Three months ago, the National Institute for Health and Clinical Excellence (NICE) in the UK released new guidelines for managing hypertension in adults. The new recommendations call for the use of Ambulatory Blood Pressure Monitoring (ABPM) to confirm a diagnosis of hypertension when a patient has a clinic BP reading of 140/90 mmHg or above. One of the major questions raised was how this would be implemented.
In an article in the Irish Medical Times, Professor Eoin O’Brien (Professor of Molecular Pharmacology, Conway Institute, University College Dublin) commented that implementing the new guidelines would “mean in effect that some 13 million patients with high BP in the UK, will have to be offered ABPM not only to confirm the diagnosis, but also for the follow-up assessment of treatment efficacy”. Currently, many are speculating that the availability of ABPM in the UK does not support this level of use. Prof. O’Brien also goes on to state that “the problems recognized by NICE are the training of healthcare professionals [and] the provision of sufficient numbers of validated ABPM devices”. In a video interview discussing the NICE guidelines Dr. Rajiv Agarwal (Professor of Medicine, Division of Nephrology at Indiana University) echoed the concern that ABPM may not be widely available and also goes further to state that ABPM may not be applicable in all cases.
So what is the solution? Prof. O’Brien addresses the availability issue by suggesting that provision of ABPM should be moved to pharmacies. He further notes that this adoption of ABPM by pharmacies has begun in Ireland. Among the benefits listed out by Prof. O’Brien is the creation of broader access to ABPM for more people and patient awareness and involvement in the control of their BP. On the other hand, Dr. Agarwal advocates for use of home BP monitoring in addition to ABPM. He states, “I like Tom Pickering's recommendations on this. He recommends that if you are newly diagnosed with hypertension that you perform home blood pressure monitoring. [The average BP level observed with home BP will determine the next step in the treatment process.] Using a stepped care approach might actually minimize costs and make it more broadly applicable.”
The final outcome will take time to manifest, but the current ongoing discussion of the new guidelines shows that they are relevant and that the need for improved diagnosis and management of hypertension exists. Prof. O’Brien and Dr. Agarwal’s proposed solutions for assuring successful implementation of the new NICE guidelines are just two of many other possible solutions. What would be your proposed implementation plan?