Clinical Posters 421 – 426
421 Hypertension can be more confusing than we think
Hypertension can be more confusing than we think Case: A 58 year old keen cyclist attended A&E perplexed as he was unable to find his way around his usual cycle route. His family had been concerned for 3 days as he was confused and unusually fatigued. On examination his AMT was 3/10, examination was otherwise unremarkable except his blood pressure which was 249/141. He was previously diagnosed with hypertension and stopped taking his anti-hypertensives without medical advice three years earlier. MRI brain revealed an acute thalamic infarct with background changes in-keeping with chronic hypertensive damage. He was diagnosed with a stroke secondary to malignant hypertension. Despite successfully controlling his blood pressure he remains cognitively impaired.
Relevance Hypertension is primarily diagnosed and managed in general practice. This case demonstrates that uncontrolled hypertension can have devastating acute consequences as well as chronic end organ damage.
Discussion Many of our younger patients rarely attend the GP. We should use these infrequent encounters as opportunities to provide health promotion.When diagnosing patients with hypertension it is key that patients understand why treating hypertension is important. Often younger patients are reluctant to accept that they have a chronic health condition as they feel well. Compliance with medications and annual reviews can be poor.This young patient has developed a severe consequence of poorly controlled hypertension which sadly will have a significant impact on himself and his family. We hope that this case will reinforce the significance of patient education in those with hypertension.
422 Clinical pharmacists in general practice
Aims This 6-month project aimed to demonstrate that expanding the General Practice workforce, to include clinical pharmacists, can reduce pressure on GP appointments and improve management of patients with specific long term conditions and those on specific and multiple medications.
Relevance Increasing demands on general practice have led to a feeling of crisis. Recruitment of GPs to posts in rural GP practices is becoming increasingly challenging. Clinical pharmacists in GP practices, working closely with the practice team, means GPs can focus their skills where they are most needed.
Content A team of 14 pharmacists (8 whole time equivalents) worked across 20 practices, providing a range of support. Evaluation of the project has, in partnership with an academic team from a regional university’s school of medicine, pharmacy and health, aimed to assess the level of integration of the pharmacists with the GP practice workforce, in addition to the quality, volume and cost impact of their work.
Outcomes Pharmacists delivered 8400 medicines reviews, resulting in over 3000 individual medicines changes. The pharmacists also undertook nearly 8000 tasks, assigned to them by other staff. At the time of writing, the evaluation work is still not complete, though we expect to show significant benefit based on data received and an earlier small-scale pilot project.
Discussion The local CCG have already commissioned an enhanced service to maintain clinical pharmacist support for the remainder of this year: recognition of the potential improvement to patient care, reduction in GP workload and overall costs savings that are possible by utilising the skills of clinical pharmacists in general practice.
423 Physiotherapists in general practice
Aims Increasing demands on general practice have led to a feeling of crisis. This pilot scheme, as part of a larger programme of transformative work, aimed to address the increasing and changing patient demand for access to primary care. Based on the learnings from pilot projects in West Yorkshire and Cumbria, it aimed to reduce the pressure on GPs by offering patients direct access to physiotherapists working in their practice and able to offer assessment, initial treatment and advice. The aim was also to reduce the number of inappropriate referrals to secondary care, by offering easy and rapid access to this specialist support.
Content 6 GP practices were involved and the physiotherapists, working under the title of MSK Practitioner, offered between 11 and 15 hours of clinic time per practice and received referrals either directly, via receptionists, or following a GP consultation.
Relevance Direct access to practice-based physiotherapists could reduce pressure on GPs and offer a high quality service for patients.
Outcomes A total of 1554 patients were seen over this relatively short pilot project. 36% of patients seen by the service were discharged at first visit with advice only. The remainder were either treated and subsequently discharged after 1-2 follow-up consultations, referred for ongoing community physiotherapy or further investigation as appropriate. Only 2.7% were referred onto community physiotherapy and 1.4% referred back to a GP. Feedback from practices has been positive and patients rated the service highly, with overall patient satisfaction scores of 98%.
Discussion This project adds further weight to the argument for diversifying the general practice workforce to release pressure on GPs.
424 A review into preventing strokes in patients with atrial fibrillation across 1028 GP surgeries resulting in 886 strokes prevented and cost savings of £22m
Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting more than one million people in the UK. Patients with AF are five times more likely to have a stroke, and when a stroke is related to AF there are increased levels of mortality, morbidity, disability, and longer hospital stays. Around 7,000 strokes and 2,000 deaths could be prevented every year through effective detection of AF and protection with the right anticoagulant drugs.
