USER MANUAL

HYPERTENSION CLINICAL AUDIT IN

PRIMARY CARE
Appropriate Management of Hypertension in
Primary Care

Family Health Development Division

and Disease Control Division, Ministry of Health Malaysia
2019

Version 1.1
Copyright © Ministry of Health Malaysia

All rights reserved. This document may not be reproduced, in whole or in part, in any
form or means, electronic or mechanical, including photocopying, recording, or by
any information storage or retrieval system now known or hereafter invented, without
written permission from the publisher.

First edition 2019

Suggested Citation:
Ministry of Health 2019. User Manual: Hypertension Clinical Audit in Primary Care.

Editors:
Feisul Idzwan Mustapha, Mastura Ismail, Arunah Chandran

Published by:
Non-Communicable Disease (NCD) Section. Disease Control Division,
Ministry of Health
Level 2, Block E3, Complex E
Federal Government Administration Centre
62590 Putrajaya
MALAYSIA

Tel: +603-88924409
Fax: +603-88924526
Website: www.moh.gov.my
TABLE OF CONTENTS
1. Introduction ................................................................................................................................ 1
1.1. Hypertension in Malaysia ..................................................................................................... 1
1.2. Justification for Clinical Audit in Primary Care ...................................................................... 1
2. Objective ..................................................................................................................................... 2
3. Methodology .............................................................................................................................. 3
3.1. Scope of audit ........................................................................................................................ 3
3.2. Audit population .................................................................................................................... 3
3.3. Sample size and sampling method ........................................................................................ 3
3.4. Data collection and analysis .................................................................................................. 4
3.5. Indicators and Targets ........................................................................................................... 6
4. Follow-up action (at clinic level) ................................................................................................. 6
References ....................................................................................................................................... 7
Members of the Technical Working Group ..................................................................................... 8
List of Appendices ............................................................................................................................ 9
1. Introduction
Patients have rights to have good and quality health care. Clinical audit is an
important tool in assessing the quality of patients’ health care and management
delivered in any health care facilities. It can be done by various ways including
assessment of patients’ record or through direct observation of a consultation.

Through this process, the weaknesses and strength of patients’ management

whether documented or observed can be identified. It is not a fault-finding process,
rather as an avenue to provide improvement of clinical knowledge for the health care
providers hence improving the quality of the patients care at long term.

1.1. Hypertension in Malaysia

Hypertension is an important medical and public health issue. The National Health
and Morbidity Survey (NHMS) 2015 has shown that the prevalence of hypertension
in Malaysia for adults ≥18 years has increased from 32.2% in 2006, 32.7% in 2011,
then slightly decreased to 30.3% in 2015. Over the years, the proportion of those
diagnosed versus undiagnosed remained at a ratio of 2:3.

No significant difference between genders was observed. In terms of the main ethnic
groups, the Bumiputera from Sabah & Sarawak have the highest prevalence,
followed by the Malays, Chinese and lastly the Indians.

The relationship between blood pressure (BP) and risk of cardiovascular events is
continuous, consistent and independent of other risk factors. The higher the BP, the
greater the chance of myocardial infarction, heart failure, stroke and kidney
diseases. The presence of each additional risk factor, such as dyslipidaemia,
diabetes mellitus or smoking status, compounds the risk. Therefore, the main aim of
identifying and treating high BP is to reduce these risks of end organ damage.

1.2. Justification for Clinical Audit in Primary Care

Numerous studies have examined the impact of non-adherence of healthcare

providers to the clinical outcome of patients with Non-Communicable Diseases
(NCDs) including hypertension. Non-adherence of doctors to guidelines is thought to
contribute significantly to poor delivery of clinical care, resulting in poor clinical
outcomes.

The relationship between BP and risk of cardiovascular events is continuous,

consistent and independent of other risk factors. The higher the BP, the greater the
chance of myocardial infarction, heart failure, stroke and kidney diseases. The
presence of each additional risk factor, such as dyslipidaemia, diabetes mellitus or
smoking status, compounds the risk. Therefore, the main aim of identifying and
treating high BP is to reduce these risks of end organ damage or end organ
complications.

