therapy onceBP is normalisedby 25.9%of GPs. Thesepracticeswerenot significantlyinfluencedby yearsof experienceor by beinga GP in a teachinghospitalsystem (P > 0.1 and P > 0.5, respectively). The study suggests that physician recognition and management of hypertension is still inadequateand this might in part be related to a generalheavy patient load. In addition, continuedmedical education is essential for physicians for the purpose of improving our management skills. Keywords:
General
physician;
Hypertension;
Management;
Treatment;
Compliance;
Education;
Developing
com-
munity
1. Introduction Hypertension is known to be one of the most common cardiovascular diseasesin our adult population [l]. Recent reports suggestit might in fact be the most common 121.Except for the prevalence *An
abstract
of this work
was presented
at the 6th Intema-
tional Interdisciplinary Conference on Hypertension in Blacks, Salvador,
Bahia, Brazil, l-5 August 1991. address: Dept of Medicine/Nephrology, University of Newcastle Upon Tyne, Ward 4, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN, UK.
‘Present
0167-5273/95/$09.50 0 1995 Elsevier SSDI 0167-5273(95)02409-P
Science
Ireland
Ltd. All rights
cited for various occupational and social groups, the prevalence for our population is not known. Most of our detected hypertensives present late [3] and comply poorly with therapy and clinic appointment [4], with a resultant high morbidity and mortality [5]. Even in parts of developed communities, it is observed that half of hypertensives might not be detected, half of the detected are untreated and half of the treated are uncontrolled (the rule of halves) [6], and in general, blood pressure detection and management appear quite inadequate [7]. Studies carried out among some reserved
194
J.O.B.
Olubodun
/International
hypertensives suggest that physicians might be partly to blame with regard to the poor detection and drug compliance in hypertension [4,8]. To identify the cause(s) of ineffective management of hypertension, three aspects need to be closely examined: The management of the disease by the physician - is he/she rendering effective management?; the receiver of the management (the patient) - is he/she cooperating and complying with the management?; the agent(s) used in treatment - is it readily available to the patient and, if so, is it effective? This study tries to examine the first aspect. Following a study suggesting that ignorance is the major reason for poor drug compliance in our environment [4], this study was carried out to assess and evaluate the approach of general physicians (GPs) to the management of hypertension. It is believed this will help in a further understanding of the complex problems of poor drug compliance and blood pressure control in our hypertensives. 2. Materials
and methods
A questionnaire aimed at obtaining information directly from GPs regarding their approach to the management of hypertension was designed for this study. GPs were chosen because they occupy a key position in the management of hypertension. They have the first contact with most patients and, if they fail to make the diagnosis early, their patients may escape diagnosis until a stage of complication. All the GPs in two university health centres and one Polytechnic health centre, the general outpatient and staff clinics of two teaching hospitals and randomly selected private hospitals in two of the states in Nigeria were studied. Letters were written to the physicians informing them of the study and urging them to complete the questionnaire while the bearer waited. The questionnaire was comprised of structured questions covering the following themes: sex, number of years in practice and medical degrees, diagnostic approach, including the level of diastolic blood pressure at which treatment is usually instituted, drugs usually first prescribed, levels at which parenteral drugs are employed, information on health education and follow-up programmes
Journal
of Cardiology
51 (1995)
193-197
and the average number of patients attended to on a weekly basis. The questions were intended to find out the usual approach of physicians to the management of hypertension, rather than whatever they know the books or standard teachings require. Therefore, to reduce the likelihood of withholding such vital information, names were not required on the questionnaire. Self-reported (habitual) practice as well as self-administered questionnaires have been reported to be reliable [9]. Mean values were calculated + S.E.M. while chi-squared test was used to assess the difference between proportional values. 3. Results This is a pilot study of 42 GPs consisting of 22 males and 20 females. They consisted of 28 GPs in government-owned hospitals, health centres of higher institutions and privately owned hospitals and 14 in general outpatient departments of teaching hospitals. Three of the physicians approached could not complete the questionnaire. They have been qualified and been in medical practice for 1 to 27 years (mean 9.7 f 1.0). They have their clinics on a daily basis with a patient load of 60 to 800 per week (mean 207.5 f 29.9 per clinic week; 41.5 per clinic day). However, 2 very senior physicians who head their units do more of administrative work and therefore see an average of 10 and 20 patients per week, respectively. Twenty two GPs (52.4%) do not usually measure the blood pressure of most of their new patients. This practice is not influenced by years of experience in medical practice (P > 0.1). Fig. 1 shows the diastolic blood pressure (DBP) level at which the practitioners diagnose hypertension and institute therapy, i.e., below these levels, they will not treat. Over two-thirds start drug treatment at appropriate BP levels, while less than a third do so prematurely. 12% and 43% begin treatment after the first and second blood pressure readings, respectively, while only 38% do so after taking three readings. 31% begin treatment the same day of detecting what is considered a high blood pressure. Similarly, 31% do not investigate hypertensives before instituting therapy. With regards to drug therapy, 50% of the practi-
J.O. B. Olubodun
/ International
Journal
of Cardiology
51 (1995)
195
193-197
loo-
80 -
n >130
>llO Diastolic
blood
pressure
Diastolic
blood
pressure
at which partnteral
NR drug given
Fig. 1. The level of diastolic blood pressure at which the physicians diagnose and institute therapy for hypertension.
