a call to action: ‘beat high blood pressure’ welcome!
TRANSCRIPT
Welcome and agenda for the dayMorning:
• To gather insight about perceptions of high blood pressure, and how we might best communicate and deliver proposed actions/changes.
• To develop an understanding of how to engage the public in any BP campaigns to improve detection and management
Afternoon:
• To gather insight from representatives of the health care community about perceptions of how high blood pressure is currently managed, and how we might best communicate and deliver proposed actions/changes.
• To develop an report from the day which will identify support future action on this topic
2 Tackling high blood pressure
Why blood pressure?
Councillor Janet Clowes &Dr Heather Grimabaldeston, Director of Public Health
Cheshire East Council
What is high blood pressure?Hypertension is the medical term for high blood pressure. It means that there
is too much pressure in your blood vessels, which can damage your blood vessels and cause health problems
High blood pressure is a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and dementia
Certain factors can increase your risk of developing high blood pressure, these include:
being overweight or obeseeating too much saltnot eating enough fruit and
vegetablesnot doing enough exercisebeing of African or Caribbean
descent
drinking a lot of alcoholbeing olderhaving a family history of
high blood pressure
CAN BE LOWERED
Why do we need a system wide response?
1. High blood pressure is the second biggest risk factor for premature mortality in the UK.
2. About 30% of adults have hypertension, of which an estimated 5m are undiagnosed.
3. Hypertension is the biggest QOF disease register locally (14.8%).
4. Most outcomes related to hypertension are worse in deprived groups.
Risk factors premature mortality: Global Burden of Disease
Source: The Lancet, UK health performance: findings of the Global Burden of Disease Study 2010
Source: The Lancet, UK health performance: findings of the Global Burden of Disease Study 2010
Variation
Source: Health Survey for England 2011
unwarranted variation
30% difference - most/least deprived
CCGs achieving BP control to 140/90 in treated population ranges from 61-94%
Cardiovascular Disease – in Cheshire East
Cardiovascular Disease: Coronary heart disease (angina and heart attack), stroke and peripheral artery disease (affecting the blood vessels of arms and legs).
• Cardiovascular disease accounts for approximately a quarter of premature deaths each year in Cheshire East (approximately 250 deaths/year)
• The premature death rate from cardiovascular disease is lower than the national average but higher when compared with local authorities with similar levels of deprivation
premature deaths (heart disease) fallen by 40% ( reductions in smoking and better clinical management); men faster than women
Men and women who live in Crewe have a higher risk of early death from CVD than other people
Cardiovascular Disease key facts – where and who
Cardiovascular Disease in Cheshire East
To reduce the number of deaths in the under 75’s from cardiovascular disease
Improve identification of undiagnosed cases
• There are estimated to be:- 35,000 people with high blood pressure- 20,000 people with kidney disease- 3,300 people with diabetes
(ALL UNDIAGNOSED)
• A Health Check is offered every 5 years to those aged 40-74 who are not diagnosed with heart disease, kidney disease or diabetes
- Approximately 100,000 people are eligible
- The aim of the Health Check is to identify undiagnosed cases of disease
Delivery of a High Standard of Care
• Instigate early management and prevention within the community to prevent premature deaths
• This includes a high standard of active treatment in primary care (e.g. aggressive management of high blood pressure)
• Prompt management of an acute event is also important (e.g. hospital management of a heart attack, mini and full strokes)
In 2011/12 if all cases of high blood pressure (diagnosed and currently undiagnosed) had been optimally managed, it is estimated that 100 heart
attacks and strokes could have been avoided
Improvements can be achieved: England vs Canada
Canada began a systematic initiative to address high blood pressure in the mid-1990s as their treatment and control rates were 13% in early 90’s (now 66%) – with reductions in stroke and MI
Source: Joffres et al, BMJ Open 2013
Priority across Cheshire & Merseyside
Support from
• Directors of Public Health
• Cardiovascular Disease Strategic Clinical Network
• Kidney Clinical Network
• Primary Care Strategic Forum
• NHS England
High blood pressure steering group:
Prevention, Identification, Management
We Need Your Help to make change happen
Tackling high blood pressure: from evidence into action
Ben Lumley, Blood Pressure Programme Lead, PHE
BP System Leadership Board• England’s Blood Pressure System Leadership Board is a cross-sector
group which oversees the programme of work improve the prevention, detection and management of high blood pressure, and reduce health inequalities
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NHS England
NHS Improving Quality
The action plan• Tackling high blood pressure: from evidence into action (18 Nov 2014)
• Intended to support partners at all levels to focus upon the work that will make the biggest impact in tackling high blood pressure.
