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GPs caught between BP guidelines

With confusion over exception reporting and GPs scrutinised over the issue the Primary Care Cardiology Society has published consensus guidance

­ deputy chair Dr Terry McCormack and secretary Dr Mark Davis explain

With nearly a third of the total clinical points relating to hypertension in the new contract, exception reporting has become a key financial consideration for GPs.

The new GMS contract has introduced the term 'maximum tolerated dose'. It defines a cut-off point where the GP advises the patient to accept their current blood pressure level, either because they are not responding to treatment or because they are having unacceptable side-effects.

If the GP uses the maximally tolerated treatment code (8BLO) then this becomes an exception ­ the patient is not counted as part of the quality framework target percentage.

A sensible idea ­ but the contract does not give any advice on how the GP decides when this point has been reached. And so the Primary Care Cardiovascular Society (PCCS) has attempted to come up with a definition.

Your definition under scrutiny

The validity of GPs' new contract claims will be scrutinised by a panel of Q&O assessors made up of independent doctors, nurses and lay people who can ask a GP to justify a decision to exclude a patient.

Each practice would be wise to have a written protocol defining maximally tolerated treatment of blood pressure, based on the evidence available. This could be part of a wider practice protocol on hypertension monitoring.

Towards a consensus

The PCCS recognises practices may welcome the opinion and advice of peers in this matter and we were set the task of coming up with a definition.

But because GPs were already having to make this decision, we released an interim statement, based on discussions with Professor Bryan Williams and Professor Neil Poulter of the British Hypertension Society.

To reach a wider consensus of opinion we decided to explore this matter with PCCS members at the annual scientific meeting in York last year.

The most frequently expressed view ­ and the key addition to the final guidelines compared with the interim ­ was that the patient's informed opinion should be taken into account and that the decision to treat was agreed mutually.

The other consensus view was that up to four classes of drug should be tried to achieve optimal blood pressure management.

Other important points made were:

·Asthma was an absolute contraindication and COPD a relative contraindication to betablockers

·patients should not be referred simply because target blood pressure was narrowly missed despite being on four drugs

·patients whose blood pressure was slightly elevated but who did not require treatment for hypertension should not be coded as suffering from hypertension to ensure they did not fall within the remit of the Q&O.

Some of the individual responses by PCCS members

·Individual choice, patient dependent ­ compliance/tolerance based on BHS guidelines of four drugs

·Lots of factors to look at, should be patient-centred

·Mutual decision of GP and patient

·Four drugs, age not a factor (biological rather than chronological), PCCS should advise

·Consider classes not drugs

·Tolerate = to put up with something; synonyms = abide, bear, brook, endure, stand, stomach, suffer, put up with; therefore maximum acceptable treatment from the perspective of the patient following explanation of risks and benefits is the required concept

·Do not code as essential hypertension unless treatment is indicated

·Should be changed in next contract

·Consider trying four classes of drugs unless any are contraindicated

·Do not refer a patient with borderline control on four drugs ­ 'What would your local consultant say if you referred a patient on four drugs who had a blood pressure of 152/92?'.

What the BHS guidelines added

The guidelines recommend that patients should be referred to a specialist service in cases of multiple drug intolerance, multiple drug contraindications, persistent non-adherence, persistent non-compliance and resistance to three or more drugs.

They include therapeutic advice, such as the use of a thiazide-like drug (chlortalidone, indapamide) if a thiazide (bendroflumethiazide, hydrochlorothiazide) causes side-effects. They state that loop diuretics should not be classified as part of the hypertension treatment except in cases of renal impairment or heart failure. There is anecdotal evidence that spironolactone is useful in resistant cases as the hypertension may be due to hyperaldosteronism.

A table listing contraindications/cautions is included in the guidelines with advice such as thiazide/thiazide-like diuretics should usually be avoided in patients with a history of gout or those receiving lithium therapy.

The guidelines state that 'betablockers are contraindicated in asthma' and this is clearly an important statement in terms of exception reporting in nGMS.

