This project involved training pharmacists, who were not patient facing, to undertake a person-centred consultation and undertake hypertension review clinics in practice to help support patients to improve their blood pressure.
The rationale for undertaking the review clinics in Black people (African or African-Caribbean origin) was supported by local Clinical Effectiveness Group data which demonstrated that blood pressure was not as well controlled in this group of patients compared to the rest of the population in City and Hackney CCG. Pharmacists were tasked with inviting patients to an initial hypertension review clinic with a follow up 1-3 months later. When designing the protocol for pharmacists to undertake the hypertension clinics, the shared decision-making aspects of the medicines optimisation quality standard were particularly helpful.
In addition one of the key objectives of the review focused on whether treatment was prescribed in line with NICE hypertension guidance (NG136).
Authors: Sagal Hashi: Sagal.Hashi@cityandhackneyccg.nhs.uk Rita Shah: rita.shah4@nhs.net Dr Chris Carvalho: chris.carvalho@nhs.net
Example
Aims and objectives
Aim:
To review and improve blood pressure in black patients (African or African-Caribbean origin) with uncontrolled hypertension (>140/90 mmHg) by optimising treatment, identifying reasons for non-adherence to antihypertensive medication and providing lifestyle advice through pharmacist led hypertension clinics.
Objectives
1). Review antihypertensive medication according to NICE hypertension guidelines.
2). Provide advice on lifestyle and nutrition.
3). Understand reasons for poor adherence to antihypertensive medication and optimise treatment (referring to NICE medicines optimisation quality standards).
Reasons for implementing your project
Black people (African or African-Caribbean origin) have a much higher prevalence of hypertension and subsequent CVD, stroke, renal failure and dementia and therefore the potential risks associated with uncontrolled blood pressure are greater for this patient group.
The definition of stage 1 hypertension is a consistent reading of blood pressure of 140/90 mmHg or higher as per the NICE hypertension guidelines. Data from the Clinical Effectiveness Group (CEG) showed that blood pressure was well recorded across the population in City and Hackney.
The data shows that 5% of black patients had an uncontrolled blood pressure of >150/90mmHg compared to 2.5% of non-black patients. A further 6.7% of black patients had either a systolic blood pressure of >150 mmHg or a diastolic of >90 mmHg compared to 5.4% in the non-black population. Black populations also appear to have worse controlled blood pressure and/or abnormal blood pressures at an earlier age.
The main focus of this review was for pharmacists to support patients to improve their blood pressure by ensuring treatment was in line with NICE guidance, giving patients’ lifestyle advice and identifying if there are reasons why patients were not adhering to their medicines.
The review project was undertaken across 41 GP practices in City and Hackney CCG. 253 patients were reviewed for the first consultation and 117 followed up for a second consultation. The main improvements were to do with a reduction in blood pressure control due to improved adherence. A cost/benefit analysis is currently being undertaken to link this to outcome data in terms of reduction in cardiovascular events.
In addition as adherence improved and blood pressure was reduced this indicates that patients are taking their medication as prescribed, meaning less wastage of medication. Previously patients were still picking up their prescriptions, but not regularly taking their antihypertensive medicines.
How did you implement the project
Key stakeholders in primary and secondary care were invited to input into the project plan. The Prescribing Support Pharmacists (PSPs) who were required to deliver the project are not regularly patient facing, thus they were required to attended a one day training session delivered by a consultant cardiovascular pharmacist who trained them on how to measure blood pressure and the blood pressure targets according to NICE hypertension guidelines and what the proposed new guidelines may include.
One concern before implementation of this project was that the NICE hypertension guidelines were due to be updated. As the draft guideline was available at the time of the PSPs training day this was also reviewed and thus did not have an impact on the patient reviews. PSPs were then tasked with setting up hypertension clinics to review Black (African or African-Caribbean origin) patients with uncontrolled blood pressure in practices within City and Hackney CCG. PSPs then identified patients to invite to the clinic using the search criteria below. Patients were then followed up in clinic 1-3 months later.
Outcomes were recorded on a data collection form. To eliminate any issues on roll-out of this project, a, pilot was undertaken to test the data collection form, the length of time the consultation would take and to trial the hypertension review protocol. The costs incurred were in relation to the training that was delivered, the pharmacists time to undertake the clinics and the project evaluation costs. The CCG funded this project. A cost benefit analysis is currently being undertaken linking the reduction in blood pressure to outcomes.
Key findings
The Practice Support Pharmacists (PSP) identified 426 patients for review across 41 practices. 253 were reviewed at the first consultation 155 patients were not reviewed (mainly DNAs, cancelled appointments) 18 had recently been reviewed by a GP, practice nurse, practice pharmacist or by secondary care and therefore were not reviewed by the PSPs to avoid duplication.
Results linked to objectives:
Objective 1: Review antihypertensive medication according to NICE hypertension guidelines. 134 (53%) patients were on treatment according to NICE adult hypertension clinical guidelines.
Objective 2: Provide advice on lifestyle and nutrition. 91% of patients who were reviewed by PSPs were either overweight (28%) or obese (63%). PSPs asked each patient about their diet and lifestyle and provided relevant advice.
Objective 3: Understand reasons for poor adherence to antihypertensive medication and optimise treatment (referring to NICE medicines optimisation quality standards). PSPs reviewed 253 patients for the first consultation.
Results showed that: 132 (52%) patients were taking their antihypertensive medication as prescribed. 121 (48%) were not taking their medication as prescribed. 50 of these patients forgot to take their medication or did not believe that their medication was working. 117 patients were followed up for a second consultation. 66 of these patients had a reduction in systolic blood pressure and of these 56 patients had a reduction in both systolic and diastolic blood pressure.
Reasons are given below for the impact that the pharmacist had on reducing blood pressure: 36 patients had an improvement in adherence to their medication after the first consultation, resulting in a reduction in systolic blood pressure. 18 patients have a change to their medication, recommended by the pharmacist, which led to an improvement in their blood pressure. 4 patients lost weight due to lifestyle advice provided by the pharmacists, which may have resulted in a reduction in blood pressure. 44 patients had an increase in systolic blood pressure and of these 20 still had a blood pressure in the normal range. Of the remaining 24 patients’ poor adherence remained the main contributory factor leading to an increase in blood pressure.
Key learning points
A key learning point is that adherence to medication and lifestyle factors contributed significantly to poor management of blood pressure. Adherence checks need to be embedded into every consultation and support given to patients to improve their diets and exercise levels in addition to providing advice on smoking cessation and reducing alcohol consumption.
The City and Hackney CCG hypertension pathway is due to be updated. The pathway review group have agreed to incorporate the pathway in line with the NICE Hypertension visual aid summary. It has also been agreed that patient decision aids will be included in the pathway to aid adherence.
If the review project was undertaken again we would ensure that letters were sent out to each patient inviting them to the appointment with a follow up telephone call to motivate the patient to attend, rather than mainly sending out automated text appointments. This could result in a higher proportion of patients attending the hypertension reviews. Next time we would also collect information on past cardiovascular events to support the cost/benefit analysis and enable us to better extrapolate the results of a reduction in blood pressure to outcomes.