The role of community pharmacists in the management of hypertension

Background and aim
The rising workload in primary care and the declining general practitioner (GP) workforce has meant that new models of care to effectively manage long-term conditions, such as hypertension, are needed. Hypertension affects a third of adults in the UK and is the leading risk factor for cardiovascular events globally. Evidence from randomised controlled trials (RCTs) has shown that community pharmacist-led interventions significantly lower blood pressure (BP) over usual GP care. Despite this evidence, community pharmacists do not currently deliver hypertension management services.
This thesis investigated the extent to which the interventions from previous RCTs of community pharmacist-led hypertension management are translatable to current pharmacy practice in England.
Methods
The Consolidated Framework for Implementation Research (CFIR) was the theorectical framework used to direct the thesis. A mixed methods approach was used to address the thesis aim. First, semi-structured interviews were conducted with pharmacists to explore their views and experiences of delivering hypertension related care. Next, a systematic review and meta-analysis aimed to understand how pharmacy-measured BP compared to other BP measurement modalities. A qualitative analysis of 1,200 consultation notes was then conducted to understand the content of consultations between pharmacists and hypertensive patients in current practice. Finally, a multivariable logistic regression was undertaken on a 2 dataset of over 131,000 hypertensive ‘new medicine service’ (NMS) consultations to identify predictors for referral of hypertensive patients from pharmacies back to general practice.
Results
The interviews in Chapter 2 found that pharmacists prioritised services that provide financial remuneration over offering unfunded BP testing or monitoring. Participants outlined factors to consider before implementing hypertension services in pharmacies such as communication with GPs and access to patient clinical records. The systematic review (Chapter 3) suggested that using the 135/85 mmHg threshold for hypertension, rather than 140/90 mmHg, may be most appropriate for the community pharmacy setting due to the close association with daytime ambulatory BP readings. Analysis of routine pharmacy data found that the content of consultations closely resembled the interventions described in the RCTs of community pharmacist-led hypertension management (Chapter 4), and showed that pharmacists referred back 4% of patients to a GP during the first two weeks of new anti-hypertensive therapy (Chapter 5). Overall, this thesis has identified that the interventions themselves are unlikely to be the barrier to hypertension service implementation at present.
Conclusion
The following recommendations to pharmacists and health service commissioners in relation to implementing future hypertension management services in community pharmacies can be made, based on the findings of this thesis:
1. Pharmacists require the reassurance of having local or national-level endorsement before delivering additional hypertension services. Ideally, this 3 should also include a funding stream to enable the redistribution of their other workload to other members of staff (Chapter 2).
2. Interpret pharmacy measured BP using the 135/85mmHg threshold and confirm pharmacy readings with home BP before making treatment or referral decisions if necessary (Chapter 3).
3. Further training for pharmacists to conduct hypertension management may not be required as pharmacists currently provide evidence-based advice related to hypertension management (Chapter 4).
4. A model of intervention that avoids referral back to a GP for final approval should be considered to minimise a GP’s workload (Chapters 2 and 5). Alternatives could include referring to a general practice pharmacist or allowing community pharmacists to manage patients themselves through an agreed PGD if they do not possess the permissions to prescribe.

Advisor: McManus, R
Sheppard, J
Prinjha, S