Hypertension Case-Finding Service reminder (#4): ABPM

This is the fourth of a series of articles to help pharmacy owners and their teams to maximise the potential of the Hypertension Case-finding Service (HCFS).

The re-launch of the service, including the ability to use the wider pharmacy team to provide parts of the service, allows pharmacy owners to review how they provide the service and this series of articles will focus on a range of topics to support you in doing that.

The service has two stages – the first is identifying people at risk of hypertension and offering them a blood pressure measurement (a ‘clinic check’).

The second stage, where clinically indicated, is offering ambulatory blood pressure monitoring (ABPM). The blood pressure test results are then shared with the patient’s general practice to inform a potential diagnosis of hypertension.

As a result, the service specification requires that pharmacy owners must have both a blood pressure monitor and an ABPM device to be able to offer both parts of the service.

Why is it important to have an ABPM device?

ABPM is seen as the gold standard for diagnosing hypertension[1]. Use of ABPM[2]:

• Provides more measurements than a conventional blood pressure measurement[3];
• Allows the real blood pressure to be reflected more accurately by repeated measurements;
• Provides a profile of blood pressure away from the medical environment, thereby allowing identification of individuals with a white coat response[4]; and
• Shows blood pressure behaviour over a longer period of up to 24 hours rather than giving a snapshot of blood pressure.

ABPM can also assist general practice colleagues in further investigating and supporting clinical management by:

• Demonstrating the efficacy of antihypertensive medication over a period of up to 24 hours;
• Identifying patients whose blood pressure does not reduce at night-time and who are probably at high risk; and
• Demonstrating a number of patterns of blood pressure behaviour that may be relevant to clinical management.

Financial considerations

Compared to clinic blood pressure meters, ABPM devices are expensive. The incentive fees that were negotiated as part of the service were intended to help pharmacy owners to fund the capital cost of purchasing a suitable clinic blood pressure meter and an ABPM. The incentive came to an end at the end of March 2024.

To fulfil the service requirements, pharmacy owners may also want to consider the economics involved regarding outright purchase of ABPMs versus the option of renting equipment.

Beyond the considerations for pharmacy owners when initially selecting what equipment to buy to be able to provide the service, the service presents a new challenge; how do you protect an expensive piece of equipment that will be regularly loaned out by the pharmacy but forms a vital part of provision of the case-finding aspect of the HCFS?

In order to best protect an ABPM device, pharmacy owners will need to consider:

• How best to ensure the device is returned to the pharmacy promptly;
• How to cover the cost of damage or loss of equipment;
• Ongoing costs of calibration, servicing and any ancillary items; and
• How to ensure, where a device eventually needs to be replaced, it is affordable to do so.

What options are there to assist?

Loan agreement – A template loan agreement, which can be found at cpe.org.uk/hypertension, is available to assist pharmacy owners to highlight and explain to patients the terms associated with the loan of the ABPM and their responsibilities for caring for the equipment while using it. Such agreements are fairly common practice where NHS equipment is being loaned to patients.

Insurance – Pharmacy owners are encouraged to explore their insurance cover options with their existing insurance providers, trade organisations and other insurance providers, to ensure they have considered how best to protect their ABPM device.

Service/repair/calibration plans and loan equipment – Scoping providers and planning these arrangements in advance, may support reducing both long term costs and the time involved in arranging maintenance of ABPM devices when needed.

What other frequently asked questions (FAQ) have there been regarding ABPMs?

A range of FAQs, including questions raised by pharmacy owners about ABPMs and some of the considerations, can be found at cpe.org.uk/hypertension.

[1] Kario K, et al. Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network – PMC (nih.gov) J Clin Hypertens (Greenwich). 2021 Mar;23(3):411-421.

[2] O’Brien E. Ambulatory blood pressure monitoring in the management of hypertension – PMC (nih.gov). Heart. 2003 May;89(5):571-6.

[3] Staessen JA, et al. Modern approaches to blood pressure measurement – PMC (nih.gov). Occup Environ Med 2000;57:510–20.

[4]  Owens P, Atkins N, O’Brien E. Diagnosis of white coat hypertension by ambulatory blood pressure monitoring – PubMed (nih.gov). Hypertension 1999;34:267–72.