Structured care and multiple drug regimens can help GPs achieve good blood pressure control in their patients with hypertension, as Dr Alan Begg explains
The importance of hypertension management is evident from the prominence it has been given in the nGMS contract’s quality and outcomes framework (QOF).Approximately 29% of the 550 clinical points available in the QOF relate to the management of blood pressure.1 The hypertension disease category offers 105 points (Table 1) and a further 53 are available from managing blood pressure in patients in the CHD, stroke and diabetes categories.
In addition to the points available under the clinical indicators, a further 15 points can be achieved by meeting indicators 11 and 17 of the section on records and information about patients. Ten points are available for measuring the blood pressure in 55% of patients aged 45 years and over, in the preceding 5 years, with an additional five points offered for reaching the 75% threshold.
This in effect means that for the first time we have an incentivised national screening programme for hypertension. However, it puts the onus on primary care teams to assess these patients fully, and manage them appropriately, depending on their cardiovascular risk (Box 1 and Box 2).
Identifying patients at risk – BP 1
The distinction between primary and secondary prevention is best seen in terms of a continuation of risk. For patients with mild hypertension, the decision on therapeutic treatment is based on a measurement of that risk, but for those with target organ damage, such as established vascular disease, heart failure or strain, renal damage, diabetes or fundal changes, a raised blood pressure needs to be lowered effectively; however, the QOF sets a lower target only for patients with diabetes.
Those patient groups at higher risk where the benefits of a greater reduction of blood pressure are important need to be identifiable within the hypertension register and their blood pressure controlled accordingly.
Box 3 gives the Read codes used in case finding for hypertension.
|Table 1: The clinical indicators for hypertension|
|Clinical indicator||Points||Payment stages|
|BP 1||The practice can produce a register of patients with established hypertension||9|
|BP 2||% of patients with hypertension whose notes record smoking status at least once||10||25||90|
|BP 3||% patients with hypertension who smoke offered smoking cessation advice or referral to specialist service, offered at least once||10||25||90|
|BP 4||% of patients with hypertension in whom there is a record of the blood pressure in the past 9 months||20||25||90|
|BP 5||% of patients with hypertension in whom the last blood pressure reading (measured in past 9 months) is 150/90 mmHg or less||56||25||70|
|Box 1: Assessment of patients with hypertension|
|Assessment should include:|
|Box 2: Read codes for patient assessment|
|Urine protein test|
|No left ventricular|
|Box 3: Hypertension Read codes|
|not otherwise specified||G20z|
|Benign essential hypertension||G201|
|Malignant essential hypertension||G200|
|Box 4: Action Read codes|
|Never smoked tobacco||1371|
|Smoking cessation advice||8CAL|
Reducing cardiovascular risk – BP 2 and 3
The benefits of stopping smoking to reduce cardiovascular risk are not in doubt.2 The excess risk posed by smoking can be avoided by stopping smoking before middle age, and after one year of abstinence the excess risk of death from myocardial infarction and cerebral arterial disease is decreased by half.2,3 Patients with hypertension who are at increased risk would therefore have more to gain by stopping smoking.
However, there is doubt as to the ideal method of ensuring long-term smoking cessation. Our practice has resisted patient demands for smoking cessation adjuncts, such as nicotine replacement therapy, unless they form part of our risk assessment and smoking cessation programme.4
The success of this approach is that all risk factors can be identified and targeted.However, a recent systematic review of 23 randomised controlled trials found limited evidence for the effectiveness of stage-based interventions in changing smoking behaviour, when compared with non-stage-based or no intervention.5
Box 4 gives the action codes for BP indicators 2 and 3.
Reaching blood pressure targets – BP 4 and 5
Interventions to improve blood pressure control
A Cochrane review has looked at the following interventions to improve blood pressure control:6
- Patient education
- Physician education
- Health professional (nurse or pharmacist) led care
- Organisation to improve delivery of care
- Appointment reminder systems.
