We believe this is the first time that the RAND/UCLA Appropriateness Method has been used in South Africa to develop hypertension quality indicator statements from the hypertension management guidelines. From 102 guideline-based quality indicators, 45.1% of the quality indicators were rated both appropriate and feasible with agreement to improve the management of patients with diagnosed hypertension at the PHC level in South Africa.
Lifestyle and behavioural changes can lead to improved hypertension outcomes in mild hypertension without the need for antihypertensive treatment, and even in resistant hypertension (30), and it is important to maintain advice on a healthy lifestyle during drug therapy. Lifestyle advice is also important as previous research reported that 16.6% of people with hypertension indicated that financial difficulties were the cause of challenges in accessing medicines (31).
Monitoring intermediate outcomes in the management of hypertension is an important intervention in improving quality of care and patient outcomes (11,20-21,32). They assist with increasing the number of patients who are at the treatment goal of a blood pressure ≤140/90 mmHg and those currently not yet at their goal as well as informing future interventions for individual patients currently not at their treatment goals (8).
Whilst the panel agreed that all the indicators under the dimension ‘blood pressure levels’ were appropriate, they agreed that it was not feasible to determine the number or percentage of all patients with blood pressure above the target goal (>140/90 mmHg) in the context of PHC in South Africa. They were also equivocal on one of the indicators under this dimension, which was about determining the number or percentage of patients with controlled blood pressure (≤140/90 mmHg). The decisions of the panellists on the indicators under the dimension of ‘blood pressure levels’ can be considered appropriate, considering that the panellists found all the indicators in the dimension of ‘intermediate outcome’ as appropriate and feasible. All the indicators under the dimension ‘intermediate outcome’ are about the number or percentage of patients with a blood pressure of ≤ 140/90 mmHg with no adverse or medicine reactions in patients who are already on hypertension medication in different steps of the algorithm of hypertension management. The data on the indicators under the dimension ‘intermediate outcome’ can indirectly lead to the number of patients who are not at treatment target goals (blood pressure level). Consequently, the agreement of the panellists that the use of the indicators under the ‘blood pressure level’ is not feasible. Their decision may also have been based on the evidence that measuring quality requires measuring positive outcomes, count, or percentage of patients with a blood pressure of ≤ 140/90 mmHg in this case, and not vice versa (8).
The panel found most of the indicators under the dimension ‘treatment’ and ‘blood pressure level’ appropriate but either with equivocal feasibility or not feasible. Further work will be required to modify the indicators especially those encompassing adherence to the stepwise approach to the management of hypertension. Indicators rated appropriate and feasible under the dimension ‘referral’ may assist in identifying the data for which indicators, under the dimensions ‘blood pressure levels’ and ‘treatment’, were intended for. Based on the assumption that guidelines in the management of hypertension at the PHC level are adhered to, the indicators under the dimension ‘referrals’ would provide the measure in which the indicators under ‘blood pressure level’ and ‘treatment’ dimensions were intended for.
Most of the indicators under the dimensions ‘monitoring’ and ‘review of patients’ were found appropriate and feasible. These indicators underpin the importance of recording activities and measurements that should be undertaken with the patient during the visit and provide the basis for quality of health care actions addressed in other dimensions. This is also important as it facilitates population level data collection with accurate data, which can then be used to inform future interventions needed to improve and sustain the quality of care at the PHC level in South Africa.
Most of the indicators under the dimension ‘tests’ were also found appropriate and feasible. This is imperative as these indicators are about recording of the tests that were performed with patients. Consequently, providing a measure of whether the prescribed tests are conducted within the prescribed frequency amongst the hypertension patients at the PHC level in South Africa.
Conclusions and implications for patient care
As mentioned, hypertension currently exerts a considerable health and economic burden on South Africa (13), with evidence that patients are currently not receiving the necessary evidence-based care in PHC facilities (5,12). Moreover, the focus on monitoring patients with hypertension in South Africa is an imperative given the low levels of reported medication adherence (33), the fact that one‑third of patients often do not receive all their antihypertensive medicines from PHC facilities due to supply chain issues and generally poor access to quality care (7,12). Applying the care stated in these indicators would improve the outcomes, including their quality of life, amongst patients with confirmed diagnosis of hypertension being treated at the PHC level in South Africa.
The indicators and framework for hypertension management from this study can be replicated for the management of type 2 diabetes mellitus and other NCDs in South Africa, which is a priority of the National Department of Health (3). Substandard quality of care contributes to the global disease burden and unmet health need in the population (3,17). This is especially important given the high prevalence of hypertension among people with diabetes in Africa and the urgent need for an integrated differentiated service delivery (22). Better monitoring and management of patients with hypertension will lead to improved quality of care, reduced avoidable harm, morbidity and mortality and will result in a more efficient use of scarce health care resources.
Consequently, our findings have implications not only for key stakeholder groups in South Africa to improve the care of patients with hypertension in the public system, but also across Africa. This study used the RAM which promotes robust, credible, and valid hypertension quality indicators as this methodology combines the available scientific evidence and expert opinion in the management of hypertension (28, 34). It is a practical, real-world method, designed to identify appropriate clinical steps tailored to patient needs and grounded in everyday practice of practitioners and facilities (23). Unlike other consensus techniques such as the Delphi Technique, the RAM incorporates interactive discussion of indicator statements between panellists in Round 2. In addition, a multidisciplinary panel of experts, all involved in the day-to-day management of people with hypertension, and from different provinces of South Africa, were used in the development of possible indicators. The mixed sample of panellists resulted in a wide variation of relevant views to hypertension management, including members of the South African hypertension guidelines, to enhance the possible utility of considered indicators. Two people chaired the panel meeting, a clinical and a methodologist expert, to add strength to the process and findings. Online RAM panel meetings have been used successfully, in part in response to restrictions imposed by the COVID-19 pandemic, with online meetings at a reduced cost (34).
Hypertension is the leading modifiable cardiovascular disease risk factor in South Africa and this study provides a possible solution to the current lack of quality measuring tools of healthcare provided to patients with hypertension at the PHC level, by identifying 46 evidence-based quality indicators specifically tailor-made to suit South African public PHC level settings. In addition, in view of the overlap in risk factors, prognosis, and treatment of hypertension and diabetes, agreed indicators also provide a platform to improve the monitoring of the management of patients with diabetes in PHCs based on the hypertension monitoring template. This approach can subsequently be used to develop quality indicators for all other high priority NCDs in South Africa and elsewhere in Africa. The use of the RAM has enabled researchers and practitioners to develop a preliminary but clearly outlined framework of indicators for the monitoring and management of people with hypertension receiving care from PHC in South Africa. Sound and reliable information is the foundation of decision-making in healthcare and appropriate next clinical steps for people with confirmed NCDs (18).
The WHO, World Bank Group and OECD have identified five foundational elements critical to delivering quality health care services as being health care workers; health care facilities; medicines, devices, and other technologies; information systems; and financing (17). It is imperative to develop and apply a tested hypertension management framework that is congruent to these foundational elements in South Africa as well as Africa as a whole, to enhance the potential utility of applying the indicators. Outcomes from consensus techniques have face or content validity but the next step of the ongoing indicator development and testing protocol will be to test the 46 developed hypertension quality indicators for their data feasibility, reliability, and validity. In addition, to determine what implementation strategies might be needed in terms of workforce, facilities and medicines supply to apply the indicators at the PHC level in South Africa. Testing will also consider the clinimetric properties of the indicators to assess their value as measurement instruments as well as assess the appropriateness of hypertension management in the context of routine PHC/ambulatory care practice in South Africa, including the availability of routine data (35).