Opportunistic Screening for Atrial Fibrillation and Hypertension in a South London Community Pharmacy

Abstract

1.1 Background and Aim: Hypertension is the second biggest cause of disability and death in England, due to complications such as heart failure, myocardial infarction, chronic kidney disease and stroke. Complications related to hypertension are costing the National Health System (NHS) over 2 billion every year. Additionally, a quarter of adults, nearly five million people, in England have high blood pressure without even knowing it as hypertension is not symptomatic. Prevalence of hypertension is not gender related but will increase by age ⁽¹⁾. Atrial fibrillation (AF) is a progressive and common medical condition associated with high rates of morbidity and mortality. Moreover, hypertension and ageing are two main risk factors for AF which may lead to complication such as heart failure and stroke ⁽⁷⁾. AF is present in 5% of people who are 65 years and nearly in 10% of people who are 80 years. It has also been estimated that around 2.5 million people in the United States and 4.5 million people in the European Union are suffering from AF ⁽⁸⁾. Complications of AF are costing NHS over 2.8 billion every year ⁽⁹⁾ so early diagnosis and treatment is more health/cost effective for the patients and the NHS. Additionally, community pharmacies have great potential for opportunistic screening of hypertension or AF due to wide accessibility and the large number of aged people who visit the pharmacy on a regular basis ⁽⁹⁾. The mission of the AF/hypertension screening in community pharmacies is not only to improve quality of services but also reduce NHS costs, demand on General Practitioner (GP) appointments and Accident and Emergency (A&E) attendances ⁽¹⁾. The focus of this study is firstly, to test the feasibility and applicability of combined AF and hypertension screening in a community pharmacy in south London. Secondly, to identify potential pharmacist training and knowledge related barriers to delivery of such a service and finally, to estimate the prevalence of undiagnosed AF/undertreated/unrecognised hypertension.

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1.2 Methods: An AF opportunistic screening service in community pharmacy was operated from 15th of March 2018 for approximately two weeks in Tooting area. The main operating procedures for AF/hypertension screening are: client engagement, blood pressure measurement, ECG monitoring, home blood pressure measurement, interpretation of results and questionnaires collection from both pharmacists and patients.

1.3 Results: Regarding on pharmacist survey, 40 questionnaires were distributed to the community pharmacies. 14 surveys had been collected. The respond rate was 32%. Regarding on patient AF/hypertension screening, 66 people with average age of 55 years were approached in a community pharmacy. 4 people had offered HBPM and 34 people had AF/hypertension screening.  The average time spent in each patient was 15 minutes. In addition to this, the response rate for BP measurement was 100% while the response rate for ECG was 52%. The average age of patient was 55 years.

1.4 Conclusions and implications

According to the achieved results from 34 screening; 6 high blood pressures and a possible AF was detected so the average % was calculated to be 10%. The achieved results proved that community pharmacies are not feasible for AF/hypertension screening. The average % of barrier was also calculated to be 16%. The main barrier was identified to be fee for service. The prevalence of AF and hypertension was calculated 3% and 17%.  The participants average age was calculated to be 55 years and the average time was calculated in each patient was 15 minutes.

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 Keywords

Atrial fibrillation, Hypertension, Cardiovascular, Blood Pressure, Stroke, Electrocardiogram,

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Opportunistic screening for atrial fibrillation and hypertension in a south London community pharmacy

List of Abbreviations

AF: Atrial Fibrillation

BP: Blood Pressure

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NICE: National Institute for Health and Care Excellence

BPU: Blood Pressure Unit

UK: United Kingdom

GP: General Practitioner

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HBPM: Home Blood Pressure Monitoring

ECG: Electrocardiogram

CE: Conformité Européene

NHS: National Health System

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PHE: Public Health England

MUR: Medicines Use Review

A&E: Accident and Emergency

CCGs: Clinical Commissioning Groups

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PURE: Prospective Urban Rural Epidemiology

HIC: High-Income-Countries

UMIC: Upper-Middle-Income-Countries

LIC: Low-Income-Countries

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Contents

1.0 Introduction ……………………………………………………………………………………… 6

1.1 Hypertension is a common and often silent cardiovascular risk factor …………………….. 6

1.2 Incidence of hypertension in the UK and South London ……………………………………… 6

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1.3 Hypertension is underdiagnosed and undertreated ………………………………………… 6