Educational interventions directed towards either the physician or the patient were not found to be associated with clinically important reductions in systolic or diastolic blood pressures;6 and although nurse or pharmacist led care may be a promising way forward, the only clear results were related to one trial.
The US Hypertension detection and follow up trial found that a system of register, recall and regular review in tandem with a stepped care approach to antihypertensive drug treatment was effective in reaching blood pressure targets and reducing all-cause mortality.7
In our practice, for maximum effectiveness we have implemented a similar approach instead of relying on opportunistic encounter during the last 9 months of the accounting year.
Improving adherence to drug treatment
Drug treatment cannot be effective in lowering blood pressure unless patients are willing to take their medication regularly. It is important therefore to engage with the patient and explain the need to reach targets and to employ multiple drug therapy. Simpler dosing regimens, such as fixed-dose combinations or once-daily dosing, improve adherence.8
Sequencing of drugs
The British Hypertension Society’s recommendation to use the AB/CD algorithm for the sequencing of blood pressure lowering drugs has been reinforced by the results of the ASCOT trial.9,10
The profile of the hypertension patients in the trial reflected that of patients in general practice. Patients randomised to an amlodipine and perindopril regimen had better outcomes than those randomised to receive atenolol and bendroflumethiazide; however, both groups showed significant blood pressure reductions.
A mean sitting blood pressure of 164/95 mmHg at baseline was reduced to 137/78 mmHg.When the trial was ended prematurely, 60% of patients without diabetes had reached both the SBP and DBP target blood pressures of <140/90 mmHg, while 32% of patients with diabetes had reached the target of <130/80 mmHg.10 This success has been attributed to a step-wise approach to the introduction of medication and a refusal to accept sub-optimal control.
Older people tend to show greater variability in blood pressure levels. In the elderly, it is important to take both seated and standing blood pressure measurements after initiating therapy because of the possibility of orthostatic hypertension.
If the fall in systolic blood pressure is ?20 mmHg with postural symptoms, treatment may be titrated to the standing values, making it easier to reach blood pressure targets.
See Box 4 for the action codes used in blood pressure monitoring.
|Box 5: Exception Read codes|
|BP 1||Patient unsuitable||9h31|
|BP 5||Maximally tolerated blood pressure treatment||8BLO|
|Angiotensin-converting enzyme inhibitor:|
|Angiotensin II receptor antagonist:|
|BP 5||Calcium-channel blockers||No exception|
|Alpha-blockers||codes have been|
Exception codes are given in Box 5 (above).
Maximum tolerated blood pressure treatment
Reaching blood pressure targets in certain patients can be extremely difficult for a variety of reasons, which include poor therapeutic response or unacceptable adverse reactions.
The contract allows practices to record when they consider the patient is receiving his or her maximum tolerated blood pressure treatment. Once the appropriate code is set the practice will not be financially penalised if the target blood pressure is not reached.
As there is no national guidance on what constitutes maximally tolerated blood pressure treatment, the Primary Care Cardiovascular Society has issued a consensus statement to guide practices on this issue.11 Practices are advised to develop a written protocol to define maximally tolerated treatment based on the best available evidence, which they can present to the QOF assessor in support of their approach. Box 6 gives the key points relating to maximally tolerated blood pressure treatment.
|Box 6: Maximum tolerated blood pressure treatment – key points|
The benefits of treating patients over the age of 80 years with anti-hypertensive therapy are not clear.
A meta-analysis of the data from randomised controlled trials of antihypertensive drugs which included patients over the age of 80 years has shown the benefit of treatment in this age group in preventing strokes, major cardiovascular events and heart failure.13 There was no treatment benefit for cardiovascular death and all-cause mortality.
The Hypertension in the Very Elderly Trial should give clearer guidance on the safety and efficacy of preventing stroke and death with anti-hypertensive therapy in this age group.14
Patients already taking medication should continue after they reach 80 years. In our practice we take the decision to treat those over 80 therapeutically at the time of diagnosis on an individual basis, taking into account:
- Biological age
- Existing co-morbidities
- Presence of end-organ damage.
