System-wide approach to improving hypertension in Primary Care

Problem

Globally, hypertension is the greatest risk factor for attributable deaths, accounting for 20% of all deaths in 2019. In the UK, more than 1 in 4 have hypertension, leading to significant morbidity, mortality and estimated to cost the NHS more than £2 billion annually, excluding societal costs. The UK's poorest are 30% more likely to have hypertension than the richest. Hypertension increases the risk of mortality from COVID-19, contributing to the excess mortality observed with the pandemic. Epidemiological studies within UK demonstrate up to 37% of known hypertensives remain uncontrolled reflecting the enduring gap and missed opportunities. Our goal was to design and implement a novel remote BP monitoring pathway, that could be swiftly and cost-effectively implemented within multiple practices by leveraging pre-existing, widely available technologies.

Approach

We prospectively utilised a combined system (Non-adoption, Scale-up, Sustainability and Spread Framework) and behavioural (COM-B) approaches to investigate the problem at individual, group and organisational levels, informing intervention and implementation. Searches were used to identify sub-optimally controlled hypertensive patients while providing free BP monitors to those without one. A digital pathway utilised accuRx (London) enabling patients to submit multiple BP readings over a seven-day period. An average BP is autonomously calculated and returned, with one-click coding into EMIS. Paper options avoid digital exclusion. A suite of EMIS (Leeds) templates, protocols and alerts were developed to support the ongoing identification and management of patients, integrating into practice workflows.

Findings

For practices to leverage the benefits of Home Blood Pressure Monitoring (HBPM), they must be confident in the accuracy of the reported readings, while patients must be assured of their capacity to take accurate readings. The more intensive the education and training prior to starting HBPM, the more likely engagement and control. Collaborating with care coordinators (CC) has allowed us to deliver this level of education while minimising individual practice burdens. Providing HBPM training to newly appointed CCs has helped embed it within their work, whilst collaborating with the CCG has enabled a pilot of group consultations for uncontrolled hypertensive patients. Final evaluation will involve a detailed case study of implementation, barriers and facilitators and a mixed-methods evaluation of experiences, clinical and interpersonal effectiveness, and impact with an emphasis on inequalities.

Consequences

Improved BP control may lead to an 80% reduction in stroke incidence, indicating significant individual and population benefits. While HBPM has been shown to be accurate and effective in clinical trials, there remains a paucity of knowledge surrounding real-world implementation. With over 30% of hypertensive patients already owning a BP monitor, a lack of a systematic approach limits its benefits. Effective implementation of HBPM will be beneficial in facilitating not only the recovery from COVID-19 but also moving towards better pro-active, personalised, and preventative care.