Fig. 3. Diastolic blood pressure levels at which parenteral antihypertensives are usually instituted. NR, no response.
tioners first treat their new hypertensives with sedatives only, on the presumption of a background anxiety, while 21.4% treat with both sedatives and anti-hypertensives, and the remaining 28.6% treat with anti-hypertensives alone (Fig. 2). 45.2% institute parenteral anti-hypertensives from DBP of 110 mmHg, as against 38% who do so from DBP of 130 mmHg (Fig. 3). Diazepam (for presumable anxiety), thiazide diuretics, methyl dopa and intravenous hydrallazine were the drugs mostly employed. Overall, 24 (57.1%) usually give their patients a limited form of health
education regarding the need for regular and indefinite treatment and follow-up while 18 (42.9%) do not usually do so. The 24 consisted of 10 (71.4%) of the 14 who practice in the teaching hospital system and 14 (50%) of the 28 practicing outside the teaching hospital. This difference is, however, not statistically significant (P > 0.05). Therefore, being a general physician in a teaching hospital system does not appear synonymous with better practice in terms of appropriate patient education. This practice is also not related to years of medical practice (P > 0.1). However, most of the physicians give patients follow-up appointments and ask about drug regularity. 25.9% request their hypertensive patients to stop drug therapy when blood pressure returns to normal. 4. Discussion
lnltlal
treatment
coven
Fig. 2. The initial therapy usually instituted by the physicians. Anti-HT, anti-hypertensive.
Most of the GPs studied do not usually measure the blood pressure of all their new patients. ‘Unfortunately’ or rather ‘fortunately’, hypertension is only diagnosed by measuring the blood pressure. However, it is quite significant that these physicians each attend to an average of 42 patients each clinic. With such heavy patient load, it is impracticable for physicians to measure the blood pressure of all patients. Ways of dealing with this problem include increased involvement of nurses
196
J.O.B.
Ohbodun
/International
Journal
in blood pressure measurement and a ‘spaced out’ appointment system as previously advocated [lo]. The management of hypertension appears to pose a great problem worldwide, as some studies in the western world also indicate that 75% of men and 58% of women were not receiving satisfactory treatment [6] and that only 49% of American hypertensives might be on treatment with only 21% controlled [I 11. The study further indicates that hypertension is sometimes diagnosed and treatment started at inappropriate blood pressure levels. This practice appears to be independent of years of experience. A practice based on the World Health Organisation criteria for diagnosing and starting treatment for hypertension remains standard teaching in medical schools and should be maintained as standard practice. The ‘routine’ use of sedatives in hypertension is unjustified. The reason for employing intravenous therapy from DBP of 110 mmHg is unknown. This is probably based on a misconception of the cutoff point for severe hypertension. The use of parenteral anti-hypertensives should be strictly reserved for hypertensive crises (encephalopathy, malignant). Cerebrovascular events increase at diastolic pressures below 80-90 mmHg in longstanding hypertensives [ 121 as a result of readjustment of cerebral autoregulation [ 131. Three recently reported cases illustrate this [14]. Caution should therefore be exercised in lowering blood pressure. Though the tradition is not to discontinue therapy in hypertensives, recent evidence suggests that this may be reviewed, though carefully and with follow-up, in those who have had a good control for some years [ 151. It is appreciated that the investigation of hypertension might be hindered in some centres as a result of limited facilities coupled with the ‘pay-asit-is-done’ system of health care in our hospitals. This is unaffordable to most patients, in a setting where the individual is largely responsible for health care costs. Despite this, however, affordable tests should be done where indicated. Poor drug compliance in our patients was observed to be mostly due to ignorance and only secondarily due to economic reasons, and the former appeared to be a result of failure of proper education [4]. The
