Making the most of practice nurses
Dr John Wood explains how his practice follows both the British Hypertension Society and NICE guidelines while also achieving maximum quality points
While the debate about the BHS and NICE hypertension guidelines continues, our practice felt the need to reach a consensus approach to managing hypertension. We also wanted a stronger role for the practice nurses in monitoring hypertension, but this was being hindered by an out-of-date protocol.
To develop a new protocol we had to try to understand the differences and similarities between the new guidelines and GMS. The main points are summarised in table 1.
This review identified a major problem. Mild hypertension (grade 1) is now defined as a BP persistently between 140/90 and 160/100.
Both BHS1 and NICE2 guidelines say antihypertensive therapy is not needed in this group if they are not diabetic and have a low cardiovascular (CVD) risk. Therefore the GMS quality and outcomes target BP of <150 0="" is="" inappropriate="" for="" this="">150>
We could be managing mild hypertension perfectly and still lose points.
What we did
The GMS hypertension register is defined as 'established hypertension'. For our new protocol this has been interpreted as 'treated hypertension'.
The low-risk mild hypertension group are now EMIS Read-coded as 'Raised blood pressure' (R1y2) and are also monitored using the latest guidelines. They are therefore excluded from QOF, yet still receive best care. Our three protocols are outlined on page 58.
Both BHS and NICE guidelines promote
10-year CVD risk assessment as a tool for communicating risk to patients and as an aid to clinical decisions (table 2), a move away from the narrower assessment of only CHD risk. So we have incorporated CVD risk in the annual review as suggested by step 12 of the NICE guideline.
We feel the review of CVD risk does not need annual blood tests. This remains a clinical decision that depends on the GP and the patient. As a general rule we plan to screen lipids, glucose and renal function every three years in our uncomplicated hypertensive patients.
This emphasis on providing information and lifestyle advice reflects the NICE guidance. We found the best source of written information for patients is the Mentor PILS Leaflet L89 'Hypertension' accessed from EMIS, especially if the Mentor library is kept updated.
What we achieved as a result
This protocol has been designed to help practice nurses diagnose and monitor raised BP and treat hypertension. The choice of treatment remains a decision for the GP and patient, and the nurses have the freedom to refer to the GP at any time. It meets all the current targets and follows the latest guidelines. It maximises both patient care and QOF points. Undoubtedly the goal posts will change in the future and the protocol will need to be revised, but it is a model that works for us.
I find it is useful to be able to place the guidelines into perspective. The latest CVD risk charts and hypertension guidelines say they are purely guidance. There are many other factors that skew CVD risk, and it makes sense that those with the highest BP and highest cholesterol would benefit the most from treatment.
A recent practice audit identified 440 patients with a current or previous record of 'hypertension' who did not have diabetes or CVD and were not on a statin. The much- quoted ASCOT-LLA3 trial headlined a 36 per cent reduction of coronary events in hypertension when on a statin. The original paper quantifies this as an absolute risk reduction of 3.4 per 1,000 patient years with no significant difference in overall mortality. This translates to a 'numbers needed to treat' of 294 a year. Applying these figures to our 440 patients, if they were all prescribed a statin, only 1.5 coronary events would be prevented each year and no lives would be saved.
While CVD risk assessment is a useful tool for communicating advice to patients, it would appear there is a need to improve the understanding and communication of 'risk' within the profession.
John Wood is a GP registrar in Lancaster
·Control weight (BMI 20-25)
·5 portions fruit/veg daily
·Reduced salt intake
·Reduced fat intake
·Moderate caffeine and alcohol intake
(M Ã21 u/wk, F Ã14 u/wk)
·Urine protein, blood
-fasting lipid profile
1 Williams B et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004; 328: 634-640
2 NICE Clinical Guideline 18. Essential hypertension: managing adult patients in primary care. August 2004. ISBN: 0-9540161-6-5 http://www.nice.org.uk/pdf/CG018fullguideline.pdf
3 Sever PS et al. ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): A multicentre randomised controlled trial. Lancet 2003; 361: 1149-1158