• Draws on the best evidence (including new economic analysis) and professional judgment of our group to:• Recommend most pressing issues on blood pressure pathway to address
• demonstrate roles for a wide range of organisations to achieve this
• set out what key partners have already pledged to do in support of our ambition
• Overarching themes:• Tackling inequalities: identifying approaches and targeting to achieve this
• Partnership: need system leadership at all levels across government, health system, voluntary sector and beyond
• Local leaders: change and implementation is influenced and driven by local professionals
www.gov.uk/government/publications/high-blood-pressure-action-plan
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Prevention (1 of 2)• High blood pressure is preventable, and risk of
cardiovascular disease is reduced down to a threshold of 115/75mmHg
• Key risk factors include excess weight/salt/alcohol, physical inactivity
• 15% reduction in population salt intake achieved in last decade seen as main contributor to lower population blood pressure (↓3mmHg systolic)
• Over ten years, an estimated 45,000 quality adjusted life years could be saved, and £850m not spent on related health and social care, if England achieved a 5mmHg reduction in the average population systolic blood pressure
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Detection
Prevention
Management
What percentage of risk factors associated with someone having their first heart
attack are modifiable?
90% Men
94% Women
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study
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Prevention (2 of 2)Key approaches (plan sets out more fully how different groups contribute):
• reducing salt consumption and improving overall nutrition at population-level
• improving calorie balance to reduce excess body weight at population-level
• personal behaviour change on diet, physical activity, alcohol and smoking, particularly prompted through individuals’ regular contacts with healthcare & other institutions
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• Examples of actions identified:• PHE dedicated programmes on diet and obesity, physical activity,
alcohol and healthy places
• Department of Health responsibility deal
• British Heart Foundation 2014-2020 strategic ambition on prevention
• Deliver NHS England Making Every Contact Count action plan
Detection
Prevention
Management
Key approaches (plan sets out more fully how different groups contribute):
• more frequent opportunistic testing in primary care, achieved through using wider staff (nurses, pharmacy etc.), and integrating testing into the management of long term conditions
• improving take-up of the NHS Health Check, a systematic testing and risk assessment offer for 40-74 year olds
• targeting high-risk and deprived groups, particularly through general practice records audit and outreach testing
Detection• Testing advisable at least every five years, more frequent re-
testing for those with high-normal blood pressure. Diagnosis never based on a single test, normally followed by ambulatory (24 hour monitor) or home testing.
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Prevention
Detection
Management
Management• NICE recommend lifestyle treatment for all with hypertension –
can achieve dramatic reduction. If drug therapy, 80% require 2+ agents to achieve blood pressure control. NICE treatment target (for adults under 80 years) 140/90mmHg.
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Key approaches (plan sets out how different groups contribute):
• local leadership and action planning for system change, to tackle particular areas of local variation, and achieve models of person-centric care
• health professional support (communication, tools & incentives) to bring practice nearer to treatment guidelines
• support adherence to drug therapy and lifestyle change, particularly through self-monitoring of blood pressure and pharmacy medicine support
Prevention
Detection
Management
Resource hub• PHE wants to support local leadership in tackling high blood pressure, and
has gathered resources in one hub to help those planning and delivering high blood pressure services and initiatives
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www.gov.uk/high-blood-pressure-plan-and-deliver-effective-services-and-treatment
• Resources include data, guidance, tools, case studies and examples of emerging practice
• The PHE team welcomes feedback and ideas for new resources to include, particularly any local case studies – please email [email protected]
The future
• Future programme activity will include supporting:
• PHE, working with and reporting to the Blood Pressure System Leadership Board, will continue to pursue this agenda and provide support to local leaders
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Clinical leadership, particularly in primary care Local leadership, with local government as the hub for public health
and wider local partner networks Tools, evidence and economics Public and community engagement
What is your role in tackling
high blood pressure?
