The national CVD programme supports the delivery of targeted interventions to increase diagnosis and optimise treatment of CVD risk factors.
To support the above, the hypertension (HT) programme has a target of detecting 80% of the expected population with HT.
In NWL, the HT prevalence rate in adults >18 is c13.3%. National HT prevalence estimates are between 16 to 33%. Hounslow borough registers a gap of c9.6% between the expected c21.8% and actual c12.2% prevalence rates.
The Project
To improve blood pressure (BP) control of patients already diagnosed with hypertension or at risk of CVD within three PCNs- Chiswick, Hounslow Heath, Feltham & Bedfont. The risk stratification framework helped identify patients from the following priority groups:
- Group 1: Patients have a last recorded systolic BP >180 mmHg and/or diastolic BP >120 mmHg
- Group 2:
- Patients have a last recorded systolic BP >160 mmHg and/or diastolic BP >100 mmHg
- Patients have a last recorded systolic BP >140 mmHg and/or diastolic BP >90 mmHg if BAME, with CVD, CKD, diabetes or BMI >35
- Patients with no BP reading in 18 months.
- Group 3: Patients who have a last recorded systolic BP >140 mmHg and/or diastolic BP >90 mmHg- all other patients.
Project Implementation
- Feltham & Bedfont PCN: Commenced BP@Home monitoring in April 2022 and continued until March 2023. Focused on: Priority 2 and 3 patients. PCN applied the BP@Home guidance. Pharmacists ran searches using UCLP Framework, contacted patients via telephone /text and enrolled them. Patients were advised on how to check BP. PCN recorded individual patient BP. Initial BP and actions taken including blood tests, medicines optimisation and lifestyle advice as appropriate. Patients were discharged once BP control was achieved. Search was re-run regularly to capture new patients.
- Chiswick PCN: Commenced in October 2022 until March 2023. Focused on: Priority 1, 2 and 3 patients. The PCN operated a blood pressure hub model from November 2022 where registered patients from Chiswick Health Practice could drop in on a specific day each week for blood pressure checks. It used UCLP searches plus additional searches locally for a combination of diagnosed and undiagnosed patients; the latter including patients with uncontrolled blood pressure. 4-day BP readings were requested and face to face invitations sent to patients. The team dedicated a GP and other resources e.g., a pharmacy technician for the programme. The hub has accommodated patients from the other Chiswick practices since March 2023.
- Hounslow Heath PCN: Commenced in October 2022 until March 2023. Focused on Priority 1 patients (Most at risk). The PCN used UCLP searches to identify patients with high BP readings in clinic and who had no follow up. It focused on patients in Bath Road surgery initially and contacted patients via telephone offering telephone / face to face appointment. It dedicated one morning clinic to review these patients, along with spending some parts of other clinics to further review these patients. It planned to enrol a minimum of 5 patients/ practice across the PCN, ideally targeting Priority 1 patients and then filtering down the groups as necessary.
Developing the Logic Model Evaluation Framework
Public Health team members supported the project team in defining the type of research best suited to their objectives, the instrument(s) to be used, and guided them in applying the Logic evaluation tool. The team advised on selecting the most appropriate technique for framing the evaluation questions, and ensured they were fit for purpose. This helped project colleagues to identify and clarify the evaluation outcomes.
Evaluation -The Logic Model
The Logic Model helped evidence the following outcomes:
Short-term
• Increased skills and knowledge for patients to monitor BP at home
• Increased positive feelings and activation of related values for patients in relation to monitoring BP at home
• Increased access to BP equipment & support services
• Increased skills and knowledge for PCN staff to support patients monitoring BP at home
Medium-term
• Improved care pathways for patients at risk
• Improved condition self-management for those with a CVD condition
• Improved confidence to take responsibility for health and well-being
• Sustained improvement in BP control
Patients and staff surveys were carried out between mid-April and mid-May and additionally a review of a random sample of 5 case records per PCN.
Patient survey main findings included:
• Most respondents - 81%- found using BP monitoring device to be ‘Easy’
• 59% respondents felt they received the support they needed from staff
• Positive experience in participating in the project.
• Most respondents -72%- felt they received the right advice or treatment on what to do next.
• Lifestyle changes- 67%- reported at least one lifestyle change including diet and exercise regime.
• <10% respondents reported negative experiences, main themes being:
o Lack of feedback or follow-up
o Unclear guidance for some during the project
o Equipment issues (Cuffs not fitting properly, 24hr ambulatory machines reported to be uncomfortable)
o Hours of the readings was an issue for the participant due to work.
Staff survey’s main findings:
• Overall a helpful experience in carrying out the project
• Satisfied with results locally to date in comparison to initial expectations
• Identified patients at high risk and stratified them into groups
• Remote assessments and increasing patients’ self-management skills
• Staff and patient information packs were useful
• New hypertension cases identified in Chiswick & Hounslow Heath PCNs
Challenging aspects and areas for improvement:
• Limited time availability - time consuming to recruit patients and keep them engaged – admin support
• Recording results – data sets, data collection and recording processes
• Unclear KPIs.
• Earlier start of BP implementation group meetings in programme cycle
• Inadequate provision of blood pressure monitors
Lessons Learnt: - To sustain the progress:
• Continue to run searches, contact patients & implement regular reviews in surgeries
• Promote healthy BP within the PCN
• BP@ Home monitoring as a BAU activity in the PCNs.
• Focused community outreach to improve detection and prevention of hypertension.
The Logic Model is part of the Population Health Management Framework, all training resources are available here