Blood pressure monitoring in community pharmacy

Abstract

Ambulatory blood pressure monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour blood pressure (BP). ABPM complements home BP monitoring (HBPM) by assessing white coat hypertension, diagnosing masked hypertension, and providing information on nighttime dip and morning surge. The aims of the research were to identify pharmacist-led contributions in patient empowerment of BP self-monitoring and the application of ABPM in community pharmacies. The objectives were to: 1) Appraise HBPM and ABPM devices, 2) Propose pharmacist interventions supporting patient empowerment of BP self-monitoring, 3) Assess feasibility of introducing ABPM in community pharmacies. In phase 1, HBPM and ABPM devices available on the market were appraised in terms of cost, technical specifications and accessibility. In phase 2, a data collection sheet to assess practice of BP patient self-monitoring and an action plan to facilitate patient empowerment were developed and validated. The data collection sheet and action plan were implemented by means of an interview to 120 participants on antihypertensive therapy recruited from 4 community pharmacies by convenience sampling. In phase 3, 10 patients satisfying the inclusion criteria (newly diagnosed with hypertension, recent change in medication and/or dose, or patient reported non-compliance to hypertension management), were recruited by purposive sampling from phase 2 for 24-hour ABPM. The feasibility of introducing ABPM in community pharmacies was evaluated. For phase 1, 25 HBPM devices and 3 ABPM devices available locally were analysed and compared. For phase 2, 66 out of 120 participants claimed to own an automatic upper arm oscillometric HBPM device. For the participants who self-monitor BP (55%), ways to improve HPBM technique, frequency and follow up of BP results were identified by the researcher. For the participants who do not self-monitor (45%), benefits of HBPM and devices available were explained by the researcher. Out of the 66 participants who self-monitor, 30 participants were found to have elevated BP. Using the chi-square test, no statistical significance (p>0.05) was found between self-monitoring and BP reading. An action plan was devised for each participant by the researcher depending on the participant’s needs, mainly addressing monitoring frequency, BP reading results and the participant’s action towards home BP readings. For phase 3, GIMA® 24 hours ABPM + Pulse Rate Monitor was chosen based on cost and availability. Ten participants accepted and 10 refused since they believed ABPM would be burdensome (n=6) or felt embarrassed to be seen with the device (n=4). Successful 24-hour ABPM was achieved in 9 participants. Each appointment required 30-60 minutes of pharmacist’s time, led to a report which was used by the pharmacist to provide patient recommendations. Four patients were referred to their physician. Despite challenges related to sleep disturbance (n=2) and bruising (n=2), application of ABPM was well-accepted by the rest of the patients. Pharmacist-led ABPM service in community pharmacies in a collaborative care context is feasible and contributed to identifying patients requiring further assessment. The action plan developed addressed strategies applicable to patients defaulting HBPM. Pharmacists must prioritise those patients with uncontrolled BP despite self-monitoring, identifying reasons and ways to improve HBPM.