For some patients evaluation and initial investigation will indicate the need for specialist referral. Practices should consider whether to exclude this group temporarily from QOF targets, pending the outcome of the specialist assessment. Such patients include those with:
- Severe hypertension
- Secondary causes of hypertension
- Multiple drug intolerance or contraindication
- Unusual blood pressure variability.
Update of exception reporting
New Read codes for coding patients as exempt from a single indicator or a whole indicator group were released in October 2003 to support the nGMS contract.
The Quality Management and Analysis System (QMAS) is now used by all practices participating in the QOF, and from October 2005 practices will be able to submit exception details to QMAS for incorporation within the QMAS reports.
These details will cover:
- Recent registration
- Recent diagnosis
- Type of exception code recorded
- Counts of exception reasons.
Comparative values for the clinical indicators will appear in the practice reports, allowing us to compare our level of exception rates against local rates in the primary care organisation and national rates.
Quality and outcomes framework update
There has been no new evidence to indicate the optimum blood pressure level. Ensuring that all patients reach the audit standard remains a reasonable goal, as long as practices are aware that the lower the blood pressure the better, especially in patients with diabetes and those with evidence of end-organ damage.
The ASCOT trial provides compelling evidence that all patients with hypertension on treatment should be given a statin, and this advice must be included in any update.A regimen of calcium-channel blocker plus ACE inhibitor and a statin gave a non-fatal myocardial infarction and fatal coronary heart disease rate per 1000 patient-years of 4.8, compared with a rate of 9.2 for the current most commonly used regimen of a betablocker and a thiazide.15
The equivalent rates for fatal and nonfatal stroke were 4.6 and 8.2. This equates to an average relative risk reduction of 46%.
An essential component of all future QOF monitoring visits must be to ensure that practices take a structured approach to the comprehensive management of all their patients with hypertension.
- Investing in General Practice.The New General Medical Services Contract. www.bma.org.
- Brown R, Larkin J, Davis R. Current concepts in the management of smoking cessation: a review. Am J Manag Care 2000; 6: 394-404.
- NHS Centre for Reviews and Dissemination. Smoking cessation: what the health service can do. Effectiveness Matters 1998; 3: 1-4.
- National Institute for Clinical Excellence. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation.Technology Appraisal Guidance No 39. London: NICE, 2002.
- Riemsma RP, Pattenden J, Bridle C et al. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. Br Med J 2003; 326: 1175-7.
- Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. The Cochrane Database of Systematic Reviews 2003; Issue 1. Art. No.: CD005182. DOI:10.1002/14651858. CD005182.
- Hypertension detection, follow up Program Cooperative Group. Persistence of reduction in blood pressure and mortality of participants in the hypertension detection and follow up program. JAMA 1988; 259: 2113-22.
- Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. The Cochrane Database of Systematic Reviews 2004; Issue 3. Art No.: CD004804. DOI 10/1002/14651858. CD004804.
- Williams B, Poulter NR, Brown MJ et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18: 139-85.
- Dahlof B, Sever PS, Poulter NR et al; ASCOT investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366: 895-906.
- McCormack T, Davies M. The definition of maximally tolerated blood pressure treatment.Br J Cardiol 2005; 12: 156-60.
- Brown MJ, Cruickshank JK, Dominiczak AF et al; Executive Committee, British Hypertension Society. Better blood pressure control: how to combine drugs. J Hum Hypertens 2003;17: 81-6.
- Gueyffier F, Bulpitt C, Boissel JP et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet 1999; 353: 793-6.
- Bulpitt C, Fletcher A, Beckett N et al. Hypertension in the Very Elderly Trial (HYVET): protocol for the main trial. Drugs Aging 2001; 18(3): 151-64.