Insights about public knowledge and attitudes to high blood pressure
Ben Lumley, Blood Pressure Programme Lead, PHE
Public informed about disease risks
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Spontaneous knowledge of issues caused by high blood pressure
Confidence in knowledge of issues caused by high blood pressure
56
43
14
14
9
7
56
41
12
15
8
6
63
56
26
7
19
11
Asda Mobile
Total
Convenience/curiosity motivate testing
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BASE: All respondents; Total (362) Mobile testing point (236) Asda (126)Q6:And what made you decide to have your blood pressure checked today? (Top seven codes shown only)
I was interested to know what my blood pressure is
It was convenient
It’s an important thing to monitor
I was concerned I might have high blood pressure
I thought I would be able to get some advice about
my health
It was free
%
What made you decide to have your blood pressure checked today?
Views in diagnosed population
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A large number of participants used the presence or absence of
symptoms to indicate whether their blood pressure was raised
Most participants understood that hypertension caused serious complications such as stroke
Hypertension was seen by some participants as a temporary or
curable condition that would not require long-term treatment
Deliberately choosing to avoid or reduce treatment was a theme recurring in many of the studies
NICE. Clinical management of primary hypertension in adults. Clinical Guidance 127 (Full version), 2011Marshall I, Wolfe C, McKevitt C. Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. BMJ. 2012Benson J, Britten N. Patients' views about taking antihypertensive drugs: questionnaire study. BMJ. 2003; 326(7402):1314-1315
Four in every five people said they had reservations about taking
anti-hypertensives
After diagnosis – for some nothing had changed, others viewed
themselves as unhealthy or even focused on their mortality
Differences between groupsSocio-economic group
• Lower socio-economic groups (C2DE) less knowledgeable about health consequences of high blood pressure, and less positive about outcomes from treating high blood pressure if diagnosed early. (PHE surveys)
• Economic hardship and linked stress thought to worsen condition (Marshall)
Geographic and ethnic groups (Marshall et al.)
• Principal themes in attitudes were “remarkably similar”, despite recommendations for culturally-appropriate education in many studies
• Traditional diet raised as an exacerbating fact for hypertension by all groups
Segmentation (in context of testing initiative) (PHE research)
• “Not for me” (largest group) firm miss-assumptions, low levels of concern
• “Why not” likely to take a test simply because it is being offered
• “On my mind” (minority) more actively worried about their health
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Take-away pointsA caveat, studies almost universally small sample-sizes and typically based on older populations.
Two themes that are not yet consistently understood and could represent engaging ‘news’ for many people:
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High blood pressure
normally has no symptoms
High blood pressure can be
avoided in many cases
Cheshire and Merseyside: Blood pressure/hypertension
Caoimhe McKerr, Knowledge and Intelligence Team (NW)Ben Lumley, Blood Pressure Programme Lead
Local data and data tools:Using PHE Healthier Lives data
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Risk and prevention Detection
Care High risk groups
LA CCG GP
healthierlives.phe.org.uk/topic/hypertension
“ … make England’s data about many aspects of hypertension
prevalence, diagnosis and management available to everyone”
Detection• Recorded hypertension
prevalence
• Estimated hypertension prevalence
• % of estimated hypertension detected
• % of patients aged 40+ who have a record of blood pressure in last five years
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Prevention
• Deprivation
• % aged 65+ years
• Prevalence of adult healthy eating
• Prevalence of obesity in adults
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Care / High Risk Groups
• GP record of blood pressure reading in previous 9 months in people with hypertension
• Blood pressure control – e.g. maintaining ≤140/90 mmHg, with additional info for diabetes, CHD, stroke, CKD co-morbidities
• Processes for newly diagnosed - GP lifestyle advice, statins for high CVD risk
• GP physical activity assessment in people with hypertension
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Next steps• What is the bigger picture?
