The management of hypertension, or high blood pressure (usually defined as being above 140/90 mmHg) is of course vital in the general practice setting. Hypertension is the most common treatable risk factor for cardiovascular disease in patients over 50, and remains a major public health concern, particularly in England, where it affects one in three adults.(1,2)
The prominence of hypertension in the Quality and Outcomes Framework (QOF) reflects the importance of the condition to primary care professionals – it is estimated that 18% of men and 13% of women in England are hypertensive but are not getting treatment for it.(2)
Management in Practice, together with sister magazine Nursing in Practice, hosted a virtual roundtable with several general practice professionals, plus a hypertension patient, to focus on the diagnosis, management and understanding of hypertension in GP surgeries and to share best-practice approaches. The roundtable was sponsored by Omron.
Diagnosis and practice equipment
The discussion began with a focus on identifying and monitoring patients with hypertension. How is suspected hypertension confirmed, and what means and devices do the practices use to achieve this? The answers revealed several methods of identification, involving both the leadership of clinical professionals and the active participation of the patients themselves.
Dr Charles Broomhead, a GP partner at The Hawthorns Surgery in Birmingham, said his practice follows a thorough protocol with strong involvement of the practice nurse. After seeing patients who present with high blood pressure, Dr Broomhead said the next step would be for the patient to have his/her blood pressure (BP) taken two or three times over the next three weeks. If this appears to be elevated, routine blood tests are conducted, plus an electrocardiogram if the patient has not had one recently. The patient then has an appointment with the GP once the results are collated.
"If the results confirm hypertension, of course we initiate treatment," said Dr Broomhead. "If there's still some doubt, then we equip the patient with a 24-hour ambulatory blood pressure monitor (ABPM), which allows us to see what's happening over an extended period of time. What we usually say, unless the BP is really high, is that it's not a sprint to get it right – it's a marathon. We may need some time to get the diagnosis right and get the correct management plotted."
The discussion also revealed that efforts to support patients to be proactive were productive. Dr Amir Hannan, a GP at Thornley House Medical Centre in Hyde, said: "We have a BP machine in the practice waiting room itself, and we encourage patients to use this to get their BP checked without having to get an appointment, and regardless of what they're coming in for. We also encourage patients to buy their own BP machines so they can check this themselves. Ideally, the patient will then be encouraged to record their BP on HealthSpace."
However, Dr Hannan was adamant that reliance on electronic monitoring devices was not enough when making a diagnosis: "Having the patient in front of you is important, rather than just relying on the BP machines or the data," he said.
Management and challenges
From the roundtable discussion, the two key challenges for practice managers where hypertension is concerned are clearly organisational aspects and ensuring that the at-risk members of the local population are identified.
Jane Gamble, Practice Manager at Broomfield Park Medical Centre in Coventry, said her first responsibility in this area is to "recruit the right people to look after patients in a qualified manner and to make sure they have the correct tools, eg BP monitors.
"But it's also about using the information we have and organising the administrative side of things, so that we can recall the at-risk patients and get them checked. At our practice, we check patients' BP levels as part of our flu clinics. Our healthcare assistants do this, and are given specific guidelines as to when they need to send a patient on to another clinician, depending on the results."
Patrick Jordan, Practice Manager at Thornley House Medical Centre, highlighted the challenge of getting local at-risk patients to get themselves checked. "One of our biggest problems is trying to get these patients to come in," he said.
"Generally, we see the same small number of patients month in, month out – they're the ones who have a chronic disease we know about and we're treating. With hypertension, there's a lot of patients who don't necessarily know they have it, or it hasn't been recognised because we don't get them in often enough for this to be checked."
He added: "I like the idea of checking patients' BP levels alongside the flu clinic, and will try to organise that here for our flu clinics starting in October. I think that's a great idea."
A key challenge for GPs when treating hypertension is evidently comorbidity. "I rarely see somebody who's just come in with high blood pressure," said Dr Hannan. "They almost always come in with about five other things that are also wrong with them. That's a huge challenge: there's more to be done for patients but there's less time to do it."
