One of the key interventions identified by the Department of Health and NICE in reducing health inequalities within populations was through optimising blood pressure (BP) control in patients with uncontrolled hypertension. By increasing the prescribing of antihypertensives by 40% in patients with hypertension, in conjunction with other key interventions, will contribute to reducing the gap in life expectancy between affluent and deprived groups by around 6%.
In Dudley over the last 15 years we have used a variety of engagement strategies to work with primary care clinicians to address the premature mortality from hypertension related diseases, which when we started was more than double the England and Wales average.
Locally we identified that there was a significant gap between the reported and expected prevalence of hypertension with considerable variation between individual GP practice populations. We utilised guidance provided by NICE (CG127 Hypertension and previous iterations) to develop a pathway for managing hypertension at a local level: http://www.dudleyformulary.nhs.uk/download/9/hypertension-pathway
Implementation of this local guidance was supported by education of all clinicians involved in the management of hypertension. This education programme focussed on developing prescriber confidence and competence, risk stratification and case finding, practical issues including: dosing and side effects and documenting, monitoring and patient recall and follow up. Primary Care Practice Based Pharmacists (PBP) were integral to delivering this education programme, case finding and reviewing patients.
This example was originally submitted to demonstrate implementation of NICE guideline CG127. The guideline has now been updated and replaced by NG136. The example has been reviewed and practice it describes remains consistent with the BP targets in the updated guidance. The updated guideline should be referred to if replicating any aspect of this example.
Aims and objectives
- Identify patients with high blood pressure with a view to making a diagnosis of hypertension.
- Managing hypertension to the evidence based target, not just previous QOF target.
- Ensure most cost effective treatments are used to manage patients with hypertension.
- Review exception reporting annually for all patients diagnosed with hypertension.
- Reduce SMR gap between local and England average figures.
- Improve life expectancy and outcomes for those with hypertension and related diseases.
- Address issues of intra-practice variation within CCG.
- Look at ways of working with the community to identify harder to reach patients who are at the highest risk of untreated and undiagnosed hypertension i.e. middle aged males.
Reasons for implementing your project
Based on the 2015 Index of Multiple Deprivation Dudley is Ranked 118 out of 326, 1 being the most deprived and 326 being the least deprived. The QOF prevalence of hypertension in Dudley (2013/14) (All ages) is 17.7%, this equates to 54,606 people (out of the registered population of 314,852). Dudley CCG has a significantly higher prevalence of people with recorded hypertension than England and the highest recorded prevalence in the West Midlands.
In 2002, statistics gathered for what was then Dudley Primary Care Trust showed that the standardised mortality rate from hypertensive disease was double the England average. Further local audit in 2013 identified that there were 11,000 patients diagnosed with hypertension whose BP was NOT managed to 150/90mmHg and an estimated 27,800 patients were missing from hypertension registers.
There were underlying issues with identification of patients with hypertension and of practices treating patients to target, large numbers of exception reporting, issues with recall of patients following diagnosis and patient perception of hypertension, probably because this is silent and not a visible condition.
We uncovered the underlying issues through use of primary care clinical pharmacists referred to as Practice Based Pharmacists (PBPs) working with general practice to audit high risk patient groups and identify patients with hypertension who were undiagnosed. NHS health checks were used to identify patients and convert to diagnosis by PBPs, who in turn manage these patients to the evidence based target not just to previous QOF target of 150/90mmHg.
We used the local quality premium within CCG to support work of PBPs and incentivise general practice through individual practice prescribing action plans which each practice is required to submit to receive payment for taking part in the CCG practice engagement scheme. This has been in place for the last 3 years. Each year the aim has been slightly different, focussing on different patient sub-groups. We use a population segmentation approach to manage this.
How did you implement the project
Over the years our reported prevalence increased and in 2013 we used PBPs to audit progress. We found that whilst we had made significant improvements in the management of hypertension there was still 11,000 patients whose BP was not managed to the QOF target of 150/90mmHg and 27,800 patients missing from our local hypertension registers. As a result we incentivised GP practices to find the missing patients and treat to target using the PBP workforce. The method of incentivisation was a two year local quality premium (QP) aimed to increase practice hypertension registers by between 1 and 1.5%.
In order to meeting the aims of the project we drew together a range of stakeholders to inform the planning phase. These included:
- Lead commissioning manager for long term conditions
- Clinical lead GP for CVD
- Pharmaceutical adviser (who led project)
- Cardiologist (Medical Service Head at DGNFT)
- Practice Based Pharmacists (PBPs)
- Every general practice in the CCG (47 practices)
- CVD lead nurse, Office of Public Health (lead for NHS Healthchecks)
- CCG Clinical Development Committee
- CCG Prescribing Sub-Committee
- CCG Head of commissioning
- CCG Head of Quality
- Director of Public Health.
