Improving baseline assessment for newly diagnosed hypertensive patients and optimising therapy

Hypertension is a significant risk factor for premature death and disability in the UK.

Over a quarter of adults in the UK have hypertension. Overall, the prevalence of hypertension in those aged over 35 years in the 2010 health survey for England was 31% in men and 28% in women.

We carried out a project in order to improve the diagnosis and management of hypertension in our practice and make the process more standardised and to prevent delays for patient treatment and follow up.

We looked at the diagnostic criteria and initial management of new hypertension patients in comparison with NICE guidance for diagnosis and management of hypertension in adults.

An initial audit was conducted to evaluate how patients were being diagnosed and if they were having the baseline tests that are recommended by NICE guidance. This showed unwarranted variation between GPs in terms of baseline investigations following diagnosis. For example few patients were having baseline ECGs and urine checks for end organ damage, and the recommended blood tests.

As a result we identified areas that required improvements and proposed a series of changes to the practice. We acknowledged issues with workload implications for GPs and our proposal to create a nurse led hypertension clinic was accepted. The nurse led hypertension clinic would enable us to prioritise and standardise the diagnosis and treatment of new hypertensive patients and those with known hypertension coming for their follow-ups.

Following the implementation of the nurse led hypertension clinics there was a second audit to compare the same criteria following the introduction of a nurse led hypertension clinic at the practice.

The Second phase showed improvement in all the criteria measured and as a result the hypertension clinic was adopted as a permanent service by the surgery.

This project not only benefited hypertension patients but also freed up more doctor appointment for patients with other medical problems and also improved knowledge and skills of the nursing team in our practice in dealing with hypertension. The nurses were already seeing hypertensive patients in their diabetic and respiratory clinics, and a collateral benefit was that they could proactively manage coexisting hypertension in patients coming for other chronic disease reviews.

Our practice covers a population size of approximately 24'000 patients. 20% of our patient population has a diagnosis of essential hypertension. Hypertension is a common chronic condition which requires monitoring for end organ damage and follow ups for treatment optimisation. This creates a large chunk of work load for our primary care workforce. Prior to our project we relied on GPs to do all of the assessment and management of hypertensive patients. The practice has a strong emphasis on training.

Prior to this project, the GP who would pick up high blood pressure readings would arrange for ambulatory blood pressure monitoring or sometimes make a diagnosis after one blood pressure measurement which was not in line with NICE guidance.

There was a haphazard approach to dealing with results of ambulatory blood pressure monitors (ABPM). GPs were overloaded with messages about normal and abnormal ABPM report results. The GPs were all dealing with the abnormal results in various non-standardised ways. The patients would sometimes not be given written information and would go back to see the GP after ABPM.

If the ABPM was abnormal the GP would make the diagnosis and they would then arrange investigations to look at end organ damage and see the patient for another consultation to go through the results. This was adding pressure to the already precious GP appointment system, and also meant patients could have delays of weeks between the ABPM test and actually starting further investigations or treatment. This process was not efficient and was variable from one GP to the next in terms of time frame and also whether all of the recommended investigations were ordered.

As GPs were the main point of contact for those patients, this meant that a significant proportion of appointments were allocated to the management and follow ups of hypertension patients. This process was not standardised and patient experiences differed from one GP to the next.

By implementing a nurse led clinic and clear guidance, we identified a way of making the process more efficient and involve the GP in only more complex cases.

We presented the initial audit findings and our proposal at the practice meeting. We included all relevant stakeholders such as GPs and nurse, practice manager, health care support workers. Everyone was in agreement of the potential benefits of this project and enthusiastic to implement it including patients.

Initial audit data was presented to all key stakeholders in the practice. We aligned this project with other difficulties that were being experienced by the surgery. We knew that we could not just rely on an audit telling the GPs that they must do better. We proposed a project that would redirect this workload away from GPs. We also empowered the nurses and offered them training where they could learn about hypertension and discuss case studies. The nurses felt valued and were keen to take on this challenge.

There was also a cost implication for more nurse time that would be needed. However, we had estimated that hypertension related work can amount to around 6 GP surgery clinics per month. Cost of increasing nurse clinics was less than GP appointments.

By educating the nurses and health care assistants at the practice and developing a common pathway in accordance to the NICE guidelines, patients benefited from more efficient care, and it meant that patients were more likely to have the necessary baseline investigations in line with guidelines.

