Adherence to cardiovascular risk factor modification in patients with hypertension.

AIM: The effectiveness of the support of a healthcare practitioner and a family member in producing changes in cardiovascular risk factor modification was tested in a randomised, controlled trial in patients with hypertension. METHODS: The primary outcome measured after the 24-week intervention was blood pressure change. Secondary outcomes included patients' adherence to the programme, their knowledge about hypertension, exercise capacity, body weight, self-reported ability to control stress, adherence to medication and salt restriction, as well as symptoms. RESULTS: There were no marked improvements in blood pressure regulation in either group. The differences between the experimental and control groups were 3 mmHg (CI -6.18-12.18) for systolic blood pressure and 4 mmHg (CI -1.48-9.48) for diastolic blood pressure. The estimated blood pressure effects were small increases in both diastolic and systolic blood pressure, due to larger changes in the control group. These small changes were of no clinical significance. This intervention was not successful in reducing blood pressure of hypertensive patients who participated in a lifestyle programme. Secondary outcomes did show positive changes as a result of the given intervention. The absolute difference in improvement between the two groups was significantly greater for the experimental group than for the control group for the following variables: 24% better adherence to the programme (p = 0.007); 10% higher mean percentage score of hypertension knowledge and its management (p = 0.04); 20% more patients could control their stress levels (p = 0.05); 26% more patients could control their salt ingestion (p = 0.02); and 20% had better adherence to their given medication regimen (p = 0.05). The experimental group had a statistically significant weight reduction of 1 (+/- 4) kg relative to the control group (p = 0.03). Both groups increased their exercise capacity during the trial (p = 0.03). On the completion of the intervention, significantly fewer patients in the experimental group than in the control complained of tiredness (p = 0.05). Patients who had a 75% adherence or more to the programme were found to have maintained their knowledge and their exercise capacity, but not their weight loss after a maintenance phase of 12 weeks, during which time there was no intervention. CONCLUSION: Patients in a supported environment such as the one in this study were able to modify their cardiovascular risk factors, even though there were non-significant changes in blood pressure reported in this study.

A survey of hospital outpatient services for chronic diseases in Gauteng.

OBJECTIVES: The rapid evaluation of hospital-based services for chronic non-communicable diseases, in particular aspects of the organisation of services, and indirect indicators of patient care. DESIGN: A postal survey of services for asthma, epilepsy, diabetes and hypertension at nine hospitals. Assessment over 1 week of single blood pressure (BP) and blood glucose readings at the hypertension and diabetes clinics at one regional hospital. SETTING: Nine community and secondary hospitals in Gauteng. RESULTS: Eight hospitals responded. Most did not provide specific clinics for each condition. None of the professional staff had received additional training in chronic disease management, and 7 considered their services to be understaffed. On average, nurses managed 33 patients per day (range 19-50), and doctors 53 (20-80). Mean consultation time was 9 minutes (4-20 minutes). Management guidelines were used for all conditions in 5 hospitals. Modern routine assessments were seldom employed. Estimates of regular patient attendance ranged from 25% to 75%. At the single hospital surveyed, hypertension (N = 233) was controlled in 42.5% of patients using World Health Organisation criteria (BP < 160/95), but in only 24.5% of patients by The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC6) standards (BP < 140/90). Random blood glucose was satisfactory (< 10 mmol/l) in 45.2% of diabetic patients (N = 157) while hypertension (N = 100) was well controlled (< 140/90) in 10% of hypertensive diabetic patients. CONCLUSIONS: Services for chronic diseases at non-academic hospitals in Gauteng were characterised by perceived inadequate staff numbers and training, short consultation times, infrequent use of management guidelines and standard assessments, little patient education with regard to self care, and perceived low rates of regular attendance (and hence compliance with medication). At one hospital there was a low rate of hypertension control, and unsatisfactory rates of acceptable glycaemic and BP control among diabetic patients. There is an urgent need for restructuring of services for chronic diseases and for more detailed outcomes research.

Voluntary total fasting in political prisoners--clinical and biochemical observations.

Thirty-three political prisoners on hunger strike (voluntary total fast--VTF) for 6-24 days were admitted to two hospitals in Johannesburg in 1989. They had been detained without trial for 4-32 months. Sound doctor-patient relationships were established by emphasis of the principle of full patient participation in clinical decision-making at every level, by rejection of police interference in patient care, and by refusal to discharge subjects back into detention. Depression and abdominal pains were the predominant symptoms. In 6 lean subjects with complete data the expected initial period of rapid weight loss was not observed. Before hospitalisation most subjects became dehydrated from inadequate fluid intake and an apparent absence of thirst. Serum creatinine concentrations were a better indication of dehydration than serum urea levels. Mild hyponatraemia was found in one-third of patients. Refeeding after 6-27 days of VTF was initiated with a dilute lactose-free formula diet, and was uncomplicated. Close clinical monitoring of subjects during VTF is essential, and it is recommended that prisoners should be admitted to hospital at 10% of weight loss, if not before. The health care of prisoners can best be provided by professionals independent of the police and prison services.