Design And Implementation Of An Active Database For Managing Hypertension

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Design And Implementation Of An Active Database For Managing Hypertension


Abstract


Hypertension is a silent, invisible killer that rarely causes symptoms and its complications account for about 10 million deaths worldwide every year. One of the critical factors and the cornerstone for achieving hypertension control is the patient’s adherence to the prescribed regimen. Hypertension if not properly managed can result in a wide range of complications like stroke, ischaemic heart disease and renal failure that have economic, clinical and humanistic outcome implications. The aim/ objectives of this research project is to develop application software that will handle hypertension therapy for hypertensive patient in the hospital. We have found that knowledge acquisition is one of the main problems of the development of decision support systems for hypertension guideline compliance. We exposed a RESTful API which can be applied for both web and mobile applications. This will allow us to extend the user interface, enhancing the interaction of the user with HyperCare.


Chapter One


1.0 Introduction

Introduction

An increasing number of institutions are approaching the problem of distributing and improving the use of guidelines in patient care. Electronic medical record systems have the potential of making a great impact in the increased utilization of guidelines since these systems are often used by clinicians at the time when care is delivered.4 In some cases guidelines are put into the systems in narrative form; in others, several independent logic modules react when actions prescribed by guidelines do not take place.5

Systems integrating both data-maintenance and decision support functions have requirements that span from efficient data-manipulation, typical of databases,6 to inferential elaboration, typical of expert systems.7 Active databases8 may be considered as a bridge between these two kinds of systems: they have both the efficiency of databases in handling data storage and retrieval and the power of a complete rule language in expressing complex inference mechanisms. Moreover, in active databases the knowledge is collected in schema and rules enforced by the database manager. The same knowledge is thus available and transparent to all applications accessing the database. This property, known as knowledge independence, allows knowledge to be easily maintainable.8

The inferential complexity of the guidelines for the management of hypertension and the necessity of archiving the huge amount of data acquired in periodic follow-up visits make active databases particularly interesting when developing decision support systems for hypertension guideline compliance.

HyperCare is a prototype of a decision support system for compliance with essential hypertension management guidelines,1,2 implemented using the active database language Chimera.3 The choice of this language is justified by the rich object-oriented data definition language and the expressive syntax for active rule definition offered by Chimera. Even if the system that we propose is not the first support system for hypertension management,9,10 as far as we know this is the first application of active databases to medical guideline compliance.


Statement of the Problem

Hypertension is a silent, invisible killer that rarely causes symptoms and its complications account for about 10 million deaths worldwide every year. Households often spend a substantial share of their income on hospitalisation and care following complications of hypertension. Families face catastrophic health expenditure and spending on health care, which is often long term in the case of hypertension complications, pushing tens of millions of people into poverty (World Health Organization (WHO), 2013). High blood pressure is ranked the fifth leading risk factor for cardiovascular diseases (CVDs) in Sub-Saharan Africa (Mensah, 2013). Prevalence of hypertension and rate of use of antihypertensive medication have been shown to be higher in Black subjects (Agyemang et al., 2003; 2005) and by the year 2025 about 75% of the world’s hypertensive population will be in developing countries (Kearney, et al., 2005). The overall prevalence of hypertension in Nigeria ranges from 8% to 46% and is increasing (Ogah, et al., 2012). In the recent past, Akinluaet al. (2015) reported that the overall crude prevalence of hypertension in Nigerian adults ranged from 0.1% to 47.2% depending on the benchmark used for diagnosis of hypertension, the setting in which the study was conducted, sex and ethnic group. More recently, Ajayi et al. (2016) stated that according to the WHO, the prevalence of hypertension is highest in the African Region at 46% of adults aged 25 years and above. One of the critical factors and the cornerstone for achieving hypertension control is the patient’s adherence to the prescribed regimen (Osterberg and Blaschke, 2005; Abegaz et al., 2017) yet it remains unclear as to why patients fail to take their medicines. Medication non-adherence is a serious challenge to pharmacotherapy and is associated with adverse outcomes (Piercefield et al., 2016). Maintaining medication adherence to multiple medications is a complex issue in patients with chronic diseases, particularly CVDs. The influence of non-adherence to antihypertensive medications is the most important cause of uncontrolled blood pressure.

Consequently, because of non-adherence, most (nearly 3-quarters) of the hypertensive patients do not achieve optimal blood pressure control (Abegaz et al., 2017). Non-adherence to antihypertensive medication and effective blood pressure control is still below average in developing countries (Gwadry-Sridhar et al., 2013; Lloyd-Sherlock et al., 2014; Irazolaet al., 2016; Abegaz et al., 2017; Agbor et al., 2018). In Africa, 63% of hypertensive patients on treatment were non-adherent even though successful treatment of hypertension reduces its burden and mortality (Abegaz et al., 2017; Agbor et al., 2018; Oparilet al., 2018). Hypertension if not properly managed can result in a wide range of complications like stroke, ischaemic heart disease and renal failure that have economic, clinical and humanistic outcome implications.


Aim and Objective

The aim/ objectives of this research project is to develop application software that will handle hypertension therapy for hypertensive patient in the hospital.

The objectives of the study can be summarized thus:

  1. To provide diagnosis for hypertension patients
  2. To provide therapy for hypertension patients and
  3. To monitor the patient’s health based on the therapy administered.

Research Question

  1. What is the diagnosis for hypertension patients?
  2. What is the therapy for hypertension patients?
  3. In what way can the patient be monitored base on the therapy administered?

Justification

The need for research in hypertension cannot be overemphasised since the lifetime burden of hypertension remains substantial, despite modern therapy (Rapsomaniki, et al., 2014). Essential hypertension is of public health importance because it has no identifiable cause and management is lifelong, meaning that appropriate intervention to help patient adhere to therapy would improve blood pressure control thereby preventing hypertension-related complications and mortality. Assessment of adherence is necessary firstly because it remains significantly poor among hypertensive patients; secondly, adherence is a dynamic process that needs to be followed up (WHO, 2003), and thirdly, non-adherence is the most important aspect of suboptimal medicines use. Further, continuing research in patients’ knowledge about hypertension and attitude towards antihypertensives is necessary. This claim can be corroborated with the findings of Malik et al. (2014), which showed a significant association between patients’ knowledge and blood pressure control status and drug adherence. Therefore, a research in patients’ adherence may be incomplete without establishing patients’ baseline knowledge and/or attitude in order to draw a meaningful conclusion. Moreover, the need for establishing patients’ baseline beliefs about their medicines is paramount. This claim can be affirmed with the evidence by Horne et al. (2013) who postulated that adherence is influenced by implicit judgments of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it. Research on the acceptability of the prescribed antihypertensives is important firstly because of its strong relationship with adherence as it has been shown by Kozarewicz (2014); Liu et al.(2014) and Morrow et al.(2013). They showed that patients’ adherence to a medicinal product may be significantly influenced by the patients’ acceptability for that medicinal product. This claim can be substantiated with Astin’s (1998) survey, which showed that the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life. Also, Eddoukset al. (2002) have shown that 80% of a patient sample in Ethiopia used phytotherapy because it was cheaper, more efficient and better than modern medicine. This study will be able to give insight into factors that contribute to non-adherence to antihypertensive medicines, with a view of promoting the safe and effective use of antihypertensives, and efficiency of health systems generally through appropriate intervention.

Pharmacist’s intervention delivered alone or in collaboration with other health care professionals including education enhances blood pressure control and improves adherence to antihypertensive therapy (Omboni and Caserini, 2018). Also, Walsh et al. (2006) has reported that focus on hypertension by other health professionals in addition to the patient’s physician was associated with substantial improvement of hypertension control. The strategies to improve hypertension control include, among other things, patient education, self-management, and patient reminders. Additionally, Munroe et al. (1997); Charbotet al. (2003); Machado et al. (2007) and Mogardoet al. (2011) have all reported that pharmacists’ intervention improved adherence and reduce blood pressure levels in patients treated with antihypertensive agents. There is strong desire for this research because no previous study unraveled the key factors that may positively influence adherence to antihypertensive medicines and blood pressure control in populations from this region of Nigeria.


Chapter Five


Conclusion and Recommendation

HyperCare is a prototype of a decision support system for essential hypertension care management according to international guidelines. In this prototyping phase of the system, no complete clinical validation of HyperCare has been carried out.

Nevertheless, the results of the described work are significant mainly for two reasons. First, they prove that an active database may be applied to encourage guideline compliance, supporting knowledge independence and a level of data-handling efficiency not easily achievable using traditional expert system shells. Second, they show that an expressive active database language as Chimera may be useful as a prototype language to formalize the functionality of a complex decision support system like HyperCare (see the IDEA methodology 3). In particular, the high expressiveness and readability of the Chimera language allowed the consulted medical experts to read and understand the code of HyperCare. This gave them better understanding and greater confidence in the functions supported by the prototype. Knowledge acquisition is one of the main problems of the development of decision support systems. We have found that a readable prototyping language may speed up this phase allowing the experts to directly suggest the best way to represent knowledge.

The development of a complete product would require a considerable increase in the number of rules implemented in the central strata of the HyperCare prototype and the definition of a class for any disease that may possibly interfere with hypertension treatment. However, during the prototype development attention has been paid to implement at least an example, if not many, of all the possible types of rules and classes required in a full implementation.

Versions of HyperCare for low-cost and widespread computer systems are under consideration. A Chimera-SQL translator is currently under development.3,15 It is our intention, as soon as this tool will be available, to translate HyperCare to Oracle SQL16,17. This will grant to the system the robustness of a commercial database and will allow us to extend the user interface, enhancing the interaction of the user with HyperCare. Finally, this Oracle version of HyperCare will be thoroughly validated in clinical environment.

Although current versions of Oracle SQL directly support active rules, Chimera was preferred to Oracle SQL for the prototyping of HyperCare because its code is much more readable by medical experts and easier to program.


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