Hypertension in the elderly is mentioned in the original full version of the guidelines with the warning that in older people with significant postural hypotension (SBP falls equal to or greater than 20mmHg) treatment may need to be titrated to the standing BP values. The benefits of BP-lowering therapy in people over the age of 80 have not yet been established.

Those on treatment who reach 80 should continue on their treatment. No clear guidance can be given for those patients over 80 who require initiation of therapy. We await the publication of the Hypertension in the Very Elderly Trial (HYVET) in 2006 to answer this question.

NICE ­ management of hypertension in adults in primary care 2004

The recent NICE guidelines consider the management of essential hypertension. They do not consider hypertension management in patients with different co-morbid conditions. They state that betablocker contraindications include asthma, coronary obstructive pulmonary disease and heart block. They advise that only dihydropyridine calcium-channel blockers should be prescribed with a betablocker. Patients over 80 should be offered the same treatment as younger patients, taking account of any co-morbidity and existing drug use.

Terry McCormack is deputy chair of the PCCS and a GP in Whitby, North Yorkshire

Mark Davis is secretary of the PCCS and a GP in Leeds

Hypertension and the new GMS contract

·158 out of 550 clinical indicator points relate to management of blood pressure (29 per cent of the clinical points).

·BP Indicator 5. Ongoing management. The percentage of patients with hypertension in whom the last blood pressure (measured in the past nine months) is 150/90 or less. 56 points awarded for 70 per cent achievement.

·CHD Indicator 6. The percentage of patients with coronary heart disease in whom the last blood pressure (measured in the past 15 months) is 150/90 or less. 19 points awarded for 70 per cent achievement.

·Stroke Indicator 6. The percentage of patients with TIA or stroke in whom the last blood pressure (measured in the past 15 months) is 150/90 or less.

5 points awarded for 70 per cent achievement.

·Diabetes Indicator 12. The percentage of patients with diabetes in whom the last blood pressure (measured in the past 15 months) is 145/85 or less.

17 points awarded for 55 per cent achievement.

Exception codes:

'patient on maximum tolerated anti-hypertensive therapy' (8BL0)

'Betablockers contraindicated' (8I26)

Within the contract it states that:

'...Practices will not be expected to report why individual patients were exception reported....However, practices may be called on to justify why they have excepted patients from the quality framework and this should be identifiable in the clinical record.'

The Primary Care Cardiovascular Society guidance on

coding of maximally tolerated blood pressure treatment

·Follow the British Hypertension Guidelines (BHS) or Joint British Society Guidelines to justify your treatment policy.

·Have a clear written policy in your practice as regards maximal treatment of blood pressure based on the BHS guidelines.

·If not contraindicated you should use four classes of drugs and if this fails to control your patients, or is not tolerated, you should consider referral to a specialist clinic.

·In the patient aged over 80, if the standing systolic blood pressure falls by more than 20mmHg you should record the standing figures as your measure of control.

·Patients aged over 80 should be treated subject to individual clinical judgment, taking account of any co-morbidity and their existing

burden of drug use.

·The patient's opinion should be taken into account and recorded before using the exception code.

·Ensure that you can justify your decisions to your quality and outcomes framework assessment panel and consider talking to panel members for guidance on these issues.

The Whitby Group Practice hypertension protocol copyright Whitby Group Practice 2004

The following is a copy of the hypertension protocol drawn up by

Dr Terry McCormack's practice. Because it is a practice policy, it is

not all evidenced based ­ for example no more than three drugs in

the over-80s ­ but may serve as a useful template for other

practices drawing up their own protocols.