of Cardiology
51 (1995)
193-197
present study appears to support this. A few studies have pointed to physician non-compliance in taking certain simple tests to improve their patients’ compliance [ 16,171. The doctor-patient communication gap needs to be ‘bridged’ and the physician has to take the initiative. While our inadequacies might partly be related to heavy patient load and limitation of facilities, we must be mindful of the need for improving our management skills through continued education [ 16,181, which has been found to be highly effective [ 191. The establishment of small education and social worker units in our major hypertension clinics, as is done in some diabetic clinics, might partly resolve the inadequacies resulting from heavy patient load [S]. Funding is required for a larger scale study of this subject (for which a protocol has been written) among physicians involved in managing hypertension. References
ill
Akinkugbe 00. World epidemiology of hypertension in blacks. In: Hall W, Saunders E, Shulman NB, editors. Hypertension in Blacks: Epidemiology, Pathophysiology and Treatment. Chicago: Year Book Med Pub, 1985; 3-16. disease in el121 Olubodun JOB, Ambali A. Cardiovascular derly Nigerians seen in a new Teaching Hospital. Cardiol Elderly 1994; 2: 511-515. JOB, Cole TO, Falase AO, Lawal SOA. Elec[31 Olubodun trocardiographic hypertrophic patterns in hypertensive Nigerians. Int J Cardiol 1991; 30: 97-102. JOB, Falase AO, Cole TO. Drug compliance [41 Olubodun in hypertensive Nigerians with and without heart failure. Int J Cardiol 1990; 27: 229-234. from stroke and other complications 151 Anim JT. Mortality of hypertension in Accra. W Afr J Med 1984; 3: 85-90. H. 161 Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe Control of blood pressure in Scotland: the rule of halves. Br Med J 1990; 300: 981-983. and management of hy[71 Kurji KH, Hains AP. Detection pertension in general practices in North West London. Br Med J 1984; 288: 903-906. BG. Strategies to imIs1 Reichgott MJ, Simmons-Morton prove patient compliance with antihypertensive therapy. Primary Care 1983; 10: 21-27. MB, Stemberg B. Assessment of salt use at 191 Mittelmark the table: Comparison of observed and reported behaviour. Am J Pub1 Health 1985; 75: 1215-1216. 1101Olubodun JOB. Essential hypertension in a developing community: Obstacles to early detection and effective treatment. Afr Health 1991; 13: 25-26.
J.O.B.
Olubodun
/International
[l l] National High Blood Pressure Education Program Working Group Report on Primary Prevention of Hypertension. Arch Int Med 1993; 153: 186-208. [12] Beevers DG. Overtreating hypertension. Br Med J 1988; 297: 1212-1213. [13] Anonymous. Dangerous antihypertensive treatment. Br Med J 1979; ii: 228-229. [14] Olubodun JOB. Management of hypertensive crises: A call to caution. Afr Health 1992; 14: 34-35. [15] Hundson MF. How often can antihypertensive treatment be discontinued? J Hum Hypertens 1988; 2: 65-69. [16] Fletcher CN. The art of clinical communication. Med Digest 1981; 7(4): 5-11.
Journal
of Cardiology
51 (1995)
193-197
197
[17] Blackwell B, Gutmann NC. Compliance. In: Birkenhager WH, Reid JL, Bulpitt CJ, editors. Handbook of Hypertension: Epidemiology of Hypertension. Pub. Elsevier, Amsterdam 1985: 453-472. [18] Nosier N, Wood D. Management of hypertension: the problem of physician adherence. J Am Med Assoc 1976; 235: 2297. [19] Inui TS, Yourtee EL, Williamson JW. Improved outcomes in hypertension after physician tutorials: a controlled trial. Ann Int Med 1976: 84: 646-651.