Hypertension November 2016 Helen Williams, Consultant Pharmacist for Cardiovascular Disease Anna Hodgkinson, Senior Clinical Commissioning Pharmacist November 2016

Hypertension High blood pressure (hypertension) (>140/90mmHg) is one of the most important preventable causes of premature morbidity and mortality in the UK Major risk factor for stroke, heart attacks, heart failure, chronic kidney disease, cognitive decline and premature death Risk associated with increasing blood pressure (BP) is continuous - each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke People from the most deprived areas are 30% more likely than the least-deprived to have high blood pressure, and the condition disproportionately affects some ethnic groups including black Africans and Caribbean Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. https://www.nice.org.uk/guidance/cg127/chapter/Introduction Systolic BP – top number Diastolic BP – bottom number Given deprivation and ethnic mix in Lambeth, HYPERTENSION IS THEREFORE A PRIORITY

Hypertension: Equality objective Part one – to obtain a snapshot profile of the age, sex and ethnicity of people registered with Lambeth GP practices diagnosed with hypertension with both controlled and uncontrolled hypertension Part two – to identify if interventions currently in place for hypertension management meet the needs of our population looking specifically at age, ethnicity and sex

Part one Baseline analysis (31st December 2015) demonstrated that those less likely to have adequate BP control were: In their 30’s Mixed white and black Caribbean (13%) or mixed white and black African (12%) Little difference between men and women Previous analysis (using Datanet) demonstrated that those less likely to have adequate BP control were: Younger people (<65) Black African and Caribbean groups Men With a significant proportion of patients who were uncontrolled were recorded as only having one or two antihypertensive medications suggesting optimisation may not have occurred.

Part two Identification of patients Practices were asked to identify ALL patients with a systolic blood pressure >160mmHg and/or a diastolic blood pressure >100mmHg. Patients who had been diagnosed in the previous 6 months and those on the palliative care register were excluded. Those diagnosed in previous 6 months excluded as looking at persistently uncontrolled patients – they will still be in phase of initiating/titrating treatment. Those on palliative care register excluded as tight BP control not required – aim to avoid unnecessary polypharmacy and medication side effects in these patients Some patients were identified from the register (and prior readings) as having a SBP 160 or over and/or a DBP 100 and over but on attending for a review actually had BP’s below both of these thresholds. Data from these patients was still collected. Develop practice hypertension action plan Practices were then asked to develop and implement a local hypertension action plan

Management options 1. Review by GP and practice nurse Medicines optimisation Support patients with medication adherence 2. Review at the specialist led virtual clinic 3. Refer to community hypertension service 4. Refer to hospital hypertension service Further investigations As seen, wherever the patient is seen or managed the same will be offered. Patients will be stratified based on complexity Differences are : VC: specialist CVD pharmacists provide expertise Community clinic: specialist CVD pharmacists provide expertise and have longer appointment slots to dedicate to patients who require more time to discuss their medicines Hospital clinic: Consultants/Specialist Doctors provide the expertise and have access to specialist investigations for those patients who need

Sample characteristics 45 practices submitted data for 1,982 patients All data given in percentages

Sample characteristics 45 practices submitted data for 1,982 patients All data given in percentages

Results 26 patients did not respond to invitations for an initial BP review from the practices A further 445 (22.5%) failed to attend for follow up readings despite repeated invitations from the practices Significant proportion of patients discussed at VC not engaging with services (14%)

Results Systolic BP 172.9 147.9 - 25.0 14.5 Diastolic BP 106.5 89.8 Patients with initial SBP ≥160 (n=1231) Initial mean BP Final mean BP Difference (n) Difference (%) Systolic BP 172.9 147.9 - 25.0 14.5 Patients with initial DBP ≥100 (n=648) Initial mean BP Final mean BP Difference (n) Difference (%) Diastolic BP 106.5 89.8 16.7 15.7

Results Age Ethnicity Sex All age groups improved Older age group improved more than younger age groups Younger age groups more likely to not engage with intervention compared to older age groups Ethnicity All ethnic groups improved Improvement appears greatest in South Asian and other ethnic groups compared to black groups Other ethnic groups less likely to engage with intervention compared to white groups Sex Both sexes improved but improvement was greater in females compared to males Males less likely to engage with intervention Other is that patients who were discussed at virtual clinic and those that were not had similar reductions in BP

Targets Target % of patients meeting criteria at baseline % of patients meeting criteria at endpoint NICE systolic BP for under 80’s (<140mmHg) 3.4 39.6 QOF systolic BP (<150mmHg) 9.6 61.7 NICE/QOF diastolic BP (<90mmHg) 33.2 68.5 As noted previously – some people included did have a first reading of BP that did not meet thresholds but were still included. Actions suggested at virtual clinics: Titration of current meds: 21.3% Within class change in meds: 2.3% Initiation of new medication: 32.7% Review concordance: 21.6% Lifestyle: 9.7% 24 hour monitoring: 5.6% Community hypertension clinic referral: 4.0% Secondary care referral: 4.5% Any referral: 8.5% SUGGESTS ROOM FOR MEDICINES OPTIMISATION NICE = National Institute for Health and Care Excellence QOF = Quality and Outcomes Framework

Conclusions (1) For those that are engaged in primary care services: Those with initial systolic blood pressure ≥160mmHg achieved an average reduction of 25mmHg = 55-70% reduction in risk of stroke = 45-55% reduction in risk of coronary events M R Law et al. BMJ 2009;338:bmj.b1665 Those with initial diastolic blood pressure ≥100mmHg achieved an average reduction of 16.7mmHg There were no differences in outcomes achieved based on age, gender or ethnicity Achieved huge reductions in blood pressure and reduced the risk of mortality from ischaemic heart disease and stroke in our population BUT we still have more progress to make Need to work on: Engagement of those who are not engaging Continuing work on medicines optimisation and look at reducing the variation across practices Increasing prevalence and find the missing patients

Conclusions (2) Challenges: Future direction: Still a proportion of people with high blood pressure who are not engaging with general practices. Further data analysis is being undertaken to assess any underlying inequalities in this group Future direction: Exploring inequalities in engagement with primary care services Continuing work on optimising medicines for those with hypertension Exploring options to increase the prevalence of hypertension