Hypertension: Improving blood pressure management in primary care

Aim:

To ensure hypertensive medication and lifestyle interventions are optimised in all patients diagnosed with hypertension with a systolic BP ≥160mmHg and/or a diastolic blood pressure ≥100mmHg

Objectives:

• To identify the cohort of patients in Lambeth with documented systolic BP ≥ 160mmHg and / or diastolic BP ≥ 100mmHg
• To provide practices with resources and clinical support to reduce the BP in this cohort of patients
• To evaluate the reduction in BP achieved during the course of the project in the selected cohort of patients
• To identify if interventions in place for hypertension management meet the needs of our population looking specifically at age, ethnicity and sex

Lambeth has a diverse population and is the 44th most deprived local authority in England (IMD 2015). Our population is young, ethnically diverse and 30% of our whole population is of black ethnicity. We have a higher rate of admissions for hypertension compared to 10 comparator CCGs and the national data shows an increased rate of hospital admissions for stroke. Hypertension is therefore a particular issue for Lambeth.

High blood pressure (BP) is one of the most important preventable causes of premature morbidity and mortality in the UK. It is a major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. The risk associated with increasing BP is continuous - each 2 mmHg rise in systolic BP is associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. In order to maximise the outcomes, our project focused on hypertensive patients at highest risk of events by identifying those with last documented systolic BP ≥ 160mmHg and / or diastolic BP ≥ 100mmHg.

Treatment of high BP relies on lifestyle measures and medication. In Lambeth CCG, analysis indicated that there was a significant opportunity to improve medicines optimisation for patients with hypertension.

Over the past 5 years, local commissioning priorities have predominantly focused on optimising outcomes for people diagnosed with hypertension, including development of pharmacist-led hypertension clinics, baseline assessment of hypertension management focusing on patients not meeting the Quality and Outcomes Framework (QOF) BP indicators and development of a community hypertension service run by specialist cardiovascular pharmacists incorporating virtual and community clinics to address some of the themes identified by the baseline assessment.

These initiatives have helped to improve overall hypertension management - since 2011-12, an additional 4165 patients have achieved BP control, defined as blood pressure of 150/90mmHg or less, however QOF data 2015 suggests that there are over 7500 people with detected hypertension not currently controlled to these levels.

Equity profiling analysis in 2011 showed that those less likely to have controlled BP in Lambeth were in their thirties, mixed white and black Caribbean or mixed white and black African.

The project was funded as part of the Lambeth Clinical Commissioning Group (CCG) general practitioner (GP) delivery scheme for 2015/16 in order to maximise engagement of the GP practices across the borough. GP practices were asked to identify all patients on their register with a systolic BP ≥160mmHg and/or a diastolic BP ≥100mmHg.

Patients who had been diagnosed in the previous 6 months and those on the palliative care register were excluded. GP practices were then asked to develop and implement a local hypertension action plan and offered resources to support optimisation of BP in the project cohort including:

• provision of up-to-date algorithm based BP management guidance based on NICE hypertension guidance.
• the opportunity to participate in a virtual clinic – a discussion with a member of the community hypertension clinic or cardiovascular clinical lead regarding the management of up to 20 of the patients identified from within the project cohort. Key elements covered in these discussions included current prescribing guidelines and rationale, addressing clinical inertia, initiation of new medicines and dose titration of existing therapies, non-adherence, lack of patient engagement. The outcome of the virtual clinics was development of an individualised patient action plan for each of the patients discussed, which the GP practice would discuss with the patient and implement. The principles of management discussed in these virtual clinics were to be applied across the rest of the project cohort identified within each GP practice.
• the opportunity to refer complex patients to the pharmacist-led community hypertension clinic for adherence and medicines optimisation support GP practices were required to submit baseline BPs and the BPs achieved by the end of 2015/16 to allow the project to be audited.

A total of 45 practices submitted data for 1,982 patients. Of the initial 1982 patients: 26 patients did not respond to invitations for an initial BP review from the practices and a further 445 (22.5%) failed to attend for follow up readings despite repeated invitations from the practices during the timescale of the project.

Of the remaining 1526 patients followed up; the following BP reductions were achieved:

• In 1,231 patients with an initial systolic BP ≥ 160mmHg (mean systolic blood pressure at baseline 172.9 mmHg); the mean reduction in BP across the cohort was 25mmHg (95% confidence interval 23.9 to 26.2 mmHg;
• In 494 patients with an initial diastolic BP ≥ 100mmHg (mean diastolic blood pressure at baseline 107.9 mmHg); the mean reduction in BP across the cohort was 17.9mmHg (95% confidence interval 16.8 to 18.9 mmHg).

Achievement of the NICE recommended systolic BP of < 140mmHg for those under 80 years old rose from 3.1% at baseline to 39.3% at the end of the project (number increasing from 47/1526 to 600/1526); while achievement of the QOF indicator of systolic BP < 150mmHg rose from 9.6% to 61.7% (number increasing from 146/1526 to 942/1526). Achievement of the NICE recommended and QOF indicator diastolic BP < 90mmHg rose from 33.2% to 68.5% (number increasing from 505/1522 to 1042/1522).

In terms of the equalities objective, the data showed significant BP improvements in all age groups, ethnic groups and both sexes; however:

• The older age group improved more than younger age groups and younger age groups were less likely to engage with interventions offered
• Improvement appeared greatest in those of South Asian ethnicity and other ethnic groups compared to Black groups, whilst other ethnic groups were less likely to engage with the interventions offered compared to white groups
• Improvement was greater in females compared to males and males were less likely to engage with interventions offered. The project demonstrated a significant improvement in BP control in a high risk cohort of poorly controlled hypertensive patients. Evidence demonstrates that an average 25mmHg reduction in systolic BP, as delivered by this project across a cohort of >1200 patients, will lead to a reduction in stroke risk of more than 60% and a reduction in CHD risk of more than 45% (M R Law et al. BMJ 2009;338:b1665). Future work will focus on strategies to engage the patients in whom follow up was not achieved during the course of the project.

The success of this project was down to a number factors including:

• Strong clinical cardiovascular (CV) leadership within the CCG alongside the involvement of commissioning leads, the medicines optimisation team and public health in developing the project to ensure both CCG and primary care buy-in; as well as ensuring local specialist services in the community and acute care were fully informed and working to the same objectives.
• Defining a manageable cohort of high risk patients to focus on alongside careful project design to avoid excessive paperwork for GP practices and maintain a primary focus on supporting practices to deliver better patient care. Data collection tools were designed to be simple to complete, but robust enough to evaluate the impact of the project
• Development of locally produced resources and pathways to support project delivery, including the commissioning of a community based hypertension service and the delivery of virtual clinics within GP practices. The virtual clinic model brought specialist CV support into the GP practice. This allowed review of current practice and encouraged an evidence-based approach to clinical decision-making for patients with high BP. The multi-faceted approach allowed clinicians to tailor the support based on the needs of their practice / patients.
• Inclusion of the project in the funded GP delivery scheme, ensuring practices were resourced for the work done in delivering the project, not for achieving a specific BP target for each patient. We recognised that QOF indicators and NICE defined clinical BP targets are difficult to achieve in every patient – practices were tasked with implementing interventions which would achieve a reduction in BP, as any reduction in BP is associated with a reduction in CV risk.
• Regular evaluation of progress and feedback to primary care to maintain momentum.