• What is the overall picture for the area or practice? Are just one or two, or several, indicators ‘red’?
• How do they compare with areas with similar deprivation and demography?
• Is there a problem with one or two, or most, of the practices in the area?
• What is the role of other factors such as deprivation, obesity and determinants of health?
• Download data for further analyses
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Supplementary data sourcesPublic Health Outcomes Framework
The outcomes in this framework reflect a focus not only on how long people live, but on how well they live at all stages of life
http://www.phoutcomes.info/
Cardiovascular disease profiles
These profiles allow you to download a cardiovascular disease (CVD) health profile for each clinical commissioning group and strategic clinical network in England, with the interactive version allowing comparisons.
http://www.yhpho.org.uk/ncvinc
Longer Lives
Longer Lives highlights premature mortality across every local authority in England, giving people important information to help them improve their community’s health.
http://healthierlives.phe.org.uk/topic/mortality
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Acknowledgements• Knowledge and Intelligence Team (North West)
• Catherine Lagord, NHS Health Checks, PHE
Contact and further support
[email protected]; 0151 231 4528
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Questions:• Do people know and care what their blood pressure is?
• If no- why?
• If yes- why?
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Insights from local populations: Halton and Knowsley
Dr Ifeoma Onyia, Halton Borough Council
Dr Sarah McNulty, Knowsley Borough Council
Objectives
Evaluate local residents attitudes to getting their BP checked and how we can encourage them to do so.
Current behaviour and barriers
Evaluation of messages and existing campaigns
What should a call to action look like?
Who did we ask?
408 face to face interviews across Widnes and Runcorn
All lived within Halton
Age range 30 – 70 year olds
Equal M/F ratio
All registered with a GP in Halton
40% employed; 25% retired; 1%Education; Unemployed/carer/ disabled/ homemaker
What they said about themselves
Half described themselves as overweight
One in three in fair, poor or very poor health
Over one in three disabled
Why did they have a BP check?
Part of a check-up
Recommended by GP/nurse
Unwell
Underlying health problems
In hospital
Every time see GP
Checked regularly
Links with NHS Health Checks
72% had heard of NHS HealthChecks
37% could recall an invite
Of those invited 82% attended
Younger females and working less likely
Most expected BP would be checked
Some expected checks on eyes/ feet/ cancer
Inertia largest barrier to going for check
Understanding of BP factors
SymptomsLight-headedness (40%)
Hot/flushes
Headaches
Blurred vision
None ( 5%)
CausesStress (40%)
Unhealthy lifestyle (20%)
Overweight
Not eating enough Fruit and Veg
Excess Alcohol
Hereditary
Other illness
Salt
Understanding of Impacts
Heart attack @ 76%
Stroke @ 58%
Next danger @ 4%
( kidney/ diabetes/ nosebleeds/ blindness etc)
Focus groups
Healthy foundations segment
Town Age range Participants
Unconfident fatalists Huyton Mixed 9 (5 women and 4 men)
Health conscious realists
Kirkby ≤ 40 7 (5 women and 2 men)
Live for today Prescot 41 - 70 9 (5 women and 4 men)
Attitudes
General concern but low understanding about definition, signs symptoms and treatment.
Better awareness amongst those with long term conditions eg diabetes or on the pill.
Perception that a diagnosis of high blood pressure is a life sentence.
Importance of having checks
Prevention
‘It can save your life’ (Health Conscious Realist and Live for Today)
‘They can prevent you from becoming more ill if you do have high blood pressure’ (Health Conscious Realist)
Want more info on how to get checked and how often.
Barriers to having checks
Poor access to GP prevents regular checks.
Inertia
‘I’m OK; I’m not at that age right now’ (Unconfident fatalist)
Lack of information
‘People are not aware of how serious high blood pressure is’ (Unconfident fatalist)
Who should do BP measurements?