The pathway

Template letters for patients undergoing ABPM:

A template letter advising patients on what to expect during their ABPM appointment and why it is required and possible diagnosis of hypertension.

Depending on the result of the investigation we designed 2 further letters.

The first one advising patients of a normal ABPM result and advising them to have their blood pressure measured in 5 years or earlier and sign posting them to further information.

The second letter advised patients of further investigations such as urinalysis, blood tests and ECG and advising them to book an appointment with the nurse led hypertension clinic.

We then designed a template on our IT system to input required data such as blood pressure readings in each arm, height, weight, BMI, pulse, smoking data, blood test results and target blood pressure values according to comorbidities which would be used in the hypertension clinic by the nurses.

We also designed a flow chart (see attached document) to guide nurses in term of blood pressure targets and also the appropriate medication to start depending on patients age and comorbidities and subsequent up titrating of the medication and also advising them on when to involve GPs in complex cases.

The second phase of the project involved a re-audit and we worked with public health to share the learning.

The proportion of newly diagnosed hypertension patients that were offered ABPM increased from 90% to 94% after our project. There were still patients who were diagnosed with hypertension by the hospital or in other clinical settings, which is why there were still some patients not having the ABPM. Also, the remaining hypertension population might have been started on treatment following readings within the severe hypertension criteria.

The proportion of patients that had urine dipstick and albumin creatinine ratio measured following diagnosis increased from 10% to 44%.

Patients who had urine dip after diagnosis of hypertension markedly increased from 14% to 69%

Documented advice to have optician review or fundoscopy results significantly increased from 0% to 31%.

The number of patients who had ECG reduced from 90% to 75%. This was due to the fact that not all newly diagnosed patients required ECG as some might have had one recently for other purposes such as investigation for cardiac problems.

Qrisk calculation increased from 66% to 75%; this enabled early detection of patients that might benefit from primary prevention with statins and for GPs to have discussion with them.

The proportion of patients that did not have a blood test after diagnosis decreased from 19% to 13%.

After implementation of the new pathway and nurse led clinic, 100% of patients received the template letter explaining results findings and 100% had follow up arranged as a results as required.

We demonstrated a clear benefit in all the criteria measured and the project and outcomes will be further adjusted and reviewed with further audits in the future.

The nursing staff felt more confident in dealing and managing patients with hypertension. They have shared their experiences and mentioned that this upskilling has helped them when dealing with patient during other chronic disease clinics. Due to their awareness they are able to consider hypertension treatment optimisation for patients that they might be seeing for other issues.

Optimisation of therapy: This project led to treatment being initiated earlier. Median time for patients who needed treatment to be started was 7 days after the project (compared to median wait of 17 days prior to the project). Once treatment was started the titration of treatment was faster. Most patients were treated to target within 8 weeks, whereas prior to the project this process took up to 4 months.

The project involved the whole practice including GP registrars, nursing team, GPs, IT team, secretaries and dispensary.

The project was able to make a difference in patient care and adopted as a permanent service thanks to the involvement of the whole practice.

This project enabled education and development of new skills in the nursing team who were already involved with diabetes and respiratory clinics.

More importantly this project improved the quality and standardised the care of hypertension patients as per the NICE guidelines and prevented delays in treatment by making the process more streamlined.

The project also indirectly benefited our whole patient population as more GP appointments were available to treat patients with other medical problems. We have freed up an estimated 6 surgeries for GPs each month, which translates to around 90 GP appointments.

Treatment to target BP was achieved faster through the new intensive nurse led hypertension monitoring and up-titration. Most patients were treated to target within 8 weeks.

The attached PDF document shows the outcomes in graphic forms. The template letters and materials used to guide the nursing staff have also been attached in this document.

What could have been done differently?

The patients in the practice are navigated through reception, and we realised in hindsight that it was important to educate the reception team in relation to this new patient pathway. Once this was done the reception team were able to direct patients more effectively, and also were able to highlight the benefits of this pathway (as opposed to seeing a GP).

We involved patients later in the process, and we certainly would advocate involvement of patients within the pathway redesign to anyone wishing to implement this in their work place.

Outside resources are available to guide service improvement, and we eventually involved the local CCG and public health. We could have done this sooner.