1.4 Hypertension screening in community pharmacy …………………………………….….…. 7

1.5 Atrial Fibrillation (AF) is an important risk factor for ischaemic stroke ………………….… 9

1.6 Incidence of AF in the community ………………………………………………………….… 9

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1.7 AF is underdiagnosed and undertreated …………………………………………………… 10

1.8 Combined Atrial fibrillation/hypertension and screening related services in community pharmacies ………………………………………………………………………………………… 10

1.9 Devices for AF and hypertension screening in primary care ……………………….……. 11

1.10 Aim and objectives …………………………………………………………………..……… 11

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2.0 Methodology ……………………………………………………………………………………. 11

2.1 Study setting …………………………………………………………………………………… 12

2.2 Calculating sample size ………………………………………………………………………. 12

2.3 Design the questionnaire …………………………………………………………………..… 13

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2.4 Ethical approval ………………………………………………………………………….……. 13

2.5 How patients will be enlisted and what they will undergo as part of the study …………. 13

2.6 Data collection …………………………………………………………………………………. 15

2.7 Data analysis ………………………………………………………………………….………. 15

2.8 Data storage and handling …………………………………………………………………… 16

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3.0 Results …………………………………………………………………………………………. 16

3.1 Pharmacist’s response rate ……………………………………………………………..…… 17

3.2 Pharmacist’s demographics …………………………………………………………………. 17

3.3 Perception ……………………………………………………………………………………… 18

3.4 Patient’s response rate ………………………………………………………………………. 21

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3.5 Patient’s demographics ………………………………………………………………………. 22

3.6 Blood pressure measurement results ……………………………………………………… 23

3.7 ECG monitoring results ………………………………………………………………………. 23

3.8 Overall knowledge & correlating factors …………………………………………….……… 25

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4.0 discussion and conclusion

4.1 discussion

4.2 conclusion

4.3 practice implications

5. References

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Appendix 1

Opportunistic screening for atrial fibrillation and hypertension in a south London community pharmacy

1.0 Introduction

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1.1 Hypertension is a common and often silent cardiovascular risk factor

Hypertension is the second biggest cause of disability and death in England, due to complications such as heart failure, myocardial infarction, chronic kidney disease and stroke. Complications related to hypertension are costing the National Health System (NHS) over 2 billion every year. Additionally, a quarter of adults, nearly five million people, in England have high blood pressure without even knowing it as hypertension is not symptomatic. Prevalence of hypertension is not gender related but will increase by age ⁽¹⁾.

1.2 Incidence of hypertension in the UK and South London

Globally, hypertension is the second biggest risk factor for disease after poor diet, while in the UK high blood pressure is the third biggest risk factor for disease after tobacco smoking and poor diet. It also has been reported by Global Burden of Disease that prevalence of high blood pressure for adults in England is 31% for men and 26% for women ⁽²⁾.

The Cohort study in the UK Clinical Practice was designed to estimate incident of hypertension in primary care between 1995 to 2015. To start this study 1,317,290 patients who use antihypertensive drugs were recruited. The participants were current users of three hypertensive drugs including a diuretic. The outcome of this study proves a nonlinear increase from 1.75 prevalence cases to 6.56 cases per 100 participants between 1995 to 2015. This study also demonstrated a 1.43 time rise in comparing prevalence between people who are 80 years or over and those who are between 65-69 ⁽³⁾.

According to the NHS Wandsworth Clinical Commissioning Groups (CCGs) the prevalence of hypertension, stroke and transient ischaemic attacks in 2015 was reported 8.5%. the NHS CCGs in 2011 also reported that the prevalence of AF was 0.7% in the Wandsworth area ⁽⁴⁾.

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1.3 Hypertension is underdiagnosed and undertreated

Regarding on hypertension prevalence, awareness, treatment and control a study was set by Prospective Urban Rural Epidemiology (PURE). 142,042 adults aged 35 to 70 years from different communities and countries including 3 High-Income-Countries (HIC), 10 Upper-Middle-Income-Countries (UMIC) and 4 Low-Income-Countries were participating in this

study. Hypertension prevalence in this study was defined by using an automated digital device for blood pressure measurements when the average of two readings were over 140/90 mmHg while control of hypertension was defined when the blood pressure was lower than 140/90 mmHg. Awareness was also defined based on individual’s self-reports while treatment was defined base on regular use of antihypertensive drugs. The outcome of this study shows 57,840 participants had hypertension while 26,877 were aware of being hypertension. Most of these participants were receiving antihypertensive drugs but the hypertension in minority were controlled. Table 1.1 shows the outcome of this study.