Lambeth clinical commissioning group (CCG) developed a programme of virtual clinics focused on reviewing a group of patients with uncontrolled high blood pressure (BP), with a view to agreeing and subsequently implementing patient specific management plans to improve BP control.
The programme was delivered between April 2014 and March 2015. In this high-risk patient group, the virtual clinic model significantly improved BP control with an associated reduction in cardiovascular risk.
Hypertension is one of the most important preventable causes of premature morbidity and mortality. Raised BP is associated with an increased risk of:
- myocardial infarction
- heart failure
- chronic kidney disease
- cognitive decline
- premature death
In Lambeth CCG in 2014, local data highlighted that more than 8,000 people with hypertension were found to have a BP above the Quality and Outcomes Framework (QOF) audit standard of 150/90mmHg. The CCG therefore implemented this virtual clinic programme with the aim of improving BP control in a high-risk group of hypertensive patients.
What was involved
A Prescribing Improvement Scheme (PIS) was developed, which involved:
Practice-level identification of all people with poorly controlled BP at high risk, defined as a systolic blood pressure (SBP) ≥160mmHg and or a diastolic blood pressure (DBP) ≥100mmHg, by using a standardised search tool.
Delivery of an in-practice virtual clinic by the pharmacist-led community hypertension service in which the management of up to 20 of the patients identified by the search was discussed with the practice, and individualised management plans were agreed.
The GP practice implemented the individualised patient management plans with patients over the subsequent 3 months and also applied the principles of management highlighted in the virtual clinic to the whole patient group identified by the standardised search. Local hypertension guidelines were distributed to the practices and, where appropriate, patients were referred to the community hypertension service or a secondary care hypertension service for more intensive follow up.
The GP practices submitted baseline and post-intervention BP recordings to receive payment under the PIS.
What went well
All 45 practices in the CCG submitted data for a total of 1,982 patients and of these, 1,526 patients were successfully followed up.
Patients with a baseline SBP ≥160mmHg (n=1231) demonstrated a mean reduction in SBP of 25mmHg (95% confidence interval 23.9 to 26.2 mmHg; p<0.0001). Patients with a baseline DBP ≥100mmHg (n=648) demonstrated a mean reduction in DBP of 16.7mmHg (95% confidence interval 15.7 to 17.6 mmHg; p<0.0001). BP reductions of this magnitude have been shown to deliver a 50% to 60% reduction in coronary heart disease events and a 60% to 70% reduction in stroke
The programme was well received by GP practices with many indicating that they made changes as a result, including:
- nominating a practice lead for hypertension
- discussing BP management regularly in clinical meetings
- addressing adherence issues proactively
- identifying patients suitable for referral to the community hypertension clinic for more intensive management
What could be improved
The programme identified a group of patients with uncontrolled BP who were not engaging with their GP practice and therefore could not be reviewed and optimised. The CCG needs to consider how the unmet need of this group of patients can be effectively addressed.
Adherence was highlighted as a major underlying issue for poor BP control and the CCG identified that there is an opportunity to utilise community pharmacists to support patients with their adherence to treatment at the point of medication supply, which needs to be further explored.
This model has since been rolled out in a neighbouring CCG, with a similar impact on BP control. It is likely the programme will need to be revisited on a cyclical basis to address the large unmet need in BP control.
Helen Williams, Consultant Pharmacist for CVD, Southwark CCG, Clinical Adviser for AF, AHSNs Network, CVD Clinical Lead, Lambeth CCG