There were several factors critical to the success of the project:
The pharmaceutical adviser designed the audit with support from the cardiovascular lead nurse at the Office of Public Health. This was approved by the CCG Prescribing Sub-Committee and rolled out to every GP Practice through the PBP team who completed the audit. Audit returns were analysed and the audit was written up by the Pharmaceutical Public Health Team who in turn presented this after editing by the cardiologist and clinical lead for CVD at the CCG, to the CCG key decision making committees.
- An awareness of issues at GP practice level within the CCG
- CCG/ practice comparisons to expected prevalence
- Discussions at practice level on how to improve this within local GP practice populations.
- PBPs resource ‘free’ to GP Practices to support practices working beyond QOF.
- PBP expertise in managing hypertension- involved utilising broader medicines management skills including independent prescribing.
- Analysis of health economy impact of untreated and unmanaged hypertension.
Key challenges and how these were overcome included:
- GP practice engagement: addressed by the introduction of the GP practice engagement scheme, production of hypertension action plans and introduction of CCG Local Quality Premium for hypertension over a 3 year period.
- Clinical priority for CCG: addressed by highlighting in CCG commissioning intentions.
This was carried out within the budget envelope for the PBP resource, the PBPs have an annual work plan which they adhere to and is signed off by the Prescribing Sub-Committee of the CCG.
Clinical Audit findings:
- 11,000 patients diagnoses with hypertension whose BP is NOT managed to 150/90mmHg
- 27,800 patients missing from hypertension registers
- 2/3 practices’ hypertension prevalence improved as a result of the audit
- 63% due to newly diagnosed HT
- -37% pts receiving treatment but no diagnosis code
- Treatment to 140/90mmHg was achieved by 90% practices meeting this standard (Standard is 50%, inter-practice variation 6-99%)
- BP5 (treatment to 150/90mmHg) increased from 73-85% of practices meeting this standard (Standard is 60%)
- 550 (2% register) declined HT monitoring- all received information
- Link between deprivation and higher levels of undiagnosed hypertension
- Despite inc in prevalence Dudley, is still considerably below national prevalence figures
Projected benefits post audit:
- Potential cost saving of £13M (HARMS) over 5 years for the estimated 27,800 pts missing (£469/pt)
- Potential savings not included for those 11,000 pts whose BP is not managed to 150/90mmHg
- By reducing BP from 150/90mmHg to 140/90mmHg, the risk of CHD is reduced by 22% and the risk of stroke is reduced by 41%.
- Locally agreed Quality Premium for Hypertension for 2013/14, 14/15 and 15/16.
- At the end of March 2014, over 2000 patients reviewed as a result of Quality Premium work.
- 1096 new patients diagnosed with hypertension over two years, exceeding the QP target for each of the years 13/14 and 14/15.
- For every 1,000 patients controlled, 16 strokes and 12 MIs could be prevented each year.
- The Hypertension register for Dudley CCG has grown by 1096 patients in last two years.
- Prevalence of hypertension has increased since 2004/5 from 13.4% to 17.7% in 2014/15.
Projected cost savings:
- For every 1,000 patients controlled, 16 strokes and 12 MIs could be prevented each year.
- Assuming cost of a stroke is about £8K (acute care + ongoing cost/year) then a minimum of £127K / year saved on reducing strokes alone.
- Assuming MI costs are approx £7.5k then £90K saved.
- Therefore in one year, changing behaviour has enabled us to save £200K and also receive 2 x QP monies for CCG to reinvest into services.
- We still think there is further work to be done and are now focussing on treating to target and case finding through NHS Health checks and EMIS S&R of high risk patients such as peripheral arterial disease and chronic kidney disease.
*costs based on:
- Kaiser Permanente quote NNTs* of 63 and 86 for stroke and heart attack (MI) respectively to prevent one event or a NNT of 36 for both events combined.
- This means that for every 1,000 patients controlled, 16 strokes and 12 MIs could be prevented each year.
- NICE estimates that an MI costs an average of around £7k for acute care and £1,900 ongoing costs over a 5 year period.
- The equivalent costs for stroke are around £4,300 and £18,300 respectively.
- This means that for every additional 1,000 patients controlled, there are £469k of savings for the NHS over 5 years, or £469 per patient.
- This would mean a total potential cost saving of £13m over 5 years for the 27,800 patients missing from hypertension registers in Dudley.
The latest data demonstrates that the direct standardised mortality rate from hypertension related diseases is statistically and significantly below the national average and that the direct standardised mortality rate from stroke is also declining. The graphs in the supporting material illustrate the reported prevalence compared to expected prevalence of hypertension and the directly standardised rates for hypertension-related disorders, which demonstrates impact.
Key learning points
Work is ongoing to embed hypertension management into the medication review process, making the evidence-based target and increasing the payment thresholds a key feature of the Dudley Long term Conditions Framework, which has replaced QOF. This provides evidence of Dudley’s commitment to managing hypertension.
Factors key to success include:
- Resource support (in the form of a PBP) for completing the audit and reviewing patients
- PBP clinical skills in managing a hypertensive patient
- CCG and GP practice engagement is imperative
- Clinical workforce/ support is ideal
- Changing behaviors is the biggest challenge to overcome with clinical staff.