In 2006, the Institute for Health Management, MOH, conducted a survey entitled
“The adequacy of outpatient management of essential hypertension at MOH

1
hospitals and clinics”. That survey reported overall that only 28.5% of patients have
adequate BP control, and a high proportion of patients did not have relevant
investigations done or documented at the recommended time frame.

For diabetes care at MOH health clinics, an annual diabetes clinical audit
mechanism has been implemented since 2009. For hypertension patients without
diabetes, the quality of care at MOH clinics is still currently not monitored
systematically. Therefore, there is an urgent need to introduce an audit mechanism
to monitor quality of care systematically throughout the country.

For the management of hypertension, the MOH has published the Clinical Practice
Guidelines: Management of Hypertension 5th Edition 2018. A “Model of Good Care
for management of hypertension patient” has been derived from this document, and
shown in Appendix 1.

2. Objective
The main objective of this Audit is to assess the quality of care for patients with
hypertension seeking treatment at MOH health clinics.

The specific objectives are:

(1) To assess adherence of healthcare providers (HCPs) to clinical guidelines of

management of hypertension
(2) To assess the adequacy of blood pressure control
(3) To determine the coverage of target organ damage evaluation
(4) To determine the coverage of cardiovascular risk factors assessment

2
3. Methodology
The implementation of the audit is under the responsibility of the Family Medicine
Specialist (FMS) services, coordinated by the Family Health Development Division.

At the district level, the most senior FMS will be the District Audit Coordinator. The
FMS will be responsible to ensure that the audit is implemented as planned following
this guideline. In clinics with no FMS, the District Medical Officer of Health will
nominate a senior MO to take this responsibility.

Data collection and analysis will be conducted by FMS and Medical Officers that
have completed the training.

3.1. Scope of audit

The Audit of the hypertension treatment card/record will be conducted in all MOH
health clinics providing care for hypertension patients throughout the country. Certain
category of primary care services settings are excluded i.e. Klinik Komuniti, Klinik
UTC, upgraded Klinik Desa only for MCH services.

Audit will only be conducted once a year (July to September), and data will be
collected from the hypertension treatment card/records utilised by the health clinics.

3.2. Audit population

Inclusion criteria

1. Adult patients (≥18 years) with hypertension

2. On active follow-up for a minimum of 12 months and on pharmacological
management (anti-hypertensives)

Exclusion criteria

1. Patients diagnosed with diabetes

2. Defaulted follow-up of more than six months
3. Diagnosed with end-stage renal failure
4. Pregnancy
5. Severely ill, or emergency cases

3.3. Sample size and sampling method

Based on the main audit outcome variables i.e. proportion of patients with adequate
BP control and proportion achieving adequate quality of hypertension care, it was
determined that the minimum sample size required for each district is 330. It is
recommended that the numbers of patient records sampled from each health clinic

3
should be apportioned accordingly based on the estimated number of hypertension
patients per clinic.

Subsequently, based on the number of patient records to be audited, the

recommendation is for the patient records selection to be distributed over a one-
week period evenly. Each day, the records should be selected through systematic
sampling of an interval of every three patients.

It is also recommended that certain periods of time are avoided for data collection,
e.g. rainy seasons, festive seasons, school holidays, or pre- or post-extended public
holidays, to avoid sampling biases.

3.4. Data collection and analysis

Data collection and analysis at the health clinic level will be conducted by trained
FMS and Medical Officers.

Data collected from the hypertension treatment cards will be entered into the audit
form KK/HPT/001 as shown in Appendix 2. The data dictionary and instructions are
shown in Appendix 3.

After completion of data collection for the health clinic, a summary is prepared using
form KK/HPT/002, shown in Appendix 4. The data dictionary and instructions are
shown in Appendix 5.

All completed forms KK/HPT/002 from all audited health clinics will be submitted to
the District Health Office. At the District Health Office, the officer responsible for
Primary Care will extract the required data on level of BP control to enter into form
PKD/HPT/001 as shown in Appendix 6. This form will then be submitted to the State
Health Department.

At the State Health Department, the officer responsible for Primary Care will compile
form PKD/HPT/001 from all districts, to complete for JKN/HPT/001 as shown in
Appendix 7. This form will then be submitted to the Bahagian Pembangunan
Kesihatan Keluarga (Cawangan Primer), copied to Bahagian Kawalan Penyakit
(Cawangan NCD).

