Authors (including presenting author) :
Hui LC(1), Chen XRC(1), Leung SH(1), Li YC(1)
Affiliation :
(1)Department of Family Medicine and GOPC, Kowloon Central Cluster (KCC)
Introduction :
Hypertension (HT) is the most common chronic disease managed in the primary care. Severe hypertension (SHT) is defined as severely elevated blood pressure (BP) of 180 mm Hg or more systolic, or 110 mm Hg or more diastolic. Acute SHT accompanied by acute target-organ injury (hypertensive emergency) requires immediate treatment, whereas asymptomatic SHT patients often have preexisting poorly controlled HT and usually can be managed in the outpatient setting. Inappropriate referral of patients with asymptomatic SHT to emergency hospital may impose unnecessary burdens on the health care system. A series of comprehensive strategies to manage patient with SHT would enhance the clinical safety among SHT patients in our community and reduce burdens in emergency care.
Objectives :
1)To implement community interventions in management of patient with severe SHT 2)To evaluate the clinical outcomes of patients with SHT after implementation of interventions
Methodology :
From year 2017, different interventions were implemented to enhance clinical safety among patients with SHT managed in GOPCs in KCC, they are: 1)Departmental wide promulgations with series of educational meetings on hypertensive management to all front-line doctors, regular audit on proper BP measurement technique among supporting staff and standardized protocol on home BP machine validation. 2)Clinical guideline update: Guideline for managing patients with hypertension was updated in 2019. Doctors should attend patient who have SHT with symptoms of central nervous system with priority. Patient who were suspected to have hypertensive emergency should be referred to emergency department. Asymptomatic SHT patient should be managed according to clinical guideline and follow-up should be provided within two weeks. 3)Data-driven approach in hypertensive risk monitoring: list of SHT patients were sent to clinic in charge of individual clinics regularly for review of patients’ clinical conditions. SHT patients who had been regularly followed up in 6 GOPCs of KCC from 1st Apr 2018 to 31st Mar 2019 were retrieved from the CDARS. Electronic medical records of patients in CMS were reviewed. Outcome measures included referral rate to emergency department, time interval of follow-up, changes to antihypertensive drug treatment, BP control and cardiovascular events including stroke, myocardial infarction and cardiovascular death.
Result & Outcome :
Totally 182 patients with SHT were managed in 6 GOPCs of KCC during the study period. Their average age was 61.8 (±14.1) years old and the proportion of male (51.1%) and female patients (48.9%) were similar. Among them, only 13 patients (7.1%) were referred to emergency department in hospitals and most of them (144 patients, 79.1%) had a follow-up visit at GOPC within 2 weeks.108 patients (59.3%) had medication augmentation by either increasing the dose of antihypertensive or addition of new antihypertensive drugs. Among the 74 patients (40.7%) with no medication changes, 55 patients (75.6%) were diagnosed with white-coat hypertension (WCH) by 24-hour ambulatory BP monitoring (ABPM). Overall, 84 patients (45.9%) achieved a normotensive BP (< 140/90 mm Hg) within 6 months follow-up. For SHT patients who were followed up in GOPCs, none of them had documented cardiovascular events within a 6 months follow-up. In conclusion, with the implementation of comprehensive strategies via a team-based approach, SHT patients could be managed safely in the primary care setting and hence reduce the burden to the hospital.