In his view, joint working between the practice manager and the clinicians is "absolutely critical" to achieving success in identifying patients at risk of hypertension. "The practice manager is so important, because they will come to a practice meeting and say, 'The population manager is saying we're not doing great on this area, why's that?' And then the clinicians will refocus in again. Managers provide the context for clinicians to excel."
Patient expectations and clinical goals
Does a "typical" hypertension patient exist? While both GPs recognised certain risk factors, they agreed that such labelling would be an over-simplication. "The majority of my patients are male, though I have a substantial number of hypertensive women," said Dr Broomhead. "They tend to be overweight, have familial instances of hypertension and often have comorbidities. But I don't think you can categorise hypertensive patients – put simply, if you live longer you're likely to become hypertensive".
"I would add that social circumstances are also significant," said Dr Hannan. "If you're in a lower social class you're more likely to have an inactive lifestyle that leads to high BP." All participants stressed the importance of education and raising awareness among patients of the risks.
Dr Hannan's surgery, for instance, has an interactive website where patients can access their health records as well as health information and advice on lowering BP. The practice is keen to promote the role of self-management; but has there been any change in the general awareness of hypertension at all?
"I think that through the media, and the NHS, there's been a push for self-management over the last few years," said Jane Gamble. "If I roll the clock back five or 10 years, I didn't know anybody who had a BP monitor at home, and now quite a lot of people do. I do think there's been a move forward on the recognition that people can help themselves to some extent".
But what are the expectations from patients of what treatment will achieve? Yvonne Bennett, a patient at Thornley House Medical Centre, told the roundtable: "I'm aware of the problems that can be caused by hypertension – my father died of a heart attack. So I know it's something that should be kept in check. At the same time, I want the treatment to be suitable for me, and with as little stress as possible. It's a 20-minute hike to the practice, for instance, so I benefit from taking my BP at home, rather than having to visit the surgery each time."
"I believe in a partnership of trust with the patient," said Dr Hannan. "I would say to them: 'What do you want to achieve?' For instance, 140/90 mmHg might be the cut-off point, but if the patient feels dreadful and is getting side effects, what have you achieved? For me, the goal is to be a good doctor, listening to the patient and getting their ideas and expectations, and trying to find a common outcome."
ABPM devices and recommendations
The discussion concluded with a focus on perspectives of the available ABPM devices to support practices in identifying and monitoring patients with elevated BP levels, and how such devices could potentially be improved.
The practices diverged here – while Thornley House Medical Centre does not use an ABPM (the practice refers patients requiring this to the local hospital) Broomfield Park and the Hawthorns Surgery both do, with the machines being used in the latter practice "almost continuously," Dr Broomhead said.
"We've used ABPMs for around 15 years now," he added. "We used fundholding savings originally to buy the first machine. We've had several since then and have two at the moment. We get very few complaints about the ABPM from patients, and no patients have refused it."
"From a practice manager's point of view, purchasing an ABPM is quite an expensive piece of kit to leave the practice with the patient," said Jane Gamble. "The one concern for me was: 'How do we insure this kit in case someone drops it down the toilet?' But luckily that hasn't happened." Dr Broomhead agreed that robustness was a crucial concern when choosing an ABPM device.
Perhaps, as the participants suggested, digital technology will in time offer greater benefits for such devices. Dr Hannan said: "Telehealth and telecare is set to expand I'm sure, and having a device that could do lots of things, including BP, would be helpful. Also, so many households have broadband now – wouldn't it be great if BP readings could be WiFied over?"
1. Williams B, Poulter NR, MJ Brown et al. British Hypertension Society guidelines for hypertension management. BMJ 2004;328:593-4.
2. NHS Choices. Blood pressure (high). Available from: http://www.nhs.uk/conditions/blood-pressure-(high)
This Expert Panel Discussion was supported by Omron Healthcare. Editorial control resided with the panel members and the publisher.