The aim of this clinical assessment was to review AF patients to improve outcomes in stroke and VTE. 1,028 GP practices were reviewed for patients with AF, or clinical markers for AF. The 135,203 identified patients were then assessed using the CHA2DS2-VASc scoring system, and 125,782 were found to be in the moderate and high risk categories. These patients were assessed for current stroke prevention therapy.
The assessment procedure divided the patients into two groups, those already on oral anticoagulation therapy, 89,455, and those who were not, 36,327, to be clinically assessed in line with NICE clinical guidelines, QOF criteria, and practice specifications. Patients identified as requiring an intervention were alerted, and made the decision on their best treatment option after a consultation with their GP.
This review resulted in 28,721 direct patient interventions. It is estimated that this review prevented 886 strokes through effective stroke prevention methods, as well as saving the NHS £22 million in averted strokes. Due to the success of this review, the programme is currently being expanded to more GP practices.
425 What are the barriers to effective recognition and management of anxiety disorders in primary care? General practitioners’ own perspectives
Aims It is not clear how GPs conceptualise and manage anxiety disorders. The under diagnosis and under treatment of anxiety has significant implications for patients and health service providers. We aim to investigate what barriers exist to effective recognition and treatment of anxiety in general practice.
Content A qualitative thematic analysis was undertaken with interview data collected from 17 NHS GPs. Semi-structured interviews used vignettes to explore how GPs conceptualise anxiety, manage patients and barriers to this process.
Relevance/Impact There is a lack of research into what influences GP diagnosis and management of anxiety disorders. Unlike depression, which has been more studied has financial incentives through QOF, there is no standardised way to diagnose or manage anxiety disorders. As such, the best standards of clinical care are not always accessible to patients.
Outcomes Conceptual understanding of anxiety; Diagnostic uncertainty, particularly with regard to specific disorders (PTSD)-DSM-5/ICD-10 criteria unknown or not perceived as useful; Stigma – Diagnoses seen by some patients as stigmatising; GPs cautious to record diagnoses as may be stigmatising in future; Practice specific pressures – High referral threshold to psychiatry and variable access to psychological therapies – Time pressures.
Discussion Numerous factors influence GPs in their diagnoses of anxiety including diagnostic uncertainty, questioning the validity of an anxiety state, and a desire not to stigmatise and ‘label’ patients. Barriers to management include pressures on resources and lack of standardised care pathways. Tackling these issues is an imperative given the burden of anxiety disorders on patients’ wellbeing and the NHS.
426 Is low HbA1c associated with hypoglycaemia in intensively treated type 2 diabetes? A retrospective cohort study in primary care
Background There is concern that in some adults with type 2 diabetes, treatment with intensive glucose-lowering therapy may increase mortality, hospitalisation and morbidity. The aim of our study is to establish whether lower HbA1c levels among those prescribed insulin or sulphonylureas are associated with higher rates of clinically-recorded hypoglycaemia.
Method Using electronic general practice health record data (EMIS Web), we undertook a retrospective cohort study between 1st January 2013 and 31st December 2015. A total of 20,292 adults with type 2 diabetes registered with GP practices in three east London CCGs were included in the study. They were divided into two cohorts: those prescribed insulin +/- oral antidiabetic medication (n=7,389) and those on sulphonylureas without insulin (n=12,903) at baseline.
The primary outcome was the first clinical recording of hypoglycaemia or blood glucose less than 4 mmol/L. Secondary outcomes were all-cause mortality, first recorded fall or fracture. ResultsUsing proportional cox regression modelling, the adjusted hazard ratio (HR) of hypoglycaemia in those with low HbA1c (<53mmol/mol) compared with HbA1c 53-74mmol/mol was 1.32 (95% C.I. 1.08 to 1.60), adjusting for age, gender, sex, ethnicity, renal function, comorbidity and body mass index. The adjusted HR for all-cause mortality in those with low HbA1c was 1.32 (95% CI 1.14 to 1.53). No significant association between HbA1c and falls or fractures was found.
Conclusions In those with type 2 diabetes prescribed insulins or sulphonylureas, HbA1c levels below 53 mmol/mol appear to be associated with a greater risk of hypoglycaemia as well as mortality. These findings bolster the case for less stringent HbA1c targets in patients prescribed intensive glucose-lowering therapy in order to prevent excess morbidity and mortality.