Patient journey for hypertension and dyslipidemia in Saudi Arabia: highlighting the evidence gaps

An extensive literature review was conducted using structured and unstructured search strategies to identify studies dealing with patient journey touchpoints (awareness, screening, diagnosis, treatment, adherence, and control) for hypertension and dyslipidemia in Saudi Arabia. Hypertension was defined as an average systolic blood pressure (SBP) ≥ 140 mmHg and/or average diastolic blood pressure (DBP) ≥ 90 mmHg. Dyslipidemia was defined as total cholesterol (TC) of ≥ 5.0 mmol/L or ≥ 200.0 mg/dL [21]. Definitions of each patient journey touchpoint are provided in Additional file 1. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this review, with minor modifications to fit within the scope of this study. The evidence was mapped using MAPS (Mapping the Patient Journey Towards Actionable Beyond the Pill Solutions) methodological approach [18, 21]. The mapping strategy was divided into six steps: (1) developing a comprehensive search strategy; (2) establishing the inclusion and exclusion criteria; (3) screening and shortlisting; (4) supplementing with additional and/or local data; (5) data extraction and synthesis; and (6) evidence mapping.

An electronic structured search was conducted to identify studies published from 01 January 2010 to 31 December 2021 through Medline and Embase databases using the keywords related to hypertension and dyslipidemia and different touchpoints of patient management. The comprehensive search was designed to ensure the inclusion of all studies conducted in Saudi Arabia on hypertension and dyslipidemia. The complete search strategy is provided in Additional file 2.

To address data gaps in the structured search, an additional unstructured search was conducted through the Incidence and Prevalence Database (IPD), World Health Organization (WHO), Country’s Ministry of Health (MOH), and Google Scholar websites. No date limits were applied to the unstructured search. Data gaps were further supplemented with anecdotal data from clinical experts in Saudi Arabia.

Eligible publications were based on: (a) studies on the human adult population (aged ≥ 18 years) with hypertension and dyslipidemia that focused on the prevalence and epidemiological data from different patient journey touchpoints (awareness, screening, diagnosis, treatment, adherence, and control or remission); (b) peer–reviewed published systematic review and/or meta-analysis, narrative reviews, observational studies; (c) studies representing patient population from Saudi Arabia.

Studies with special populations such as pregnant women; patients with comorbidities, non-English language studies, thesis abstracts; letters to the editor, and editorials; studies including specific patient subgroups; duplicate records and studies without full text were excluded from the analysis.

The first independent reviewer retrieved the studies using both structured and unstructured search strategies. Studies were screened and selected based on their title and abstract. The second independent reviewer assessed the selected studies considering predetermined inclusion/exclusion criteria and reviewed the full text. Any disagreements between the first and the second reviewer were resolved to arrive at a mutual consensus. A comprehensive review through manual screening of all the selected studies was carried out again, prior to data extraction and synthesis. Furthermore, any identified data gaps were supplemented with anecdotal data from clinical experts in Saudi Arabia.

Following a thorough manual screening of all the selected studies, relevant studies were shortlisted and exported to the data extraction grid in Microsoft Excel. Quantitative data pertaining to the various patient journey touchpoints (awareness, screening, diagnosis, treatment, adherence, and control) were captured in the grid. The data extraction grid was rechecked and verified by the reviewers for consistency and accuracy. The grid was further synthesized to highlight the evidence gap map for both hypertension and dyslipidemia.

A total of 524 studies were retrieved from the structured and unstructured searches on the prevalence and the patient journey touchpoints of hypertension. Of these, 512 studies were obtained through structured search and 12 studies from unstructured search. Most of the excluded studies represented specific patient subgroups (pregnant women, patients with other comorbidities, n = 234) and diseases other than hypertension (n = 135). Other reasons for exclusion of studies were nonavailability of data on patient journey touchpoints (n = 48),  < 18 years of age (n = 34), lack of nationally representative population (n = 18), data not from Saudi Arabia (n = 5), nonavailability of full text (n = 5), duplicate studies (n = 4), case studies (n = 2), studies published before 2010 (n = 1). Twenty-eight studies from the structured and 10 studies from the unstructured searches were selected for detailed review. Twenty-four studies from the structured search were excluded as they did not match the MAPS criteria definition for patient journey touchpoints. Finally, four studies from the structured searches [10, 17, 24, 25] and 10 studies from the unstructured searches [11, 26‐34] were included in the final analyses. The literature search and study selection process are presented in Fig. 1.

