Hypertension Dashboard Diabetes Dashboard

River District

Data last updated: 5-Aug-2023

Hypertension treatment outcomes

Numerator for BP controlled: Patients with BP <140 AND <90 at their latest visit in the past 3 months

Numerator for BP uncontrolled: Patients with BP ≥140 OR ≥90 at their latest visit in the past 3 months

Numerator for No visit in 3 months: Patients with no visit in the past 3 months.

Denominator: Patients with hypertension registered before the past 3 months. Dead patients (205) and 12 month lost to follow-up patients (1,562) are excluded.

Outcomes for 7,882 patients under care (registered before 1-May-2023) between 1-May-2023 to 31-Jul-2023

BP controlled at latest visit in past 3 months

61%

4,808 patients with BP <140/90

BP not controlled at latest visit in past 3 months

17%

1,340 patients with BP ≥140/90

No visit in past 3 months

22%

1,734 patients with no visit

Patients under care

Patients under care: Registered patients with hypertension with at least 1 visit in the past 12 months. Dead patients (205) and 12 month lost to follow-up patients (1,562) are excluded.

Cumulative registered patients: All patients with hypertension registered. Dead patients (205) are excluded.

Monthly registered patients: Patients with hypertension registered each month.

Patients with hypertension with at least 1 visit in the past 12 months

10,632

1,043 patients registered in Jul-2023

of 12,213 cumulative registered patients

12 month lost to follow-up

Numerator: Patients with no visit in the past 12 months

Denominator: Registered patients with hypertension. Dead patients (205) are excluded.

Patients with hypertension with no visit in the past 12 months

10%

1,562 patients with no visit from Jul-2022 to Jul-2023

of 12,213 cumulative registered patients

Hypertension treatment cascade

Estimated adults (>30) in River District with hypertension who are registered, under care, and controlled.

Estimated population with hypertension is derived from a STEPS Community Survey conducted in 2022.

100%

250,800

Estimated people with hypertension

5%

12,213

Cumulative registered patients

4%

10,632

Patients under care

2%

4,808

Patients with BP controlled

Opportunistic screening

Numerator: Patients screened for hypertension months

Denominator: Approximate adult patients OPD per month

% of estimated adult OPD patients screened for hypertension

23%

6,900 individuals screened for hypertension in Jul-2023

of ~30,000 estimated OPD patients >18 years

Compare sub-regions

Treatment outcomes for patients with hypertension at their latest visit from 1-May-2023 to 31-Jul-2023

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Patients under care Monthly new patients registered BP controlled BP uncontrolled No visit in past 3 months
Sub-regions
Total
Jul-2023
Total
Percent
Total
Percent
Total
Percent
River District 10,539 1,043 4,808 61% 1,340 17% 1,734 22%
Cherry Blossom County 1,100 139 450 50% 145 16% 212 34%
Fern Grove County 505 106 245 84% 12 4% 56 12%
Grasslands County 321 6 120 39% 21 7% 120 54%
Hillside County 3,203 305 1,802 69% 291 11% 245 19%
Ice Caps County 867 65 500 68% 100 14% 70 19%
Mangrove County 345 100 72 50% 22 15% 15 35%
Mountain County 900 56 240 30% 108 14% 289 56%
Oceanside County 123 106 4 24% 2 12% 70 65%
Peaks County 2,104 120 972 52% 421 23% 320 25%
Rain Forest County 56 0 20 36% 6 11% 30 54%
Rivers Edge County 145 10 45 36% 19 15% 50 49%
Sunshine Coast County 203 5 103 53% 21 11% 45 36%
Tree Top County 32 6 10 50% 4 20% 5 30%
Vineland County 221 11 120 60% 20 10% 47 30%
Wind Canyon County 414 8 105 26% 100 25% 160 48%

Quarterly cohort reports

The treatment outcomes for newly registered patients at the end of the following quarter

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63%
18%
21%
Q4-2021 cohort 1,006 patients

Result from past visit in Q1-2022

66%
15%
21%
Q1-2022 cohort 600 patients

Result from latest visit in Q2-2022

60%
19%
21%
Q2-2022 cohort 892 patients

Result from latest visit in Q3-2023

68%
16%
22%
Q3-2022 cohort 1,315 patients

Result from latest visit in Q4-2023

76%
10%
14%
Q4-2022 cohort 941 patients

Result from latest visit in Q1-2023

80%
12%
8%
Q1-2023 cohort 1,281 patients

Result from latest visit in Q2-2023

Q2-2023 cohort 2,725 patients

Coming Oct-2023

BP controlled
BP uncontrolled
No visit in quarter

Anti-hypertensive drug stock

Numerator: Facilities with ≥30 patient days protocol drugs in stock.