A summary of the work flow for data collection, compilation and analysis, including
the forms required, responsible officers and timelines are shown in Figure 1 below:

4
Figure 1: Summary of the work flow for data collection, compilation and
analysis

Action Form Responsibility Timeline

1. Data collected from KK/HPT/001 FMS or MO From 1 July to
hypertension treatment 30 September
cards
2. Prepare summary of KK/HPT/002 FMS or MO 1 to 7 October
findings
3. Submit form KK/HPT/002 FMS or MO 8 to 14
to District Health Office October
4. Compilation of data of PKD/HPT/001 Officer 15 to 21
proportion of patients with responsible for October
BP meeting targets Primary Care
5. Submit form Officer 15 to 21
PKD/HPT/001 to State responsible for October
Health Department Primary Care
6. Compilation of data from JKN/HPT/001 Officer 22 to 30
District Health Office responsible for October
Primary Care
7. Submit form Officer Deadline: 31
JKN/HPT/001 to BPKK responsible for October
(cc to BKP) Primary Care

5
3.5. Indicators and Targets
Process Indicator and Target

The level of adherence of HCPs to clinical guidelines of management of

hypertension is determined by the percentage of patients with hypertension who are
audited, receiving appropriate care at the klinik kesihatan, based on the
Hypertension Clinical Audit form KK/HPT/001. The level of adherence is categorised
as follows:

 Good 80%
 Fair 50 to 79%
 Poor <50%

For the klinik kesihatan, a proportion of 30% of patients should achieve a score of
80% (category “Good”) to be considered as “Meeting target”.

Outcome Indicator and Target

The level of adequacy of BP control is determined by the proportion of patients with

hypertension who are audited, with the latest BP reading of <140/90 mmHg.

For the klinik kesihatan, a proportion of 30% of patients achieving this BP target is
considered as “Acceptable”.

Disclaimer: The indicators and targets may differ from existing clinical practice
guidelines and are guided by inputs from the expert panel.

4. Follow-up action (at clinic level)

Based on the audit findings, including the strengths and weaknesses identified, the
FMS or MO should discuss and institute remedial measures.

Remedial measures will include training and retraining of healthcare personnel using
relevant materials on appropriate management of patients for reference at health
clinics. In addition, it will also require supply of appropriate and adequate equipment
or materials to the clinic.

The evaluation process is based on an auditing approach. Auditing is done annually

so that continuous improvements based on recommendations can be accomplished.

6
References
Chambers, R., Boath, E. 2000. Clinical effectiveness and clinical governance made easy.
Radcliffe Medical Press, United Kingdom.

Kementerian Kesihatan Malaysia. 2005. Garis panduan pengendalian hipertensi.

Ministry of Health. Clinical practice guidelines. Management of hypertension. 5th Edition

(2018).

Morrell, C., Harvey, G. 1999. The clinical audit book : Improving health care through clinical
audit. Elsevier Health Sciences. United Kingdom.

NHS (National Heaith Service). 2005. A practical handbook for clinical audit. Guidance
published by the clinical governance support team. United Kingdom.

NICE (National Institute for Clinical Excellence). 2002. Principles for best practice in clinical
audit. Radcliffe Medical Press Ltd. United Kingdom.

Rao, JN., Stewart, A. 2003. Clinical audit and Epi Info. Radcliffe Publishing. United Kingdom.

Roslan Johari, MG., Haliza, AM., Tahir, A., Chandran, LR., Badrul Nizam, LB., Rosidah, SS.,
Saiful Safuan, MS., Haznee, N., Musliha, D., Nadhirah, R. 2006. A study on the adequacy of
outpatient management of hypertension cases in MOH hospitals and health centres. Institut
Pengurusan Kesihatan. Kementerian Kesihatan Malaysia. Kuala Lumpur.