The included studies were conducted both in community-based and hospital-based settings. The overall prevalence of hypertension in community-based settings ranged from 14.0%–36.0% [10, 11, 17, 25, 26, 29, 34], while the prevalence in hospital-based settings ranged from 14.8%–41.8% [24, 30, 31]. The prevalence data as reported in two studies, i.e., Global Status report on NCDs and the Kingdom of Saudi Arabia World Health Survey (KSA WHS), both in collaboration with WHO, ranged from 14.0%–21.8% [11, 26]. A nationwide multistage random sampling carried out in 20 health regions of Saudi Arabia reported a hypertension prevalence of 25.5%; 44.7% patients were aware of their condition, 71.8% patients received treatment for their condition, and 37.0% patients achieved hypertension control [17]. A subgroup analysis of the Africa Middle East Cardiovascular Epidemiological (ACE) study revealed a prevalence of 41.8% among young Saudi patients and expatriates [17].

A nationwide multistage survey carried out by El Bcheraoui et al. reported an overall prevalence of hypertension of 15.2%; further, 42.2% patients were diagnosed with hypertension [10]. About 78.9% of the previously diagnosed hypertensive patients were receiving treatment for hypertension management and 45.0% of the treated patients had achieved control [10]. Two studies involving Saudi national subgroup analysis of the Prospective Urban Rural Epidemiology (PURE) study reported data that were both standardized and non-standardized by age. The first subgroup analysis reported hypertension prevalence to be 36.0%; 56.0% patients were aware of their condition, 53.0% patients were receiving treatment, and 27.0% patients were having controlled BP [25]. Similarly, the second subgroup analysis reported hypertension prevalence (non-standardized by age) to be 30.3%; further, 61.1% patients were aware of their condition, 58.9% patients received treatment, and 30.7% reported hypertension control [29].

A nationwide screening campaign as a part of the global screening initiative, May Measurement Month, reported 100.0% screening of hypertension [26]. The campaign reported that 29.2% patients were hypertensive, 60.8% patients were aware of their condition and were receiving treatment, and 39.3% patients had their BP controlled [30]. One university-based study revealed that hypertension was prevalent among 31.0% patients [34], while one study reported 27.6% of patients to be aware of their condition [32]. The screening rates among the patients was reported to be 100.0% from three studies [30, 32, 34]. As per the data obtained from two cross-sectional studies, the average prevalence of hypertension was found to be 14.8% [29], whereas the awareness, stratified by the patients’ knowledge of SBP and DBP was reported to be 48.7% and 47.3%, respectively [33]. The detailed study characteristics are presented in Table 2.

A total of 373 studies were retrieved from the structured and unstructured searches on the prevalence and the patient journey stages of dyslipidemia. Of these, 362 studies were found through structured search and 11 studies through unstructured search. Most of the excluded studies represented specific patient subgroups (pregnant women, patients with other comorbidities, n = 168) and did not have dyslipidemia (n = 56). Other reasons for exclusion of studies were non-availability of data on stages of patient journey touchpoints (n = 82),  < 18 years of age (n = 22), lack of nationally representative population (n = 11), data not from Saudi Arabia (n = 2), non-availability of full text (n = 10), duplicate records (n = 2), and editorials (n = 1). Finally, two studies from the structured searches [35, 36] and 10 studies from the unstructured searches [11, 29, 33, 37‐43] were included. To fill the data gap, one anecdotal evidence was included in the final analyses. The literature search and study selection process are presented in Fig. 2.

The studies from community-based settings reported a prevalence ranging from 12.5%–43.0% [11, 29, 43], while the prevalence in hospital-based settings was 62.0% [41]. As per the data reported by KSA WHS, dyslipidemia was prevalent in 43.0% of the Saudi population [11].

The Saudi national subgroup analysis of the PURE study reported the prevalence to be 32.1% [29]. Two cross-sectional survey studies reported the dyslipidemia prevalence to be 12.5% and 62.0%, respectively [41, 43]. A Saudi national subgroup analysis of the SHIS (Saudi Health Interview Survey) study revealed that 17.8% participants who self-rated their health to be poor/fair were diagnosed with dyslipidemia [35]. Lipid profile screening rate was reported in only one cross-sectional survey study (34.6%) [38]. A multinational survey study, which included Saudi Arabia, reported a very high proportion of patients (94.0%) undergoing treatment, particularly with statins [36]. Likewise, the Saudi national subgroup analysis of PURE study indicated that 40.6% of the patients were undergoing lipid-lowering treatment as secondary prevention of CVD [39]. Similarly, in a prospective cohort study, although 40.0% reported as being prescribed the lipid-lowering drugs, only 15.0% received appropriate dosing [42].

The Morisky Medication Adherence Scale (MMAS) assessing medication adherence rate reported that 26.0% patients adhered to the therapy which increased to 62.0% over nine months [42]. A retrospective cross-sectional study that captured data from electronic health records (EHRs) of patients with type 2 diabetes (T2D) and dyslipidemia showed 77.4% adherence to lipid-lowering treatment, while 41.5% of the patients displayed control [40]. According to the anecdotal data provided by Dr. Ashraf Amir, 45.0% patients were found to be adherent to the treatment. The study details are summarized in Table 3.

The overall prevalence estimates of hypertension were represented in a wide range, which could be attributed to the heterogeneity of patients’ baseline characteristics, differences in the study settings (community-based or hospital-based), and difference in the severity of the disease. The prevalence reported from community-based settings were lower (14.0%–36.0%) [10, 11, 17, 25, 26, 29, 34, 35] than in hospital-based settings (14.6%–41.8%) [24, 30, 31], which is indicative that a majority of patients visiting the PHCC were with underlying cardiovascular (CV) risk factors, hypertension being one of them. This was in agreement with the results from previous studies that also showed higher prevalence of hypertension (30.0%–92.0%) [44, 45] in hospital settings compared with community-based studies (13.6%–26.1%) [46, 47]. Additionally, other reasons may include differences in the study duration between the two settings and its corresponding effect on disease severity and differences in diagnostic practices across different locations [24].

Majority of the studies revealed hypertension awareness to be strikingly low in male patients, rural population, and younger patients [25, 29, 30, 32]. On the contrary, increased awareness was observed among female patients, urban dwellers, geriatric patients, and those with chronic comorbidities [25, 29]. These findings were consistent with previous reports wherein heightened awareness was observed among females vs. males [48], urban population, and in patients with DM and CVD. [25] Although Saudi Arabia displays heightened hypertension awareness when compared with other Middle East countries, the hypertension awareness rates were still lower in comparison to other high-income countries (HICs) such as Germany and South Korea (40.0%–80.0%) [25, 49, 50]. Except for two screening campaigns held nationwide and in Eastern province, respectively, the review findings suggested a paucity in screening studies across Saudi Arabia [31, 32, 34]. The reason for high screening rates found in these studies (100.0%) is simply because all the patients underwent screening as part of the survey protocol which did not include targeted screening. However, previously reported community-based screening campaigns taking place in Eastern Province reported lower participant turnout (ranging from 21.0%-33.0%) [49, 50] for screening owing to refusal of undergoing long tedious screening procedures or lack of incentive schemes for participation [51]. Overall, the screening rates remained low in Saudi Arabia which was also similar to that observed in other Middle Eastern countries including United Arab Emirates (UAE), Iran, and Occupied Palestinian Territory (OPT) [25].

Low diagnosis rates (47.1%) trace back to lower rates of awareness and screening campaigns in Saudi Arabia. Although rates of diagnosis have improved over the last decade (from 11.5% to 47.1%), they still remain low when compared to HICs such as South Korea, Canada, and Iceland, where almost 70% of the hypertensive patients were accurately diagnosed [50, 52]. A wide variability was observed in the proportion of patients undergoing treatment (27.9%–78.9%) [10, 17, 25, 27, 29, 30]. Similar to the observations made on awareness, the participants who received treatment mainly belonged to geriatric, female, those with comorbidities and educated cohorts [10, 24, 25]. Although treatment rates in Saudi Arabia are higher, compared with UAE and Iran (45% and 43%, respectively), the treatment rates in HICs were reported to be > 70% [25, 52]. Further, proportion of patients adhering to antihypertensive medications was reported to be low in Saudi Arabia (22.5%) [28], which was similar to the findings from other Middle Eastern countries like OPT (16.9%) [53], but was lower than UAE (42.0%) [54]. Consistent with these findings, previously published studies have reported higher treatment (74.0%) and lower adherence rates (6.2%) within Saudi Arabia [52, 55]. Likewise, a huge variation was observed in the proportion of patients achieving BP control (27.0%–45.0%) [10, 17, 25, 29, 30], while HICs including Canada and Germany reported higher BP control (50.0%–69.0%) [52].

Overall, when compared with other Middle Eastern countries, the prevalence of hypertension reported within community-settings in Saudi Arabia (14.0%–36.0%) was found to be comparable with countries like Iran, Turkey, and Oman (19.2%–33.7%) [56]. The awareness in UAE, Iran and OPT ranged from 45.0%–57.0%, which was higher compared with Saudi Arabia (27.6%–61.1%). Treatment (27.9%–78.9%) and control rates (27.0%–45.0%) within Saudi Arabia were comparatively higher than that in Iran (treatment; 43.0% and control; 16.0%) and UAE (treatment; 45.0% and control; 14.0%), respectively [25]. The overall increasing trends in hypertension seen across all the patient journey touchpoints pose a major challenge to the healthcare system in Saudi Arabia. The gender differences observed in hypertension prevalence has a physiological basis as suggested by few gender-based analytical studies [57, 57‐59]. The experimental models of hypertension show a higher level of angiotensin II receptors (type 1; AT₁), which are mainly responsible for vasoconstriction, sodium reabsorption, and eventual rise in BP, in males vs. females [59]. Additionally, other challenges include disparity across various sections of the community with regards to the knowledge and attitude towards preventive healthcare, unhealthy lifestyle behavior, and lack of motivation among Saudi people to self-manage hypertension [10, 17]. Moreover, low numbers of evidence pertaining to each critical patient journey touchpoint can impede adequate implementation of health interventions among hypertensive patients (Fig. 3).

The prevalence of dyslipidemia has increased steeply over the last many years from 12.5% to 43.0% [11, 29, 41, 43]. This increase could be attributed to lifestyle changes owing to rapid urbanization, poor diet, and low physical activity [35]. Dyslipidemia (with increased low-density lipoprotein cholesterol [LDL–C]) was the leading CV risk factor (32.1%–68.6%) among other risk factors, including hypertension, diabetes, smoking, obesity (body mass index [BMI] ≥ 30 kg/m²), or abdominal obesity [24, 40, 41]. These findings were comparable to HICs in Western Europe (40.0%–60.0%) and North America (40.0%–45.0%) [60]. Elevated LDL-C over a prolonged period can increase the risk of atherosclerotic cardiovascular diseases (ASCVDs) events by almost five times, which reiterates the importance of maintaining an optimum lipid profile [61]. Dyslipidemia was also positively associated (62.0%) in patients with increased body mass index (BMI) and waist circumference (WC) along with faulty lifestyle and dietary habits such as inadequate sleep, caffeine intake, and consumption of sugary carbonated beverages [41].

A wide variability in dyslipidemia awareness level (10.5%–47.3%) was observed in geriatric patients, uneducated individuals, and rural dwellers in Saudi Arabia [33, 37]. The awareness rates pertaining to CVD risk factors including dyslipidemia in the urban educated population in Saudi Arabia were also within this range (47.1%) [62]. A small proportion of patients (34.6%) visiting the PHC underwent lipid screening in Saudi Arabia. This could be because of lack of awareness pertaining to the importance of regular screenings, especially among younger individuals (> 20 years), gender disparity, and unemployment [38]. On the other hand, UAE reported higher screening rates (49.3%) in > 8000 patients [63].

As reported by CEPHEUS study, a high proportion of patients (94.0%) with high and very high ASCVD risk underwent statin therapy. This reinstates the importance of dyslipidemia management in the primary prevention of CVD events, especially in individuals with multiple CVD risk factors [36]. However, a lower proportion of patients (40.6%) were receiving lipid-lowering treatment for secondary prevention of CVDs. This was due to the inequality in wealth distribution persistent in Saudi Arabia that led to inequality in accessing adequate treatment and poor prognosis of CVDs. These observations agree with previous Saudi studies that reported underwhelming use of high-intensity statins for secondary prevention in patients with ASCVD or sub-optimal adherence to prevention guidelines in secondary prevention of coronary events [64, 65]. Conversely, this trend was not observed in other HICs such as UAE, Canada, and Sweden, where more than half of the population received lipid-lowering treatment for secondary prevention [39]. Furthermore, a higher adherence rate (62.0%–77.4%) was observed in patients with type 2 DM and dyslipidemia which was the result of extensive dyslipidemia education programs that were undertaken at the beginning of the study [42]. The anecdotal evidence for adherence (45.0%) further calls for urgent implementation of such education programs across various communities in Saudi Arabia. Notably, the control rates were found to be lower (23.0%–41.5%) among the patients, which could be due to non-indulgence in physical activity or not having a controlled diet which reemphasizes the important role of non-pharmacological therapy along with drug therapy [36, 40]. Moreover, drug intolerance, inadequate PHC follow-up and using medications that are not evidence-based, especially in females, can hamper optimal lipid control [36].

While, the prevalence of dyslipidemia in Northern Emirates was reported to be slightly higher (72.5%) [66] compared to Saudi Arabia (12.5%–62.0%), the Gulf Registry of Acute Coronary Events (Gulf RACE) encompassing countries such as Bahrain, Kuwait, Qatar, Oman, UAE, and Yemen had a lower prevalence (32.7%) [67]. Egypt reported lower screening rate (8.6%) compared to Saudi Arabia (34.6%). In other middle-eastern countries like Jordan, Lebanon, UAE, Kuwait, and Oman, higher treatment (55.9%) and control rates (52.4%) were observed, compared to that in Saudi Arabia (treatment rate: 40.0% and control rate: 28.0%–41.5%, respectively) [36, 38, 42].

Overall, a huge scarcity in data for dyslipidemia along each patient journey touchpoint has been observed in Saudi Arabia that deters targeted management strategies (Fig. 4).

The Saudi Arabia healthcare system has rapidly evolved over the last 20 years and is home to world-class hospitals and efficient healthcare facilities. The Saudi Healthcare National Transformation Program (NTP) has been a driving force for Saudi Vision 2030 to bring about a transformation in the healthcare sector by prioritizing NCD prevention [29, 68]. However, despite the availability of adequate resources and implementation of multiple initiatives, numerous evidence gaps along each patient journey touchpoint in hypertension and dyslipidemia still persist. This may be partly due to less NCD research output from Saudi Arabia compared with other Middle Eastern countries and a smaller number of national awareness programs and multi–faceted healthcare policies [29, 68]. Furthermore, the current COVID-19 pandemic has adversely impacted the overall management of hypertension and dyslipidemia owing to partial and complete lockdowns and cancellation of in–person visits to PHCCs [69].

As the future steps to reduce CVD burden within the Saudi population, active collaborations are needed between patients, HCPs, community/hospital pharmacists, and healthcare policy makers to enhance coordination between primary care and health services delivery systems, backed by adequate funding and leadership for uniform implementation [70]. Such collaborations can also help identify barriers along the patient journey and plan future research to address them. This could be accomplished by emphasizing national-level epidemiological studies over region-based data, with bias-free study designs and protocols for hypothesis testing. Further, dissemination of study results adhering to standardized reporting guidelines such as STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) can ensure study ethics and methodological robustness [71].

Table 4 represents recommendations for enhanced patient care and health outcomes across all patient journey touchpoints, designed by all authors through mutual consensus.

This review had several limitations. Firstly, we excluded studies conducted in specific patient subgroups (pregnant women, patients with co-morbidities). However, the reason for this exclusion was solely based on the objective to understand and highlight the evidence gaps in the patient journey of hypertension and dyslipidemia, respectively. Furthermore, adding data from patients with comorbidities would have increased literature volume diluting the objectives of this study or skew the overall effect size resulting from additional treatment/patient arms. As a result, the gaps in hypertension and dyslipidemia patients’ journey may not be extrapolated from participants with comorbidities [80]. Nevertheless, this could have led to the underestimation of the overall data and can be a perspective for future research by designing appropriate study methodology. Secondly, we chose to exclude non-English language studies to overcome the reduced traceability of studies that are published in local language and the associated translation costs, although attempts were made to include local language studies with data validated by local experts [81]. Thirdly, we excluded specific study types (i.e., thesis abstracts; letters to the editor, and editorials) to ensure that studies of high quality and strong recommendations (systematic reviews followed by observational studies and narrative reviews) be considered to enable the readers make evidence-informed decisions [76]. Furthermore, we did not include publication bias analysis for the selected studies, and we did not calculate the pooled estimates for each touchpoint owing to the wide variability in data. We considered only TC while including studies for dyslipidemia without considering additional variables such as LDL-C, triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C). Finally, we could not include information on the efficacy of specific treatment intervention(s). This was again attributed to our underlying objective for this study which was to only highlight the evidence gaps in the patient journey.