Denominator: All facilities in the hypertension program.

Facilities with ≥30 patient days of hypertension protocol drugs in stock

Step 1 drugs — 94% in Jul-2023
Step 2 drugs — 64% in Jul-2023
Step 3 drugs — 90% in Jul-2023
 

Blood pressure monitors

Numerator: Facilities with 1 or more functioning BP monitors.

Denominator: All facilities in the hypertension program.

Facilities with a functioning BP monitor

98%

157 facilities with a functioning BP monitor

of 160 facilities reporting in Jul-2023

3 facilities without a functioning BP monitor:
CHC Turnip, CHC Zucchiniville, PHC Grapefruit Hill

Stock reporting by facility

Jul-2023 reports

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Facility
Sub-region
Step 1 drugs in patient days
Step 2 drugs in patient days
Step 3 drugs in patient days
BP monitors
River District 54 60 45 210
CHC Apple Orchard Wind Canyon County 54 68 90 1
CHC Bramble River Tree Top County 34 6 67 1
CHC Bumpy Hill Fern Grove County 33 92 120 1
CHC Carrot Peak Cherry Blossom County 134 0 180 1
CHC Cumin Creek Oceanside County 46 48 78 1
CHC Dandelion Wine Vineland County 44 103 12 1
CHC Elderflower Ridge Riverside County 90 21 180 1
CHC Riverside Grasslands County 40 14 22 2
CHC Rhubarb Hills Mangrove County 65 50 90 1
CHC Turnip Rain Forest County 45 109 33 0
CHC Ugly Fruit Bay Wind Canyon County 54 68 90 1
CHC Vine Bay Tree Top County 34 6 67 1
CHC Watermelon Cove Fern Grove County 33 92 120 1
CHC Weather Top Cherry Blossom County 134 180 0 1
CHC Yellow Melon Oceanside County 102 90 80 1
CHC Young Potato Vineland County

365

 12 103 1
CHC Zucchiniville Riverside County 21 45 99 0
District Hospital Strawberry Oceanside County 102 90 80 1
PHC Apricot Island Grasslands County 14 40 44 2
PHC Azalea Hills Mangrove County 65 50 90 1
PHC Bumblebee Rain Forest County 45 109 33 3
PHC Capital Town Wind Canyon County 54 68 90 1
PHC Copperville Tree Top County 34 6 67 1
PHC Cupola Fern Grove County 33 92 120 1
PHC Dartboard Hill Cherry Blossom County 134 0 180 1
PHC Deck Town Oceanside County 46 48 78 1
PHC Dune Hill Vineland County 44 103 12 1
PHC Eagle Hill Riverside County 90 21 180 1
PHC Eggplant Mountain Grasslands County 12 40 24 2
PHC El Toro Mangrove County 65 50 90 1
PHC Fang Cove Rain Forest County 45 109 33 1
PHC Grapefruit Hill Wind Canyon County 54 68 90 0
PHC Gumdrop Cove Tree Top County 34 6 67 1
PHC Happy Street Fern Grove County 33 92 120 1
PHC Hilltop Station Cherry Blossom County 134 180 0 1
PHC Iceberg Oceanside County 102 90 80 1
PHC Idaho Hills Vineland County

365

 12 103 1
PHC Jackfruit Riverside County 21 45 99 1
PHC Juniperberry Grasslands County 14 40 44 2
PHC Lard Lane Mangrove County 65 50 90 1
PHC Lobby Mountain Rain Forest County 45 109 33 3
Subdistrict Hospital Grape Mangrove County 32 40 50 1
Subdistrict Hospital Juniper Oceanside County 202 290 280 1
Subdistrict Hospital Grasslands Grasslands County 100 106 109 1
UPHC Cinnamon Hill Mangrove County 19 66 150 1
UPHC Dandelion Mountain Oceanside County 52 12 100 1
UPHC Dill Weed Grasslands County 80 90 45 1
UPHC Dry Marjoram Mangrove County 100 12 90 1
UPHC Dry Mustard Oceanside County 90 0 87 1
UPHC Dry Nutmeg Grasslands County 90 90 90 1
>180 days drug supply
<30 days drug supply or no BP monitor