7
Members of the Technical Working Group
1. Dr Mastura Ismail
Pakar Perunding Perubatan Keluarga Khas C, KK Seremban 2

2. Dr Feisul Idzwan Mustapha

Timbalan Pengarah (NCD), Bahagian Kawalan Penyakit

3. Dr Maimunah Mahmud
Pakar Perubatan Keluarga Gred Khas C, KK Jinjang, Selangor

4. Dr Jalil Ishak
Pakar Perubatan Keluarga Gred Khas C, KK Jasin, Melaka

5. Dr Lili Zuryani Marmuji

Pakar Perubatan Keluarga Gred UD56, KK Gunung Rapat, Perak

6. Dr Jusoh Awang Senik

Pakar Perubatan Keluarga Gred UD56, KK Tumpat, Kelantan

7. Dr Wan Noorazlin Wan Idris

Pakar Perubatan Keluarga Gred UD54, KK Presinct 9, Putrajaya

8. Dr Salbiah Mohamed Isa

Pakar Perubatan Keluarga Gred UD54, KK Bandar Botanik, Selangor

9. Dr Kamilah Mohamad
Pakar Perubatan Keluarga Gred Khas C, KK Kuala Berang, Terengganu

10. Dr Mazlinah Muda

Pakar Perubatan Keluarga Gred Khas C, KK Bukit Payung, Terengganu

11. Dr Noor Diana Ismail

Pakar Perubatan Keluarga Gred UD54, KK Batu 9, Selangor

12. Dr Azila Abas

Pakar Perubatan Keluarga Gred UD56, KK Pasir Akar, Terengganu

13. Dr Norhana Yazid

Pakar Perubatan Keluarga Gred Khas C, KK Kuala Besut , Terengganu

14. Dr Salmiah Sharif

Pakar Perubatan Keluarga Gred Khas C, KK Seremban, Negeri Sembilan

15. Dr Fatanah binti Ismail

Pakar Perubatan Kesihatan Awam, Bahagian Pembangunan Kesihatan Keluarga

16. Dr Noraliza binti Noordin Merican

Pakar Perubatan Kesihatan Awam, Bahagian Pembangunan Kesihatan Keluarga

17. Dr Noor Raihan Binti Khamal

Pakar Perubatan Kesihatan Awam, Bahagian Kawalan Penyakit

18. Dr Arunah Chandran

Ketua Penolong Pengarah Kanan, Bahagian Kawalan Penyakit

8
List of Appendices

Appendix 1 Model of Good Care for management of hypertension patient at the

primary care level

Appendix 2 Hypertension Clinical Audit Form, KK/HPT/001

Appendix 3 Data Dictionary and Instructions for Hypertension Clinical Audit

Form, KK/HPT/001

Appendix 4 Summary of Hypertension Clinical Audit Form, KK/HPT/002

Appendix 5 Data Dictionary and Instructions for Hypertension Clinical Audit

Form, KK/HPT/002

Appendix 6 Hypertension Clinical Audit: Proportion of patients achieving BP

target, PKD/HPT/001

Appendix 7 Hypertension Clinical Audit: Proportion of patients achieveing BP

target, JKN/HPT/001

9
 Appendix 1

Model of Good Care for management of hypertension patient at the primary care level

Blood Pressure
(repeated measurements)

SBP 130-159 mmHg SBP ≥160 mmHg

AND/OR AND/OR
DBP 80-99 mmHg DBP ≥100 mmHg

Drug Treatment
(consider combination
Assess global cardiovascular Medium/ High/ therapy
risks Very High except in the older adults)*
*either free or single pill
combination

Low to Intermediate

3 to 6 monthly follow-up with advice on

non-pharmacological management and
reassessment of CV risk

SBP <140 mmHg SBP ≥140 mmHg

AND/OR AND/OR
DBP <90 mmHg DBP ≥90 mmHg

6-monthly follow-up Drug treatment

Figure A: Algorithm for the management of hypertension

Note:
TOD = Target Organ Damage (LVH, retinopathy, proteinuria)
TOC = Target Organ Complication (heart failure & renal failure)
RF = Risk factors (smoking, total cholesterol >6.5 mmol/l, family history of premature vascular
disease)
Non-Pharmacological Management: Counsel on cessation of tobacco use, diet, physical activity,
weight reduction and stress management
 Appendix 1