Blood pressure measurement

·Use the left arm and the correct cuff size

·The lowest reading after sitting for 10 minutes is the most accurate

·Home measurements must be adjusted by adding 10/5

·In the elderly if standing systolic drops by >20mmHg record the standing BP as the sitting measurement

Diagnostic criteria

·If normal, recheck in five years

·Take four readings on four separate occasions if abnormal

·If moderate at least two weeks apart

·If severe at least one day apart

·If average is normal/mild after four readings recheck in one year

·At least one check by nurse, one by doctor

·Labile hypertension should be treated

·Do not code as essential hypertension unless treatment is indicated

Definition of moderate hypertension (BHS guidelines state that mild hypertension alone does not need medication)

·Systolic BP 160mmHg or more

·Diastolic BP 100mmHg or more

·Diastolic BP >90mmHg + target organ damage

·Treat if either systolic or diastolic raised

·Age is irrelevant (absolute risk greatest in elderly)

·Severe is 180/110 or more

Target organ damage

·Left ventricular hypertrophy (sum of R & S >40mm plus

inverted T in V5 & V6)

·Renal impairment

·Ischaemic heart disease

·Cerebrovascular disease

·Peripheral vascular disease

·Retinal changes

New contract audit targets

·Smoking status and advice offered every 15 months

·BP indicator 5 BP 150/90 or less 56 points (70%) measured every 9 months

·CHD indicator 6 BP 150/90 or less 19 points (70%) measured every 15 months

·Stroke indicator 6 BP 150/90 or less 5 points (70%) measured every 15 months

·Diabetes indicator 12 BP 145/85 or less 17 points (55%) measured every 15 months

White coat hypertension

·OMRON readings only a guide

·Home measurement must be equated to clinic reading (add 10mmHg to systolic & 5mmHg to diastolic)

·White coat hypertension may mask hypertension

·Need annual OMRON checks

Patient assessment

·Smoker?

·Excess alcohol?

·Drugs (pill/steroids)?

·FH of cardiovascular disease under 65 in female or 55 in male?

·Weight

·CVS

·Fundi (optional)

Investigation

·Urinalysis for protein

·FBC

·U&Es

·Random blood glucose

·LFTs

·g GT

·Uric acid

·ECG

·Non-fasting total cholesterol and HDL (follow lipid protocol)

Consider

·CXR (LVH)

·USS Abdomen (arterial disease, raised creatinine)

·Conn's syndrome ­ hypokalaemia, alkalosis, sodium slightly raised

·Phaeochromocytoma ­ very rare ­ VMA

(young, acute anxiety attacks)

Non-drug treatment

·Stop smoking

·Avoid saturated fats ­ <1g>

·Lose weight ­ 10% or 10kg

·Take regular exercise ­ 30 minutes' walking on five

occasions a week

·Do not add salt to food

·Reduce alcohol intake

Medication

·Tailored to individual needs/pre-existing pathology

·Three drugs often required for control ­ 60 per cent of patients

need two drugs

·Use AB/CD tables

·In monotherapy use maximum doses

·In combination therapy use minimum doses

Follow-up and nurses clinic

·Review fortnightly until controlled

·When controlled enter nurse review in six months and medication review 12 months

·Nurse review includes:

·urinalysis every time

·cholesterol check if indicated

·U&Es if on diuretic, ACE inhibitor or renal disease

·Alternate doctor/nurse reviews every six months

·Yearly doctor review if treatment stopped or white coat hypertension

·If not controlled refer to doctor

Over-80s

·If postural drop of 20mmHg systolic then enter the standing BP (lower figure) as the sitting BP

·No more than three drugs

·Stop drugs if not tolerated

Exception codes ­ Whitby Group Practice policy

·'Patient on maximum tolerated antihypertensive therapy' (8BL0)

·'?-blockers contraindicated' (8I26)

i Always strive to control the patient's blood pressure, do not abuse exception codes

ii If you do use exception codes you must justify their use in the patient's notes

iii The patient must have a say in the use of exception codes and you should record their opinion

iv Maximum therapy is achieved when four groups of drugs have been tried and either not tolerated, are contraindicated, or failed to control blood pressure

v Maximum therapy is achieved in patients who are infirm or aged more than 80 when three groups of drugs have been tried and either not tolerated, are contraindicated, or failed to control blood pressure

vi Consider referral of patients if control fails to meet audit target by more than 10/5

vii Betablocker contraindications include asthma, chronic obstructive pulmonary disease, heart block and the use of diltiazem

viii Record the standing BP as the sitting BP if the patient has a postural drop of more than 20mmHg

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