GPs should offer them to everyone regardless of what they go to the surgery for
Pharmacies
Walk-in centre
Don’t really mind as long as evidence that person doing the check had been trained
Mixed views on home testing.
Messaging territoryHeadlines that resonated with all groups
‘After cancer, high BP is the second biggest cause of early death and disability for people aged under 75’
‘Around 12.5 million people in the UK have high BP. Of these, around 5 million are not aware of it’
Simple messages, tips and information, shock factors, happy with cartoons.
However people are put off byAge 75
1:4 or 1:3. They prefer the big numbers.
• Give local stats
Knowsley messaging idea
‘x people in Knowsley have high blood pressure and don’t know it. Are you one of them? Get checked’
Communication channels
Ambient media in areas of high footfall – town centre posters, pharmacies, fliers
Bus sides/internals
Social media inappropriate for health matters
Questions:• What can we do to empower people to know and care about what their
blood pressure is?
• And what steps will you take to make this happen?
• Feedback at 12:15
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Next steps for this work• What will you do next?
• What’s your pledge? How are you going to contribute to this agenda?
• Report from the day
• Steering group – planning and coordinating
• Wider system ownership and action
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Lunch, learning and networking• DATA STATION: Check your local data on blood pressure
• BP CHECKS: Do you know your blood pressure?
• BHF: Resources available from British Heart Foundation
• PLEDGE / DIFFICULT QUESTIONS / LIGHTBULB MOMENTS
• Please return by 13:30 for the afternoon session
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Purpose of the afternoon• To gather insight from representatives of the health care community about
perceptions of how high blood pressure is currently managed, and how we might best communicate and deliver proposed actions/changes.
• To develop an report from the day which will identify support future action on this topic
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High blood pressure very frequently accompanies other conditions - relevant to most clinicians
regardless of speciality.
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Barnet K et al, Lancet 2012
Links across systemThree key strands:
• Prevention
• Detection
• Management
Overarching themes:
• Tackling inequalities: the most deprived communities are more likely to have high blood pressure – great opportunity to reduce variation in outcomes
• Partnership: need system leadership at all levels across government, health system, voluntary sector and beyond
• Local leaders: change and implementation is influenced and driven by local professionals
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Hypertension clinical guidelines
Dr Matt KearneyGP RuncornNational Clinical Advisor NHS England and Public Health England
Diagnosing hypertension
• CBPM ≥ 140/90 check up to twice more
• Offer ABPM and ensure correct cuff
• Daytime average of 135/85 mm Hg = HTN
• If ABPM not tolerated use HBPM
• ABPM for 24 hrs, 2 measures/hr during day and at least 1 at night. Average BP needs 14 daytime measurements
• HBPM – 2 readings, twice a day for 4-7 days, discard day one and take average of remaining measures
• CVD risk assessment core to diagnosis
94 Hypertension clinical guidelines
Thresholds for diagnosis
• Stage 1: 140/90mm Hg (135/85 ABPM or HBPM)
• Stage 2: 160/100mm Hg (150/95 ABPM or HBPM)
(Studies show ABPM and HBPM give values on average 10/5 lower than in the office)
95 Hypertension clinical guidelines
Drug treatment
• Stage 2 Hypertension
• Patients under 80 with Stage 1 and:• Target organ damage• CVD• Renal Disease• Diabetes• 10 yr CV Risk 20% or more
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Summary of anti-hypertensive drug treatment
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Step 4
CAStep 1
Step 2
Step 3
Aged over 55 years or black person of African or Caribbean family origin of any age
Aged under55 years
A + C + D
Resistant hypertension
A + C + D + consider further diuretic, or alpha- or
beta-blocker
Consider seeking expert advice
A + C
KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic
Implementing guidelines in real world primary care brings challenges
99 Hypertension clinical guidelines
It’s not just about knowledge transfer
• Consultations structure
• Time pressures
• Multimorbidity
• Polypharmacy
• Patient knowledge, expectations, activation, adherence
• (Lack of) follow up systems
Implementing guidelines in real world primary care brings challenges
102 Hypertension clinical guidelines
But there are new opportunities
• Wider primary care staff
• Other settings
• New models of care
• Automation
Improving detection of high blood pressure