Hypertension and diabetes comorbidity

All patients registered in the hypertension and/or diabetes programs

Patients under care Cumulative registered patients Died*
Hypertension-only 8,632 10,000 105
Both hypertension and diabetes 2,000 2,213 100
Diabetes-only 1,500 2,100 50
TOTAL 12,132 14,313 255
*Deaths may be undercounted.

Comorbid patients with BP controlled

Patients with both hypertension and diabetes with BP controlled at latest visit in past 3 months

50%

1,000 patients with BP <140/90

Age and sex of patients under care for hypertension

10,632 patients under care

Age Female (64%) Male (36%) Female and male
18-29
6%
4%
 10%
30-49
28%
17%
 45%
50-69
19%
6%
 25%
70+
12%
8%
 20%
  1. Cumulative registered patients

    All patients diagnosed with hypertension. Dead patients are excluded.

  2. Patients under care

    All patients diagnosed with hypertension with a "visit" recorded in the last 12 months. A visit can have a simplified definition: the patient had a BP measure recorded in the last 12 months. Dead patients are excluded.

  3. 12 month lost to follow-up patients

    All patients diagnosed with hypertension with no "visit" recorded in the last 12 months. A visit can have a simplified definition: the patient had no BP measures recorded in the last 12 months. Note: Some of the key indicators exclude 12-month lost to follow-up patients (i.e. the indicators only use "Patients under care") because these patients become a drag on the health system at scale and muddy the view of progress being made improving hypertension control.

  4. Died

    Dead patients are excluded from most indicators.

  5. Patients with controlled blood pressure and Patients with uncontrolled blood pressure in a month

    Controlled blood pressure in most countries is a BP measure <140 mmHg systolic AND <90 mmHg diastolic. In a simple healthcare system, you can use the most recent BP measure in a month to calculate BP control. In more complex health systems where multiple blood pressures are recorded at each visit, you may need to average the measures.

  6. Screened patients (Aggregate data)

  7. Estimated monthly adult OPD patients (Aggregate data)

Hypertension treatment outcomes

The 3 treatment outcome indicators show whether patients in the hypertension control program are visiting health facilities regularly. Blood pressure control is the best indicator to know if patients under treatment are being treated effectively.

All 3 indicators have the same denominator.

BP controlled at latest visit in past 3 months

How many patients enrolled in the hypertension control program visited a health facility in the past 3 months with a healthy blood pressure?

Why are patients registered within the past 3 months excluded? Three months gives patients time to take their hypertension medication and to get their BP controlled. Most newly registered patients have uncontrolled blood pressure and including them would not reflect an accurate picture of actual controlled patients.

Why is this important? BP controlled reflects the overall health of a hypertension control program and is the most important hypertension control indicator.

Numerator

Patients with controlled blood pressure (<140 systolic AND <90 diastolic) recorded at the patient's most recent visit within the past 3 months.

Denominator

Patients under care in the hypertension program registered before the past 3 months. Exclusions: Dead and 12 month lost to follow-up patients are excluded from the denominator.

BP not controlled at latest visit in past 3 months

How many patients enrolled in the hypertension control program visited a health facility in the past 3 months with high blood pressure?

Why is this important? BP not controlled shows which patients are coming back to care, but require continued intervention to control their blood pressure.

Numerator

Patients with uncontrolled blood pressure (≥140 systolic OR ≥90 diastolic) recorded at the patient's most recent visit within the past 3 months.

Denominator

Patients under care in the hypertension program registered before the past 3 months. Exclusions: Dead and 12 month lost to follow-up patients are excluded from the denominator.

No visit in 3 months

How many patients enrolled in the hypertension control program did not visit a health facility in the past 3 months?

Note: This can also be called "3 month lost to follow-up."

