High blood pressure is the direct cause of around 3000 deaths each year, but is also a major risk factor for cardiovascular disease, the main cause of death in the UK.1 Tackling high blood pressure and cardiovascular disease is a national priority.2-5
Data from the Health Survey for England for 1998 6 indicate that only 33% of patients with hypertension were controlled to the ‘old’ British Hypertension Society (BHS) target of <160/95 mmHg.
If the target of <140/85 mmHg, recommended by the BHS in 1999, is applied, fewer than 10% of patients were controlled.7
The BHS guidelines recommend that all GP practices or primary care organisations develop a protocol for hypertension management and that implementation of the guidelines should be audited periodically.7
Improving hypertension management in our area
In 2002, in Derwentside Primary Care Trust we decided to design, implement and evaluate a systematic, multidisciplinary approach to the management of hypertension within the PCT, in line with the BHS guidelines. This would involve:
- Developing and implementing a care pathway for the management of hypertension, to ensure that systematic care could be delivered by GPs, nurses and pharmacists.
- Developing a multidisciplinary approach to managing hypertension and setting up pharmacistled clinics to implement the care pathway.
- Identifying and recording risk factors in all patients with hypertension.
- Identifying and documenting patients with hypertension at high risk of coronary heart disease and those with pre-existing cardiovascular disease.
- Providing and documenting the delivery of appropriate advice and treatment, and offering regular review to patients with hypertension who have pre-existing, or are at risk of, CHD.
- Auditing the management of all patients with hypertension, evaluating the service developments, and comparing blood pressure management of patients attending pharmacist-led clinics with those receiving standard care.
Implementing the care pathway
We developed the care pathway based on what was then the current version of the BHS guidelines 7 and the National Service Framework for Coronary Heart Disease.4 We implemented it in two GP practices in Derwentside PCT, in Burnhope and in Annfield Plain.
Before embarking on running the clinics for hypertension patients, the pharmacist received training in blood pressure management, electrocardiography and phlebotomy.
Patients with hypertension were identified through a computer search based on Read code G3, and those due for review highlighted. The Burnhope practice selected patients deemed suitable to attend the pharmacist-led clinic. This group consisted of patients with newly diagnosed hypertension and patients with hypertension without co-existing disease.
Patients were considered unsuitable for pharmacist-led care if they had multiple comorbidities, for example CHD and asthma,and therefore visited the surgery regularly. These patients received standard care.
At the Annfield Plain practice, patients were randomly selected to receive pharmacist-led or standard care. This enabled us to expand the range of patients managed by the pharmacist and include those with similar characteristics to those receiving standard care.
The pharmacist then took over responsibility for managing clinic patients’ blood pressure according to the care pathway.
At the patient’s initial visit, which lasts 30 minutes, the patient’s blood pressure, age, weight and height are recorded and a family history taken. Data are also recorded on preexisting CHD, CVD or diabetes, lipid profile, drug therapy including side-effects, and modifiable risk factors. The patient’s cardiovascular risk is also estimated. Interventions delivered include:
- Smoking cessation advice
- Information about other modifiable risk factors such as lack of exercise, diet, alcohol consumption, and weight
- Advice and treatment to maintain blood pressure <140>
- Diabetes patients were given dietary advice and their blood pressure was treated to the lower target of <140>7
- Low-dose aspirin for patients with pre-existing CVD or, in patients over 50 years, 10-year CHD risk >=15%
- Statin therapy for patients with pre-existing CVD or 10-year CHD risk >=30%.8
At the Burnhope practice, we found 253 patients with a diagnosis of hypertension, giving a prevalence of 16.3%. The pharmacist manages 79 patients, and the practice nurse and the GPs manage 174.
At the Annfield Plain practice, 384 patients had a diagnosis of hypertension, giving a prevalence of 12.9%. The pharmacist manages 128 of these patients while the practice nurse and the GPs manage 256.
Benefits for patients
Implementing the care pathway has ensured that all patients with hypertension have received systematic, evidence-based care, and the benefits to patients have been demonstrated by audit data.
