P61
24HOUR AMBULATORY BLOOD PRESSURE MONITORING: ACCEPTED GOLD
STANDARD BY NICE, NOT NECESSARILY ACCEPTED BY PATIENTS
RESULTS FROM A TRUST-WIDE INITIATIVE
Kung T, Ahmed S, Rooks K, Moore I
Renal Unit, City Hospitals Sunderland
Introduction
Uncontrolled hypertension increases the risks of stroke, renal disease, cardiovascular disease
and other complications. The National Institute for Health and Care Excellence (NICE)
recommends the use of ambulatory blood pressure monitoring (ABPM) to reduce
inappropriate diagnosis of uncontrolled hypertension, treatment costs and side effects from
unnecessary medication. In our Trust, most primary care referrals with hypertension arrive
through renal services.
We have recently implemented a Trust-wide referral system and online request form for
ABPM to investigate patients with suspected uncontrolled hypertension. The previous referral
system was referral letter or email-based. The new protocol for referral is available on our
intranet. We operate a nurse-led ABPM clinic in our Renal Ambulatory Care department.
Method
We performed a retrospective data collection of ABPM referrals from 1st Jul 2013 to 30th Sep
2013. The patient demographics, waiting time, quality of blood pressure monitoring, blood
pressure control and antihypertensive use were audited against the NICE guideline CG127.
Results
A total of 97 referrals were made for ABPM during the 3-month period. Forty-one patients
were female and 54 were male. Sixty-nine (71%) attended their appointments and 28 (29%)
failed to attend. Median waiting time from referral to monitoring was 34 days, generally
shorter if the new system was used (mean 35 days vs 60).
Mean monitoring time was 22 hours and on average 80.5% of measurements were successful
(29 readings required in order to achieve 80% success). Ninety-nine percent of patients had
more than 14 readings as recommended by NICE. Adequate systolic BP control was achieved
in 35/69 patients, of which 31/35 patients had adequate systolic and diastolic control.
Renal physicians (67% referrals) were more likely to use the new referral system than
physicians from other specialties. Detailed medication history was available in 90/97 (93%)
patients. BP management in 60/90 (66%) followed the A(B)CD protocol suggested by NICE.
This was more likely in those referred by non-renal physicians.
Conclusions
Our new referral system reduces ABPM referral processing and waiting time but is underused
outside the renal unit. More needs to be done to improve access to ABPM in our Trust.
We have found a high rate of missed appointments (DNAs) in our study. More work needs to
be done to clarify why this is the case. Some patients have suggested their physician had not
consented them fully to the 24hour test, which many people find inconvenient, if not
unacceptable; therefore an appointment had been wasted. A leaflet has been produced to
ensure the patient is fully informed in advance of their appointment.
Clinic timing is an issue with our patients’ current shift-working patterns and, realistically, we
need to be more flexible with ABPM clinic times. A patient questionnaire is being prepared
so we can revise our service.