Why is this important? This number reflects how good facilities are at retaining patients in care.

Numerator

Patients no BP measure recorded within the past 3 months.

Denominator

Patients under care in the hypertension program registered before the past 3 months. Exclusions: Dead and 12 month lost to follow-up patients are excluded from the denominator.

Registrations

It is useful to know how many patients are enrolled in a hypertension control program and how many of those patients are "under care" (i.e. have visited at least once in the past 12 months).

Patients under care

Track the patients who have visited in the last 12 months and can be considered to be under care in the hypertension control program.

Value
Cumulative registrations in the hypertension program excluding 12 month lost to follow-up and Dead patients.
Cumulative registrations

Track all of the patients who have been registered in the hypertension program. Over time, the cumulative registrations will be a larger number than Patients under care.

Value
Cumulative registrations in the hypertension program excluding Dead patients.
Monthly new patients registered

Monthly registrations give visibility into activity on-the-ground by health facility staff.

Value
New patients registered in the hypertension program in a month who are diagnosed with hypertension (diagnosis could have happened on any date).
12 month lost to follow-up patients

Patients with no "visit" in the past 12 months (i.e. no BP measure recorded in the past 12 months).

Numerator

Patients no BP measure recorded within the past 12 months.

Denominator

Cumulative registered patients in the hypertension program. Exclusions: Dead patients are excluded from the denominator.

Treatment coverage for hypertension

This indicator gives a view of how many expected individuals in the region are under treatment for hypertension and, of those patients, how many have their blood pressure under control.

Note: The "Estimated number of adults" is usually derived from community surveys (e.g. WHO STEPS survey) and can be updated annually or even less frequently in a data system.

% of people registered

The number of patients in the region registered in the hypertension control program.

Numerator

Cumulative registrations

Denominator

Estimated number of adults with hypertension in the community.

% of people under care

The number of patients in the region registered in the hypertension control program who have visited a facility at least once in the past 12 months.

Numerator

Patients under care

Denominator

Estimated number of adults with hypertension in the community.

% of people with BP controlled

The number of patients in the region registered in the hypertension control program who have their BP controlled in the past 3 months.

Numerator

Patients with controlled blood pressure in past 3 months.

Denominator

Estimated number of adults with hypertension in the community.

Opportunistic screening

Facility-based opportunistic screening gives visibility into how many patients in the OPD (Outpatient Department) of hospitals are having their blood pressure measured to screen for hypertension.

Note: In many health systems, the number of screened patients and the approximate number of adult patients visiting the OPD are only recorded on paper and are reported monthly in aggregate.

% of OPD patients screened for hypertension

The approximate percentage of patients screened for hypertension in a month.

Numerator

Adult OPD patients with a blood pressure measure taken in a month

Denominator

Approximate Adult patients visiting the OPD of facilities per month

Monthly OPD patients screened for hypertension

The number of patients screened for hypertension in a month.

Value

Adult OPD patients with a blood pressure measure taken in a month

Cohort reports

Cohorts allow program managers to track a set of patients receiving treatment over time. The dashboard takes all the patients registered during a quarter and displays the outcome of their visit in the following quarter.

BP controlled numerator

The number of Patients with a BP <140 AND <90 at their last visit in the quarter after the quarter when they were registered.

BP not controlled numerator

The number of Patients with a BP ≥140 OR ≥90 at their last visit in the quarter after the quarter when they were registered.

No visit in 3 months numerator

The number of Patients with no visit in the quarter after the quarter when they were registered.

Denominator

New patients registered in the hypertension program in a quarter.

Drug stock and BP monitor inventory

Description...

Anti-hypertensive drug stock

Definition...

Patient days calculation

Quantity of DRUG ABC 5 mg +
Quantity of DRUG ABC 10 mg * 2
/ Patients under care * Estimated % of patients on DRUG ABC
= Patient days of drug stock

Example

  25,000 pills of Amlodipine 5 mg +
  15,000 pills of Amlodipine 10 mg * 2
/ 6,000 patients under care * 72%
= 12.5 patient days of Amlodipine

Blood pressure monitors

Definition...

Numerator

Facilities with ≥1 blood pressure monitor

Denominator

All facilities in the hypertension control program.