Hypertension is the leading risk factor for mortality in India and is associated with an estimated 1.6 million deaths from heart diseases and strokes every year. For this reason, the Indian government’s hypertension guidelines recommend that doctors opportunistically screen all adults for hypertension at all points of care, regardless of what patients initially sought care for. Despite this guideline, the majority of Indians with hypertension are still undiagnosed, suggesting that clinicians may not consistently test for high blood pressure. However, there has been limited research into how consistently doctors in India adhere to hypertension screening guidelines.
Prof. Dr. Nikkil Sudharsanan, Head of the Assistant Professorship of Behavorial Science for Disease Prevention and Health Care, conducted a study with other scientists from the USA and India to investigate the extent to which clinicians follow the guidelines for hypertension screening. The results have now been published in the journal "JAMA Network Open" under the title "Clinican Adherence to Hypertension Screening and Care Guidelines in Urban India". The journal has an impact factor of 13.353.
As part of the study, local survey staff posed as patients suffering from lower back pain (a condition unrelated to hypertension) and visited 301 randomly selected primary healthcare facilities in the two cities of Chennai and Kolkata. After each visit, the staff reported on the clinical interventions they received from the physicians. In accordance with Indian guidelines, the study investigated whether the doctors measured blood pressure at all, whether they measured blood pressure at least twice, whether they communicated the measured values to the patient, and whether they advised a follow-up examination if the blood pressure was above 140/90.
"We call this approach a standardized patient or 'mystery shopper experiment', which is considered the gold standard," explains Prof. Sudharsanan, first author of the publication. "The doctors must not know that their examinations are being analyzed. The procedure has been used in many other studies, but we were the first to apply it to hypertension screening."
Across the 301 visits, fifty-two percent of the clinics measured the patients' blood pressure at least once and only seven percent measured it at least twice. In just over half (55%) of the visits, the standardized patients whose blood pressure was measured were also informed of the measurement results. The standardized patients had high blood pressure in 19 out of 157 visits (12.1%) where blood pressure was measured. In just over a quarter (26%) of the visits, the doctors advised a follow-up appointment.
Private facilities were far more likely to measure blood pressure at least once (77%) compared to public facilities (25%). Regardless of the measurement, male patients (75%) were also more likely to receive information about their high blood pressure than female patients (43%).
In general, it was found that clinicians only follow the guidelines for opportunistic hypertension screening to a limited extent. According to the guidelines, all adults should have their blood pressure measured during a visit to the practice, but screening actually only takes place in around half of consultations. There was also evidence of poor communication of the results. These findings suggest that hypertension is likely to be significantly underdiagnosed in urban areas in India because doctors often omit essential screening measures.
"The guidelines are an important health policy measure," says Prof. Sudharsanan. "In India, however, high blood pressure is generally underdiagnosed. Since Indian adults frequently visit medical facilities, we had actually expected the detection rates to be much higher."
The study suggests that quality-improvement interventions must be aimed directly at changing clinicians' behavior. Traditional approaches such as financial incentives and sanctions may be difficult to implement in India due to limited resources, oversight and regulation. Therefore, interventions such as clinical support systems, task shifting and non-financial incentives may be more effective.
To the publication „Clinician Adherence to Hypertension Screening and Care Guidelines in Urban India” in the journal „JAMA Network Open”
To the homepage of the Assistant Professorship of Behavioral Science for Disease Prevention and Health Care
Contact:
Prof. Dr. Nikkil Sudharsanan
Rudolf Mößbauer Assistant Professorship of Behavioral Science for Disease Prevention and Health Care
Georg-Brauchle-Ring 60/62
80992 München
phone: 089 289 24990
e-Mail: nikkil.sudharsanan(at)tum.de
Text: Romy Schwaiger
Photos: "JAMA Network Open”/private