Table A: Assessment for hypertension patients and recommended frequency

Assessment: Every confirmed hypertension patient

Item First visit Every visit Annual

Take history of TOD √ √

BP √ √

Measure BMI and waist circumference √ √

Examine for evidence of cardiac failure √ √

Examine fundus for hypertensive √ √

retinopathy

Electrocardiograph √ √

Fasting blood glucose √ √

Fasting serum lipid √ √

Renal profile √ √

Urine protein √ √
 Appendix 2

KK/HPT/001

Hypertension Clinical Audit Form Audit No: _______

Klinik Kesihatan: _________________________ Patient’s IC/RN: __________________

DOB: ________________ Sex:_____________ Ethnicity: ________________________

Not Applicable
Scor Yes (1)
No Variables (PROCESS OF CARE) (-1
e / No (0)
denominator)
1. Registered in Hypertension Registry 1
2. History
 Comorbidity: Overweight/obesity; dyslipidemia, etc 1
 Symptoms of TOD/TOC 1
 HPT complications 1
 CV risk factors 1
 Compliance to treatment 1
3. Physical examination
 Weight (one year ago): _________kg 1
 Weight (latest visit): _________kg 1
 Height: _________meter 1
 BMI (one year ago): _________kg/m2 1
 BMI (latest visit): _________kg/m2 1
 Waist circumference: ______cm 1
 BP: _______/____mmHg 1
 Pulse rate: ___________ beats/minute 1
 Signs of heart failure 1
4. Annual investigations
 FSL (one year ago), LDL: ______mmol/l 1
 FSL (latest), LDL: _____mmol/l 1
 FBS 1
 Renal profile 1
 Urine albumin 1
 ALT (if indicated) 1
 ECG (At Baseline and if indicated) 1
 CXR (if indicated) 1
5. CVD risk stratification 1
6. Optimising management
 Non-pharmacological 1
 Pharmacological: Anti-hypertensive 1
 Pharmacological: Lipid lowering drugs (if indicated) 1
 Mx of hypertension complications (if indicated) 1
7. Appropriate referral (if indicated) 1
8. Health promotion (if indicated) 1
9. TOTAL SCORE 30
10 Percentage of performance
________%
(total score / denominator x 100)

(continued on next page)

 Appendix 2

(continued from previous page)

Yes (1) /
No Variables (CARE OUTCOMES)
No (0)
11 Controlled BP (<140/90mmHg)
12 Achieved at least 5% weight reduction
13 Lipid level treated to target:
 Low and intermediate risk: LDL <3.0mmol/L
 High CV risk: LDL < 2.6mmol/L or 50% reduction from baseline
 Very high CV risk: LDL <1.8mmol/L or 50% reduction from baseline

Comments:

_________________________________________________________________________

_________________________________________________________________________

_____________________

Name:

Date of audit:
 Appendix 3

Data Dictionary and Instructions for Hypertension Clinical Audit Form KK/HPT/001

No Variable Definition Score

PROCESS OF CARE
1. Registered in Patient with Hypertension registered in the 1
Hypertension Registry Hypertension Registry
2. History
 Comorbidity Ever documented Comorbidities: Overweight/Obesity, 1
Dyslipidemia, etc.
 Symptoms of Currently documented symptoms pertaining to 1
TOD/TOC hypertension and target organ damage (TOD) / Target
organ complications (TOC) e.g:
 Heart: chest pain/ exertional dyspnoea/ orthopnoea
 Brain: numbness/ weakness
 Renal : uraemia/ edema
Note: at least 2 symptoms or relevant negatives
documented will be given a score of 1
 Hypertension Ever documented hypertensive complications 1
complications  Heart: Left ventricular hypertrophy, ischaemic heart
disease, congestive heart failure
 Brain: Cerebrovascular accident (stroke)/ transient
ischemic attack/ dementia
 Renal: Nephropathy/ proteinuria
 Eye: Hypertensive retinopathy
 CV risk factors Ever documentated f the CV risk factors e.g. smoking, 1
dyslipidemia, family history of premature CVD
 Compliance to Currently documented compliance to medications 1
treatment
3. Physical examination
 Weight (one year Documented weight in kg one year from date of audit 1
ago)
 Weight (latest visit) Documented weight in kg during latest visit 1
 Height Ever documented height in meter 1
 BMI (one year ago) Documented Body Mass Index one year from date of 1
audit
BMI = weight (kg) / height (m)2
 BMI (latest visit) Documented BMI during latest visit 1
 Waist circumference Documented waist circumference (in cm) during latest 1
visit
 BP Documented BP reading during latest visit 1
 Pulse rate Documented in beats/minute during latest visit 1
 Signs of heart failure Documented elevated jugular venous pressure, 1
displaced apex beat, pulmonary crepitations and
ankle oedema or relevant negative during latest visit
4. Annual investigations
 FSL (one year ago), Documented FSL one year from date of audit 1
LDL: ______mmol/l  Should be done at least annually
 To enter LDL value if available
 FSL (latest), LDL: Documented FSL within the past one year from date 1
______mmol/l of audit
 Appendix 3