The Burnhope practice
At Burnhope, blood pressure control to the BHS audit standard (<150>
|Table 1: Blood pressure targets at the Burnhope practice|
|Patients with BP <150/90 mmHg|
|At baseline (Sept 2002)||51 (65%)||109 (63%)||160 (63%)|
|At re-audit (May 2003)||59 (75%)||125 (72%)||184 (73%)|
|Patients with BP <140/85 mmHg|
|At baseline (Sept 2002)||36 (46%)||71 (40%)||107 (42%)|
|At re-audit (May 2003)||36 (46%)||58 (33%)||94 (37%)|
However,as Table 1 shows, optimal blood pressure control (<140>
We analysed the data to see whether diastolic and systolic blood pressure readings improved over time and, if so, whether the improvement depended on the type of care patients received.
Systolic blood pressure improved over time, but this was not statistically significant, and there was no evidence that differences in blood pressure between baseline, in September 2002, and May 2003 could be attributed to the type of care patients received. Diastolic blood pressure actually rose slightly but, again, the findings were not statistically significant.
At the time of re-audit at the Burnhope practice the percentage of patients who had undergone a 3-monthly follow up, as recommended by the BHS guidelines, was 81% for pharmacist-managed patients and 76% for patients receiving standard care (77% of all patients).
At Burnhope, following implementation of the care pathway, 41 patients were started on a statin and 32 patients were commenced on aspirin.
The Annfield Plain practice
Audit standard and optimal blood pressure control of both groups had improved at the Annfield Plain practice at re-audit in October 2003, compared with 6 months earlier. More patients managed by the pharmacist achieved the audit standard blood pressure target than those receiving standard care, and this was found to be statistically significant (Table 2, below).
|Table 2: Blood pressure targets at the Annfield Plain practice|
|Patients with BP <150/90 mmHg|
|At baseline (Apr 2003)||60 (47%)||154 (60%)||214 (56%)|
|At re-audit (Oct 2003)||95 (74%)||160 (63%)||255 (66%)|
|Patients with BP <140/85 mmHg|
|At baseline (Apr 2003)||33 (26%)||86 (34%)||119 (31%)|
|At re-audit (Oct 2003)||48 (38%)||93 (36%)||141 (38%)|
For both groups, the mean blood pressure was significantly lower at the time of re-audit. The type of care also had a significant effect, with a lower mean blood pressure in the pharmacist-managed group.
At the time of re-audit at Annfield Plain, 85% of pharmacist-managed patients and 53% of patients receiving standard care (64% of all patients) had undergone a 3-monthly follow up, as the BHS guidelines recommend.
At Annfield Plain, 67 patients had been started on a statin and 94 patients were started on aspirin.
Rolling out the project
The care pathway is now being implemented in a third practice in the PCT and further audit data are being collected for all three practices.
Developing and implementing the care pathway has helped us to achieve the standards set out in the BHS guidelines and the NSF for CHD at two GP practices in Derwentside PCT.
More patients are achieving target blood pressures and all patients for whom it is appropriate are now receiving aspirin and/or a statin.
Blood pressure control is at least as good for the pharmacist-managed patients as for those receiving standard care, and patients are satisfied with the care they are receiving in these clinics.
The care pathway, which has been updated to incorporate more recent guidance from the BHS,9, 10 will be distributed to GPs, nurses and pharmacists to enable this multidisciplinary, systematic approach to the management of hypertension to be implemented throughout Derwentside PCT.
- Petersen S, Rayner M, Peto V. Coronary heart disease statistics. London: British Heart Foundation, 2003.
- Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office, 2000.
- Department of Health. Saving Lives: Our Healthier Nation. London:The Stationery Office, 1999.
- Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 2000.
- Department of Health. National Service Framework for Older People. London: DoH, 2001.
- Erens B, Primatesta P (eds). Health Survey for England: Cardiovascular disease 1998. London: The Stationery Office, 1999.
- Ramsay LE, Williams B, Johnston GD et al. Guidelines for the management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7-22.
- Brown MJ, Cruickshank JK, Dominiczak AF et al. Better blood pressure control: how to combine drugs. J Hum Hypertens 2003; 17: 81-6.
- Williams B, Poulter NP, Brown MJ et al. Guidelines for the management of hypertension: report of the fourth working party of the British Hypertension Society, 2004 – BHS IV. J Hum Hypertens 2004; 18: 139-85.