What changes have occurred in the organisation of care for hypertension, and how are current diagnostic guidelines implemented, within Primary Care in South West England?

Conference: 
Talk Code: 
2D.2
Presenter: 
Christopher Clark
Co-authors: 
Natshasha Mejzner, Christopher Clark, Lindsay Smith, John Campbell
Author institutions: 
University of Exeter Medical School

Problem

We previously examined the organisation of care for hypertension in primary care in South West England in 2007 and 2010. Subsequent NICE guidance in 2011 recommended ambulatory and home blood pressure (BP) monitoring for diagnosis of hypertension; we are currently repeating the survey to establish trends in organisation of care and to assess the implementation of out of office diagnostic guidelines.

Approach

In 2007 we distributed a questionnaire to practices in Devon and Somerset, England, via Local Medical Committee (LMC) mailings; the survey was revised and repeated in 2010. We are now distributing a third iteration online with further amendments to take account of NICE guidance, again via the LMC and also via local NIHR Clinical Research Network mailings. Responses will be collated and compared with previous rounds to measure trends in organisation of care, and report the current uptake of new diagnostic guidelines. Trends are tested with χ2 tests.

Findings

The questionnaire was distributed to 245 practices in 2007 and 2010; response rates were 31% and 34% respectively. The current iteration has, to date, been distributed to 126 practices with a 21% response rate; further mailing and follow up continues. Interim results from responses received are reported; full results will be presented to conference.Regular monitoring of BP by health care assistants (HCAs) has risen from 0% of practices in 2007, to 12% in 2010 and 38% in 2016 (p<0.001), with a corresponding fall in general practitioner (GP) and nurse shared monitoring from 69% to 33% and 15% respectively (p<0.001). Decisions to alter medication to control BP are now taken in 19% of practices by nurse prescribers, compared to 5% in 2010 and none in 2007 (p<0.001). For diagnosis of hypertension 65% of practices have access to ambulatory BP monitoring (ABPM) in house, 27% by referral and 8% have no access. 42% of practices using ABPM record daytime BP only and 58% obtain a full 24 hour record. Only 69% of practices report confidence in interpretation of ABPM results. 92% of practices have access to home BP monitoring (HBPM); the majority (80%) collect 7 consecutive days of measurements and 96% report confidence in interpreting HBPM data.

Consequences

Over 9 years BP monitoring in primary care has devolved from GPs and practice nurses to HCAs. NICE guidance on ABPM and HBPM for diagnosis of hypertension has been widely adopted through varying strategies. Practices are confident in interpreting HBPM records but less so with ABPM. Employers and professional bodies should consider continuing medical education and quality assurance implications for allied health professionals, and facilitate APBM interpretation for GPs. Future work is planned to correlate practice organisational factors with inter-practice variations in hypertension prevalence and control.

Submitted by: 
Christopher Clark
Funding acknowledgement: 
CEC is supported by a National Institute for Health Research (NIHR) Clinical Lectureship award. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.