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1. More BP testing in practices
• More opportunistic testing by clinicians
• More routine testing in people being seen for other long term conditions
• More waiting room testing eg automated systems
2. NHS Health Check – improving uptake and clinical follow up
3. More systematic audit of practice records to regularly detect people at high risk of undiagnosed hypertension – eg high last reading not followed up, other risk factors but no recent BP
4. More testing by pharmacies – eg on request and routine in MURs, NMS etc
5. More self-testing
Improving management of high blood pressure
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1. Systematic primary care audit
• Detecting people with inadequately controlled hypertension
• More frequent routine and opportunistic testing in people with hypertension
2. Integrating BP testing into management long term conditions
3. Improved implementation of NICE guidance
4. Support adherence
• Shared decision making and patient activation
5. Expand community pharmacist role
• Monitoring BP in people with hypertension
• Supporting adherence to medication and lifestyle
5. Expand self-monitoring and telehealth options
It’s quite easy to measure blood pressure inaccurately
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World Hypertension League Video
https://www.youtube.com/watch?v=egBmUw0Y0IE
• For all patients over the age of 18 years to have had a blood pressure recording documented within the preceding 3-years.
• For all patients with an initial reading >140/85 to have follow up reviews and appropriate management as defined in the Hypertension guidelines.
• For patients newly diagnosed with hypertension who are under the age of 40 years, to be referred to secondary care for full investigations
• For all patients diagnosed with hypertension to be monitored on a 6-monthly basis and their blood pressure to be maintained under 140/85.
• For all patients to receive education on the risks of uncontrolled hypertension on cardiovascular disease.
• All patients should receive advice and support on lifestyle changes to promote health, to include diet, exercise and alcohol management and smoking cessation.
The Vision
• We have an 8,150 practice population
• We have 1,333 Patients diagnosed with hypertension
• We have 111 Hypertensive patients who are above target
• We have 128 Patients over 45 years that have not had a Blood pressure recorded in the last 5-years
• We have 508 Patients aged 18-44 who have not had a blood pressure recorded in the last 5 years.
• We have 314 Patients who have a raised blood pressure reading but no diagnosis of hypertension in the last 3-years.
• How do we engage these people who have not had a blood pressure check or who have been found to have a raised blood pressure reading but not come back for a recheck.
• How do we educate this population and inform them of their potential risk of cardiovascular disease.
The Challenge
• The practice IT team would concentrate on calling for the hypertensive patients who have not attended for review and encourage them to come in.
• The practice nurse and health care assistant would contact the patients with uncontrolled hypertension and book them in for review.
• A Saturday morning clinic was set up for the 7th February to target those 128 patients over the age of 45 with no blood pressure reading in the last 5 years. These patients could also be booked in with the practice nurse or health care assistant any day of the working week for a health check. Letters were sent to all of the patients that could not be contacted by phone 18 patients attended and had a full health check and 9 patients dna’d.
• Patients aged 18-44 years, who have not had a blood pressure recorded in the last 5 years (508) will be sent letters to inform them of the importance of having a blood pressure taken and will be asked to book an appointment with the practice nurse or health care assistant.
The Plan
• Those patients who have not responded or made an appointment after their invite letters will be informed that the nurses will be calling to their homes week beginning 23rd March to record their blood pressure and weight.
• Brookvale practice will then audit the results and provide feedback to the Halton CCG
• If successful we hope to roll the program out to the other practices in Halton from June 2015.
The Plan continued
SWOB of effective BP identification and management
Strengths
Weaknesses
Opportunities
Barriers
• Move stations – 10 minutes at first then 5 minutes to add to others
• Complete all four stations
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What steps can we take to make a change?
• Work on tables to produce action plans
• What can you do to make a difference?
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