No Variable Definition Score

 Should be done at least annually
 To enter LDL value if available
 FBS Documented Fasting Blood Sugar within the past one 1
year from date of audit
 Should be done at least annually
 Renal profile Documented Renal profile within the past one year 1
from date of audit
 Should be done at least annually
 Urine albumin Documented Renal profile within the past one year 1
from date of audit
 Should be done at least annually
 ALT (if indicated) Possible indications (list not exhaustive): 1
 Symptoms of liver disorder
 Monitor side effects of certain medications
 Already known liver disorder – to monitor
 ECG At baseline and if indicated. Possible indications (list 1
not exhaustive):
 Symptoms suspected of cardiac origin (e.g. SOB,
syncope, palpitations, chest pain etc)
 Known cardiac disorders – to monitor
 CXR (if indicated) At baseline and if indicated. Possible indications (list 1
not exhaustive):
 Symptoms suspected of lower respiratory tract
origins (e.g. pulmonary oedema, pleural effusion,
tuberculosis etc)
 Known chronic respiratory disorders – to monitor
5. CVD risk stratification Risk calculated in past one year either using 1
Framingham Risk Score (FRS) or *Table 1: Risk
Stratification Table (Clinical Practice Guidelines:
Management of Hypertension 5th Edition 2018, Table
3-D)
6. Optimising management
 Non-pharma- Documented in latest visit: Weight reduction, reducing 1
cological sodium intake and alcohol consumption, regular
physical activity, health eating, cessation of smoking
and healthy living
 Pharmacological: Optimising dose and appropriate selection of anti- 1
Anti-hypertensive hypertensives
 Pharmacological: Optimising dose and appropriate selection of lipid 1
Lipid lowering drugs lowering drugs
(if indicated)
 Mx of hypertension Manage HPT complications accordingly (if indicated): 1
complications (if  Brain: Doppler/ CT scan
indicated)  Heart: Echocardiogram / stress test
 Renal: ACEI/ARB usage (unless contraindicated),
Ultrasound KUB
7. Appropriate referral (if  Indications for referral to FMS: 1
indicated) o uncontrolled HPT with optimum treatment dose
after 3 visits
o new TOC
o worsening complications
 Appendix 3

No Variable Definition Score

 Referral to Pharmacist for medication adherence
 Referral to Nutritionist/ Dietitian for MNT
 Referral to Physiotherapy/ Occupational Therapy
for weight reduction
 Referral to hospital:
o accelerated or malignant HPT
o suspected secondary HPT
o resistant HPT
o recent onset of target organ damage
o pregnancy
o isolated office HPT
8. Health promotion (if Documented for any of the following opportunistic 1
indicated) screening when indicated:
 Pap smear
 Colorectal screening
 Quit smoking
 TB screening (for high risk population)
 Pre-pregnancy care (contraception)
 Mammogram
9. Total Score  Sum of the scores based on the above marking
scheme
 Maximum score is 30
10. Percentage of 𝑇𝑜𝑡𝑎𝑙 𝑆𝑐𝑜𝑟𝑒
𝑥 100
performance 30 − (𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑖𝑡𝑒𝑚𝑠 ′𝑛𝑜𝑡 𝑎𝑝𝑝𝑙𝑖𝑐𝑎𝑏𝑙𝑒 ′ )

