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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 6, November/December 2014
296
AFRICA
Comment
The importance of guidelines
Erika SW Jones, Brian L Rayner
The management of chronic diseases crosses the line between
primary healthcare and tertiary academic medicine. New
technologies are constantly being developed and treatment
options being better defined. This has resulted in the development
of multiple guidelines
1-3
in order to standardise appropriate
therapy for chronic diseases and to disseminate the information.
Guidelines highlight current literature and new evidence, and
they create an easy step-wise approach to the management of
diseases, the targets for disease control and the standards of care.
4
There is a growing prevalence of patients with hypertension
5
and diabetes mellitus.
6
The cardiovascular complications of
these disorders are well documented (including ischaemic heart
disease, heart failure, neuropathies, retinopathy, renal failure
and stroke) and result in considerable morbidity and mortality.
However, with good care, these complications can be decreased,
controlled or prevented, limiting the adverse outcomes.
7
It has been established that the quality of care provided in
South Africa is inadequate to prevent these adverse outcomes.
Hypertension and its sequelae account for three of the top 10
causes of death in South Africa.
8
This is because blood pressures
are uncontrolled, there is poor glycaemic control and screening
for complications is inadequate. Guidelines attempt to improve
these issues. However, physician compliance with guideline
recommendations needs to be addressed in order to improve the
outcomes.
Reviews of the major trials in various chronic diseases, such
as that by Okpechi and Rayner,
9
summarise the results of the
trials but do not make the information practically available.
Accessing reviews and applying them to clinical practice requires
time and expertise, whereas guidelines are made easily available
in their local setting for healthcare providers to peruse as and
when needed.
Guidelines provide an easily accessible resource that clinicians
can review to expand their knowledge base and determine
patient care. This allows clinicians to be able to keep abreast of
current knowledge despite the rapidly expanding knowledge that
is being continuously developed. Health services and insurers
can also access these guidelines to determine standards of care
and medication recommendations. This can be the basis for
essential drug lists.
The National High Blood Pressure Education Programme
(NHBPEP) released their first guideline in 1977. This was
the first in the series of hypertension management guidelines
produced in the United States to improve blood pressure control
and management. The production and implementation of these
guidelines resulted in improved patient awareness of blood
pressure and the complications that result. As a result of this
awareness, people are more likely to visit their doctor for blood
pressure checks, the most common reason for adults to visit their
doctor.
The NHBPEP is responsible for improving blood pressure
control and outcomes; age-adjusted mortality has declined
by 70% for heart disease and by 80% for stroke over the four
decades of its existence. There has been a steady decline in heart-
related deaths over this time period, and malignant hypertension
is rare in the USA.
10
Implementing guidelines can be a difficult task and in some
instances may not improve outcomes. A study in Cape Town
in 1999
11
showed that the approach to treating hypertension
and diabetes with guidelines did not improve blood pressure or
glycated haemoglobin levels.
The implementation of the guidelines involved a multifaceted
intervention. A structured record was designed and incorporated
into the folder. This structured record was a three-sided folded
A3 sheet with multiple components: patient details, medical
history, referrals, educational topics, algorithms for hypertension
and diabetes diagnosis and management, targets, treatment
options, and a flow sheet for results. The intervention included
an educational package to train the primary healthcare providers
in the use of the guidelines.
Unfortunately this intervention did not improve blood
pressure control or glycated haemoglobin levels. There are
multiple reasons for this; the structured record was only found
in 60% of the intervention folders and was generally not used
when found in the folders. Other contributing factors include
that this was a time when the healthcare system was being
changed in South Africa by redistributing patients to primary
care facilities. The changes did not include the badly needed
increase in staffing. There was also a lack of budget to support
the implementation of these guidelines, a lack of facilities within
the primary healthcare services, and lack of time to provide the
suggested care.
This study
11
highlights two importance aspects of guidelines
and interventions. They need to be simple and suited to the
environment in which they will be implemented; and in order
to implement the guidelines, there needs to be the institutional
infrastructure to be able to manage the recommendations.
The American Heart Association has highlighted the cost of
hypertension
10
and the resultant cardiovascular complications
in the USA. They have issued a science advisory in order to
improve control. This document is an attempt to ‘identify,
disseminate, and implement more effective approaches to achieve
optimal control’. They suggest that blood pressure requires a
multifactorial approach, and the engagement of all potentially
involved persons/health systems. They suggest that best-practice
guidelines are essential in achieving the goals of blood pressure
control and cost saving. This advisory considers that lack of
control can be ascribed to fragmented healthcare services (a
major problem in South Africa) and the poor implementation of
health-system solutions at a clinical level, as seen by Steyn
et al
.
11