CARE OUTCOME
11 Controlled BP
(<140/90mmHg)
12 Achieved at least 5%
weight reduction*
13 Lipid level treat to target
Documented BP reading during latest visit, and achieved
<140/90mmHg
𝑊𝑒𝑖𝑔ℎ𝑡 (𝑙𝑎𝑡𝑒𝑠𝑡 𝑣𝑖𝑠𝑖𝑡) − 𝑊𝑒𝑖𝑔ℎ𝑡 (𝑜𝑛𝑒 𝑦𝑒𝑎𝑟 𝑎𝑔𝑜)
𝑥 100
𝑊𝑒𝑖𝑔ℎ𝑡 (𝑜𝑛𝑒 𝑦𝑒𝑎𝑟 𝑎𝑔𝑜)
Calculate the percentage of weight reduction from the previous
one year’s records
Yes = achieved at least 5% weight reduction
*calculated if initial BMI was considered overweight/obese
 Documented LDL levels within the past one year from date of
audit, and achieving the target value
 The level of LDL target is determined by the level of
cardiovascular risk, as shown in **Table 2:
o Low and intermediate risk: LDL <3.0mmol/L
o High CV risk: LDL <2.6mmol/L or 50% reduction from
baseline
o Very high CV risk: LDL <1.8mmol/L or 50% reduction
from baseline
Note: Considered as “No” if “CVD risk stratification is not done or
recorded
 Appendix 3

*Table 1: Risk Stratification (Clinical Practice Guidelines: Management of

Hypertension 5th Edition 2018, Table 3-D)
Co-existing No RF TOD TOC or RF (3) Previous MI or
Condition No TOD or or clinical previous stroke
No TOC RF (1 – 2) athero- or
No TOC sclerosis diabetes or
CKD
SBP 130-139
Medium
and/or Low High Very high
DBP 80-89
SBP 140-159
and/or Low Medium High Very high
DBP 90-99
SBP 160-179
and/or Medium High Very high Very high
DBP 100-109
SBP 180
and/or High Very high Very high Very high
DBP 110

Risk of Major CV
Risk Level Management
event in 10 years
Low-intermediate <10% Healthy living
Medium 10 – 20% Drug treatment and healthy living
High 20 – 30% Drug treatment and healthy living
Very high >30% Drug treatment and healthy living
Note:
TOD = Target organ damage (LVH, retinopathy, proteinuria)
TOC = Target organ complication (heart failure, renal failure)
RF = additional risk factors (smoking, TC > 6.5 mmol/L, family history of premature
vascular disease)
Clinical atherosclerosis = CHD, carotid stenosis, peripheral vascular disease,
transient ischaemic attack, stroke

**Table 2: Risk Stratification of Cardiovascular Risk

Low risk Individuals with a FRS-CVD score that confer a 10-year risk for CVD
<10%
Intermediate risk Individuals with a FRS-CVD score that confer a 10-year risk for CVD
10-20%
High risk These individuals include:
 Diabetes without target organ damage
 CKD with GFR 30-<60 Ml/min-1/1.73m2 (Stage 3)
 Very high levels of individual risk factors (LDL-C >4.9 mmol/L; BP
>180/110 mmHg)
 Multiple risk factors that confer a 10-year risk for CVD >20% based
on the FRS-CVD score
Very high risk Individuals with:
 Established CVD
 Diabetes with proteinuria or with a major risk factor such as
smoking, hypertension or dyllipidaemia
 CKD with GFR 30 Ml/min-1/1.73m2 (Stage 4)
 Appendix 4

KK/HPT/002
Summary of Hypertension Clinical Audit Form
Klinik Kesihatan: _________________________ District: __________________

Audit date: ________________ No. of patients audited:__________

PROCESS OF CARE
Percen
Denomi-
Variables Score1 Remarks
nator2 tage
1 Registered in Hypertension Registry
2 History
 Comorbidity: Overweight/obesity; dyslipidemia
 Symptoms of TOD/ TOC
 HPT complications
 CV risk factors
 Compliance to treatment
3 Physical examination
 Weight (one year ago)
 Weight (latest visit)
 Height
 BMI (one year ago)
 BMI (latest visit)
 Waist circumference
 BP
 Pulse rate
 Signs of heart failure
4 Annual investigations
 FSL (one year ago)
 FSL (latest)
 FBS
 Renal profile
 Urine albumin
 ALT (if indicated)
 ECG (at baseline and if indicated)
 CXR (if indicated)
5 CVD risk stratification
6 Optimising management
 Non-pharmacological
 Pharmacological: Anti-hypertensive
 Pharmacological: Lipid lowering drugs (if
indicated)
 Mx of hypertension complications (if indicated)
7 Appropriate referral (if indicated)
8 Health promotion (if indicated)
Note:
*1 Total score according to each variable
*2 Total denominator for each variable (exclude not applicable variable)
(continued on next page)
 Appendix 4

(continued from previous page)

CARE OUTCOME
Total
number Denomi
Variables % Remarks
of -nator
records
10 Records audited with score:
 80% (good)
 50-79% (fair)
 <50% (poor)
 Total 100%
11 Controlled BP (<140/90mmHg)

12 Achieved minimum 5% weight

reduction
13 Lipid level treated to target

Comments: Strengths

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Comments: Weaknesses

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Recommendations:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_______________________
Name:
Date of summary report:
 Appendix 5

Data Dictionary and Instructions for Hypertension Clinical Audit Form KK/HPT/002

PROCESS OF CARE

Score1 for items and sub items 1 to 8

For each item, to add all individual ‘Yes(1)’ from the audit KK/HPT/001

Denominator2 for items and sub-items 1 to 8

For each item, the denominator is the number of audit forms. However, for items ALT, ECG.
CXR, Management of hypertension complications and appropriate referral, the
denominator is 𝐷𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑢𝑑𝑖𝑡 𝑓𝑜𝑟𝑚𝑠 − ′𝑛𝑜𝑡 𝑎𝑝𝑝𝑙𝑖𝑐𝑎𝑏𝑙𝑒 ′ 𝑓𝑜𝑟𝑚𝑠

Percentage

𝑆𝑐𝑜𝑟𝑒
𝑥 100%
𝐷𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟

CARE OUTCOME

Item 10: Records audited with score

Item 10 in KK/HPT/002 is based on the score in item 10 of KK/HPT/001.
For item 10, the number of records that have achieved total score of 80%, 50-79%, <50%
are tallied for each category.
Then, the percentage is calculated for each category.

Item 11: Controlled BP

Item 11 in KK/HPT/002 is based on the score in item 11 of KK/HPT/001.
For item 11, the number of yes (1) in item 11 of KK/HPT/001 are tallied. The denominator is
the number of audit forms. Then, the percentage is calculated.

Item 12: Achieved minimum 5% weight reduction

Item 12 in KK/HPT/002 is based on the score in item 12 of KK/HPT/001
The number of yes (1) in item 12 of KK/HPT/001 are tallied. The denominator is the number
of audit forms. Then, the percentage is calculated.

Item 13: Lipid level treated to target

Item 13 in KK/HPT/002 is based on the score in item 13 of KK/HPT/001.
The number of yes (1) in item 13 of KK/HPT/001 are tallied. The denominator is the number
of audit forms. Then, the percentage is calculated.
 Appendix 6

PKD/HPT/001

Hypertension Clinical Audit Form: Proportion of patients achieving BP target

District/Area/Division: _________________________ Year: __________________

No. of No. of Achieve

Klinik Kesihatan patients patients BP % target
audited <140/90 (30%)
(b)/(a) x
(a) (b) Yes/No
100
1

10

11

12

District/Area/Division (Overall)

Comments:

_________________________________________________________________________

_________________________________________________________________________

_____________________

Name:

Date:
 Appendix 7

JKN/HPT/001

Hypertension Clinical Audit: Proportion of patients achieving BP target

State: _________________________ Year: __________________

No. of No. of Achieve

District/Area/Division patients patients BP % target
audited <140/90 (30%)
(b)/(a) x
(a) (b) Yes/No
100
1

10

11

12

State (Overall)

Comments:

_________________________________________________________________________

_________________________________________________________________________

_____________________

Name:

Date: