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Abstract
1.1 Background and Aim: Hypertension is the second biggest cause of disability and death in England, due to complications such as heart failure, myocardial infarction, chronic kidney disease and stroke. Complications related to hypertension are costing the National Health System (NHS) over 2 billion every year. Additionally, a quarter of adults, nearly five million people, in England have high blood pressure without even knowing it as hypertension is not symptomatic. Prevalence of hypertension is not gender related but will increase by age (1). Atrial fibrillation (AF) is a progressive and common medical condition associated with high rates of morbidity and mortality. Moreover, hypertension and ageing are two main risk factors for AF which may lead to complication such as heart failure and stroke (7). AF is present in 5% of people who are 65 years and nearly in 10% of people who are 80 years. It has also been estimated that around 2.5 million people in the United States and 4.5 million people in the European Union are suffering from AF (8). Complications of AF are costing NHS over 2.8 billion every year (9) so early diagnosis and treatment is more health/cost effective for the patients and the NHS. Additionally, community pharmacies have great potential for opportunistic screening of hypertension or AF due to wide accessibility and the large number of aged people who visit the pharmacy on a regular basis (9). The mission of the AF/hypertension screening in community pharmacies is not only to improve quality of services but also reduce NHS costs, demand on General Practitioner (GP) appointments and Accident and Emergency (A&E) attendances (1). The focus of this study is firstly, to test the feasibility and applicability of combined AF and hypertension screening in a community pharmacy in south London. Secondly, to identify potential pharmacist training and knowledge related barriers to delivery of such a service and finally, to estimate the prevalence of undiagnosed AF/undertreated/unrecognised hypertension.
1.2 Methods: An AF opportunistic screening service in community pharmacy was operated from 15th of March 2018 for approximately two weeks in Tooting area. The main operating procedures for AF/hypertension screening are: client engagement, blood pressure measurement, ECG monitoring, home blood pressure measurement, interpretation of results and questionnaires collection from both pharmacists and patients.
1.3 Results: Regarding on pharmacist survey, 40 questionnaires were distributed to the community pharmacies. 14 surveys had been collected. The respond rate was 32%. Regarding on patient AF/hypertension screening, 66 people with average age of 55 years were approached in a community pharmacy. 4 people had offered HBPM and 34 people had AF/hypertension screening. The average time spent in each patient was 15 minutes. In addition to this, the response rate for BP measurement was 100% while the response rate for ECG was 52%. The average age of patient was 55 years.
1.4 Conclusions and implications
According to the achieved results from 34 screening; 6 high blood pressures and a possible AF was detected so the average % was calculated to be 10%. The achieved results proved that community pharmacies are not feasible for AF/hypertension screening. The average % of barrier was also calculated to be 16%. The main barrier was identified to be fee for service. The prevalence of AF and hypertension was calculated 3% and 17%. The participants average age was calculated to be 55 years and the average time was calculated in each patient was 15 minutes.
Keywords
Atrial fibrillation, Hypertension, Cardiovascular, Blood Pressure, Stroke, Electrocardiogram,
Opportunistic screening for atrial fibrillation and hypertension in a south London community pharmacy
List of Abbreviations
AF: Atrial Fibrillation
BP: Blood Pressure
NICE: National Institute for Health and Care Excellence
BPU: Blood Pressure Unit
UK: United Kingdom
GP: General Practitioner
HBPM: Home Blood Pressure Monitoring
ECG: Electrocardiogram
CE: Conformité Européene
NHS: National Health System
PHE: Public Health England
MUR: Medicines Use Review
A&E: Accident and Emergency
CCGs: Clinical Commissioning Groups
PURE: Prospective Urban Rural Epidemiology
HIC: High-Income-Countries
UMIC: Upper-Middle-Income-Countries
LIC: Low-Income-Countries
Contents
1.0 Introduction ……………………………………………………………………………………… 6
1.1 Hypertension is a common and often silent cardiovascular risk factor …………………….. 6
1.2 Incidence of hypertension in the UK and South London ……………………………………… 6
1.3 Hypertension is underdiagnosed and undertreated ………………………………………… 6
1.4 Hypertension screening in community pharmacy …………………………………….….…. 7
1.5 Atrial Fibrillation (AF) is an important risk factor for ischaemic stroke ………………….… 9
1.6 Incidence of AF in the community ………………………………………………………….… 9
1.7 AF is underdiagnosed and undertreated …………………………………………………… 10
1.8 Combined Atrial fibrillation/hypertension and screening related services in community pharmacies ………………………………………………………………………………………… 10
1.9 Devices for AF and hypertension screening in primary care ……………………….……. 11
1.10 Aim and objectives …………………………………………………………………..……… 11
2.0 Methodology ……………………………………………………………………………………. 11
2.1 Study setting …………………………………………………………………………………… 12
2.2 Calculating sample size ………………………………………………………………………. 12
2.3 Design the questionnaire …………………………………………………………………..… 13
2.4 Ethical approval ………………………………………………………………………….……. 13
2.5 How patients will be enlisted and what they will undergo as part of the study …………. 13
2.6 Data collection …………………………………………………………………………………. 15
2.7 Data analysis ………………………………………………………………………….………. 15
2.8 Data storage and handling …………………………………………………………………… 16
3.0 Results …………………………………………………………………………………………. 16
3.1 Pharmacist’s response rate ……………………………………………………………..…… 17
3.2 Pharmacist’s demographics …………………………………………………………………. 17
3.3 Perception ……………………………………………………………………………………… 18
3.4 Patient’s response rate ………………………………………………………………………. 21
3.5 Patient’s demographics ………………………………………………………………………. 22
3.6 Blood pressure measurement results ……………………………………………………… 23
3.7 ECG monitoring results ………………………………………………………………………. 23
3.8 Overall knowledge & correlating factors …………………………………………….……… 25
4.0 discussion and conclusion
4.1 discussion
4.2 conclusion
4.3 practice implications
5. References
Appendix 1
Opportunistic screening for atrial fibrillation and hypertension in a south London community pharmacy
1.1 Hypertension is a common and often silent cardiovascular risk factor
Hypertension is the second biggest cause of disability and death in England, due to complications such as heart failure, myocardial infarction, chronic kidney disease and stroke. Complications related to hypertension are costing the National Health System (NHS) over 2 billion every year. Additionally, a quarter of adults, nearly five million people, in England have high blood pressure without even knowing it as hypertension is not symptomatic. Prevalence of hypertension is not gender related but will increase by age (1).
1.2 Incidence of hypertension in the UK and South London
Globally, hypertension is the second biggest risk factor for disease after poor diet, while in the UK high blood pressure is the third biggest risk factor for disease after tobacco smoking and poor diet. It also has been reported by Global Burden of Disease that prevalence of high blood pressure for adults in England is 31% for men and 26% for women (2).
The Cohort study in the UK Clinical Practice was designed to estimate incident of hypertension in primary care between 1995 to 2015. To start this study 1,317,290 patients who use antihypertensive drugs were recruited. The participants were current users of three hypertensive drugs including a diuretic. The outcome of this study proves a nonlinear increase from 1.75 prevalence cases to 6.56 cases per 100 participants between 1995 to 2015. This study also demonstrated a 1.43 time rise in comparing prevalence between people who are 80 years or over and those who are between 65-69 (3).
According to the NHS Wandsworth Clinical Commissioning Groups (CCGs) the prevalence of hypertension, stroke and transient ischaemic attacks in 2015 was reported 8.5%. the NHS CCGs in 2011 also reported that the prevalence of AF was 0.7% in the Wandsworth area (4).
1.3 Hypertension is underdiagnosed and undertreated
Regarding on hypertension prevalence, awareness, treatment and control a study was set by Prospective Urban Rural Epidemiology (PURE). 142,042 adults aged 35 to 70 years from different communities and countries including 3 High-Income-Countries (HIC), 10 Upper-Middle-Income-Countries (UMIC) and 4 Low-Income-Countries were participating in this
study. Hypertension prevalence in this study was defined by using an automated digital device for blood pressure measurements when the average of two readings were over 140/90 mmHg while control of hypertension was defined when the blood pressure was lower than 140/90 mmHg. Awareness was also defined based on individual’s self-reports while treatment was defined base on regular use of antihypertensive drugs. The outcome of this study shows 57,840 participants had hypertension while 26,877 were aware of being hypertension. Most of these participants were receiving antihypertensive drugs but the hypertension in minority were controlled. Table 1.1 shows the outcome of this study.
| LIC | LMIC | UMIC | HIC | |
| Awareness | 40.80% | 43.6% | 52.5% | 49% |
| Treat | 31.7% | 36.9% | 48.3% | 47.6% |
| – 57,840 participants were diagnosed with hypertension.
– 26,877 participants were aware of being hypertension. – Hypertension rarely controlled in most of the participants who were using antihypertensive drugs. – The rates of awareness, treatment and control is low in low educated participants as well as rural countries. – The highest rate of awareness and treatment belongs to Upper-Middle-Income-Countries. |
||||
Table 1.1 (5)
1.4 Hypertension screening in community pharmacy
According to the Public Health England (PHE) in November 2014, regarding government and health system actions to identify, treat and prevent high blood pressure, two actions were identified. Firstly, community pharmacies should promote their services to provide wider information and support for high blood pressure disease and management such as offering opportunistic screening and running Medicines Use Review (MUR) for people with a high risk of developing hypertension. Secondly, pharmacists should offer the opportunity for all adults to screen blood pressure and pulse checks on a regular basis (6). However, many pharmacies are offering blood pressure tests but raised blood pressure in one reading doesn’t mean that the person is diagnosed with hypertension because some people get anxious or stressed during blood pressure test (1). Table 1.2 shows the results on prevalence of hypertension between 2003-2011 in England by improving modifiable risk factors.
| Metric | Date: 2003 | Date: 2011 | Comment |
| Systolic and diastolic blood pressure | 129.3/74.2 mmHg | 126.5/72.8 mmHg | Improved |
| Dietary salt consumption | 9.5 g/day | 8.1 g/day | Improved |
| Physical activity | 32% of men and 40% of women were inactive | 28% of men and 37% of women taking less than 30 minutes of physical activity per week | Improved |
| Body mass index | Men: 26.9
Women: 26.7 |
Men: 27.3
Women: 27.0 |
Worsened |
| Alcohol consumption | Men: 34%
Women:28% |
Men: 31%
Women: 24% |
Improved |
In addition to this, the results of this study also show that percentage of people who had been diagnosed with high blood pressure in 2004/5 was 11.3% while this percentage was higher in 2012/13 which was 13.7%. Regarding on treatment of hypertension table 1.3 shows the people response who were diagnosed/undiagnosed with hypertension to antihypertensive drugs in three countries; England, United States (US) and Canada.
| Metric | England 2011 | England 2006 | US
2007-2010 |
Canada 2007-2009 | Comment |
| Percentage of people who are taking antihypertensive drugs – under treatment | 58% | 51% | 74% | 80% | Improved |
| Percentage of people who are taking antihypertensive drugs and achieved blood pressure <140/90 mmHg-BP controlled | 37% | 27% | 53% | 66% | Improved |
Table 1.3 (6)
According to the National Institute for Clinical Excellence (NICE) recommendations, adults over 45 years should check their blood pressure at least once every five years, while people with high-normal blood pressure should check their blood pressure in more frequently. In addition to this, half of the population in the England don’t know their blood pressure so to
raise public awareness the charity Blood Pressure UK with the assistance of hundreds of nationwide organizations and the support of the British Heart Foundation runs a campaign known as “Know Your Numbers”. This campaign offers free blood pressure in stations located in hospitals, General Practitioner (GP) surgeries, pharmacies, health clubs, leisure centers, shopping centers and supermarkets. The campaign is aiming to evaluate community based early detection of hypertension (2).
1.5 Atrial Fibrillation (AF) is an important risk factor for ischaemic stroke
Atrial fibrillation (AF) is a progressive and common medical condition associated with high rates of morbidity and mortality. Moreover, hypertension and ageing are two main risk factors for AF which may lead to complication such as heart failure and stroke (7). AF is present in 5% of people who are 65 years and nearly in 10% of people who are 80 years. It has also been estimated that around 2.5 million people in the United States and 4.5 million people in the European Union are suffering from AF (8). Complications of AF are costing NHS over 2.8 billion every year (9) so early diagnosis and treatment is more health/cost effective for the patients and the NHS.
One of the main complications of AF is ischaemic stroke caused by embolism. According to the Atrial Fibrillation Association UK, between 15-20% of AF patient will experience stroke and each stroke costs the NHS between £9,500- £14,000. However, the estimated NHS cost for stroke in the UK is about £2.8 billion while the cost of stroke in Europe is estimated at about €38 billion. On the other hand, it has also been proved that, due to poor patient knowledge about AF treatment and management, approximately half of AF survivors do not even know that the risk of stroke will rise in patients with AF. In addition to this, the Atrial Fibrillation Association UK estimated that by treating and screening AF nearly 2000 lives will be saved and 7000 strokes will be prevented just in the UK, so early diagnosed and treatment is more beneficial and cost effective for both the patient and the NHS (9).
1.6 Incidence of AF in the community
It is estimated that 1.4 million people in England are living with AF, while another 425,000 people are undiagnosed as AF is not always symptomatic (10). Moreover, AF is age-dependent and the risk of prevalence in the population aged under 50 years is less than 1%, while for those who are 80 years or over is about 10%. In addition to this, the prevalence of AF increases for male, as well as cardiovascular diseases survival. In terms of ratio, the risk of death occurrence associated AF is 1:5 for men and 1:9 in women (11).
Moreover, reviewing of 30 studies, regarding on AF screening in nine countries shows that AF incidence and prevalence will increase in aged people. The results of this review displayed in table 1.4 (12).
| Metric | Under 60 years | 60 years or over |
| Prevalence | 2.3% | 4.4% |
| Incidence | 1.0% | 1.4% |
Table 1.4 (12)
1.7 AF is underdiagnosed and undertreated
NHS England commissioned pilot study in London for AF screening in community pharmacies. In 2017 nearly 700 patients had been screened for AF in 16 community pharmacies. The results of this study show 7% of screened people had been diagnosed with AF. Regarding on the achieved results, the researchers were predicting; 1,600-1,700 strokes will be prevented each year if the AF screening replicated across the England (13).
Moreover, a study in Ireland was set in primary care aiming to evaluate the cost-effectiveness of AF opportunistic screening on people older than 65 years. The achieved results show the AF opportunistic screening is more cost-effective compare to routine care. In addition to this, the relative risk of stroke and systemic embolism on screened people is 12% low compare to routine care. Finally, this study demonstrates that frequently screening in younger age is more cost-effective than screening from age 65 years or over (14).
1.8 Combined Atrial fibrillation/hypertension and screening related services in community pharmacies
A review on six studies regarding on screening for AF/hypertension in primary care was indicating high accuracy in AF detection by using Microlife BP device while the sensitivity was 0.98, specify was 0.92 and 2332 individuals were participating in these studies. In addition to this, the review of four studies including 1126 participants proved that the highest AF diagnostic rate when 3 sequential BP with at least 2 detecting AF readings were collected. The result of this review also show improvement in septicity from 0.86 to 0.91 and sensitivity from 0.97 to 0.99. Moreover, a study with 139 participants using Home BP device demonstrated 15% AF detection on people with high probability of AF diagnosis but this need confirmation by 24 hours electrocardiography (15).
Additionally, community pharmacies have great potential for opportunistic screening of hypertension or AF due to wide accessibility and the large number of aged people who visit the pharmacy on a regular basis (9). The mission of the AF/hypertension screening in community pharmacies is not only to improve quality of services but also reduce NHS costs, demand on General Practitioner (GP) appointments and Accident and Emergency (A&E) attendances (1).
1.9 Devices for AF and hypertension screening in primary care
Microlife Watch BP Home A device (Microlife) is a blood pressure monitor approved by NICE to be used in primary care for hypertension and AF screening (16). Microlife can automatically detect irregular pulse while measuring the blood pressure (BP) (1). NICE have also approved AliveCor heart monitor and Alive ECG app (Kardia mobile) for mainly proximal AF detection in primary care. This device records electrocardiogram (ECG) and uses a mobile device application for analyzing the results. According to the NICE, two clinical studies in identifying AF reported that this device has sensitivity over 85% and specify over 90% for AF screening. In addition to this, an Australian study also found using these devices in community screening for AF was cost effective (17).
1) To test the feasibility and applicability of combined AF and hypertension screening in a community pharmacy in south London.
2) To identify potential pharmacist training and knowledge related barriers to delivery of such a service.
3) To estimate the prevalence of undiagnosed AF/undertreated/unrecognised hypertension.
2.0 Methodology
A combined AF/hypertension opportunistic screening service in community pharmacy was operated from 15th March 2018 for approximately two weeks in the Tooting area. Figure 2.1 shows the main operating procedures in AF/hypertension screening in a community pharmacy including client engagement, blood pressure measurement, ECG monitoring, home blood pressure measurement, interpretation of results and questionnaires collected from both pharmacists and patients.
2.1 Study setting
The community pharmacy (Pearl Chemist) in Tooting, South London kindly agreed to host this screening project. Dr s.Teck Khong and Henry Fok provided medical advice and cover in relation to the ECG and blood pressure recordings. The pilot had training at the Blood Pressure Unit (BPU) at St George’s Hospital NHS Foundation Trust to standardized blood pressure measurements. The Microlife Watch BP Home A blood pressure monitor and Alivecor Kardia mobile ECG devices were used for blood pressure measurement and heart rate monitoring. Both devices have been approved by the NICE and recommended to be used for routine blood pressure measurement as well as heart rate monitoring in the United Kingdom (16,17).
According to the latest census in 2011 published by the National Statistic Office; the total population of Tooting is 16,239 (18). Regarding the Tooting statistic the sample size with a confidence level of 95%, margin of error of 5% and respond distribution of 50% was calculated, using the website called Raosoft. The minimum sample size was found to be 376. As just one person was contributing in this screening, the project supervisors agreed to
screen approximately 100 people in a community pharmacy and collect 100 questionnaires from the screening participants. 13 questionnaires were also collected from the pharmacists.
2.3 Design the questionnaire
Initial research was conducted and the information gathered was used to design two questionnaires; a pharmacist’s questionnaire (appendix 1) and a patient’s questionnaire (appendix 2).
The pharmacist’s questionnaire consisted of sixteen MCQs questions in three sections. Section one – demographic information of participants, included three questions about gender, age and pharmacist working experience. Section two included three questions testing pharmacist knowledge about AF. Section three included 10 questions regarding barriers, training which can be provided for AF and hypertension screening service and the pharmacist expectation in terms of money for running such a service in their pharmacies. The pharmacists also had been asked about how comfortable they will be to run the hypertension/ AF screening service in a community pharmacy after having the related trainings. The patient’s questionnaire consisted of two forms. Form 1 included nine questions in three sections; general information, lifestyle and current or past medical conditions. Form 2 consisted of two sections, patient’s full details and GP full details.
2.4 Ethical approval
The proposal and all relevant documents including the ANNEX1, ethic application, the pharmacy participation confirmation letter, the nurse training confirmation letter and CE (Conformité Européene) marketing were submitted for ethics approval to the faculty of Science Engineering and Computing at Kingston University. Ethic was approved on 6th March 2018.
2.5 How patients were enlisted and what they did undergo as part of the study
People in the pharmacy were approached, the pilot introduced herself. Participants were informed that the pharmacy was offering free blood pressure measurement and heart rate monitoring for every individual and explained that one in every 9 adults has high blood pressure without even knowing it. High blood pressure is rarely symptomatic and is estimated to cause over 20% of heart attacks and 50% of strokes then asked them, “Would you like to know your blood pressure?”(1)
Patients wishing to be studied, were invited into the consultation room where they were informed about the process of the screening (appendix 6) and gave consent to the research team (appendix 3). Individuals consenting to be studied and complete questionnaire form 1 (appendix 2) had their blood pressure measured and heart rate and rhythm assessed. Patients also provided their GP details by filling form 2 (appendix 2) and gave consent for the study group to contact their GP if referral is needed.
Blood pressure was measured in both arms and the results were recorded. The arm with the highest reading was used for one more measurement and the reading was recorded (appendix 4). The heart rate was monitored for 30 seconds and the results were recorded too (appendix 4). Then the results were communicated to the patients as in appendix 5. In addition to this, the duration of each screening also was recorded. Finally, the patient received a blood pressure alert card which indicated their BP measurement (appendix 7) and the British Heart Foundation Charity high blood pressure/atrial fibrillation patient information booklet.
Patients were informed of their BP reading and if:
- Normal BP (90-139/60-89mmHg), patient advised to attend their GP practice in usual manner.
- High BP (Systolic BP 140-179 and/or diastolic BP 90-109 mmHg), patient offered HBPM to take 2 BP measurements every day for four consecutive days, ideally seven days. Training for HBPM was provided to the patient.
- Very high BP (systolic ≥180 and/or diastolic ≥110 mmHg), patient was informed about their high blood pressure and advised to see their GP or seek Urgent Care on the same day.
Any abnormal ECG results were sent to the cardiologist at St George’s Hospital on a daily basis. The results specified whether they related to BP/AF and the patient was contacted by the cardiologist if further investigation or referral to their GP was needed. If the patient needed to be referred to the GP, the cardiologist or offered home blood pressure monitoring they were asked to fill form 2 in appendix 2 and appendix 5 was followed for actions following result detection.
40 community pharmacists located within 8 miles of the Tooting area were approached. All pharmacists were eligible to participate in this study and filled the questionnaire in appendix
1. People who were not pharmacists were excluded (1). This study also was looking for the barriers of AF screening in community.
2.6 Data collection
All adults living in the Tooting area were targeted to participate in this study. The signed consent form and filled questionnaire were collected from each participant. In the screening approach 3 blood pressure readings were recorded and the ECG was recorded too. In addition to this the HBPM which was offered to the people with high blood pressure was recorded. The pharmacist questionnaire was also distributed to the pharmacist and the filled questionnaires were collected.
2.7 Data analysis
Key: Blood Pressure (BP), Home Blood Pressure Monitoring (HBPM), Electrocardiogram (ECG), Atrial Fibrillation (AF), General Practitioner (GP), Accident and Emergency (A&E).
Table (2.2) indicates actions following the blood pressure measurement. The actions were followed base on average of 3 BP reading.
| Results | Threshold | Actions Required |
| Normal BP
(average of 3 reading) |
Systolic BP 90-139 And/or
Diastolic BP 60-89 mmHg |
Patient should be advised to continue with their GP in accordance with their usual care pathway |
| High BP | Systolic BP 140-179 And/or
Diastolic BP 90-109 mmHg |
HBPM has to be offered to the patient. Patient should take two BP measurements every day for four consecutive days, ideally seven days. Training for HBPM will be provided to the patient. |
| Very High BP | Systolic BP≥180
And/ or Diastolic BP≥110 mmHg |
Inform the patient about their high blood pressure and advise them to see their GP or seek Urgent care on the same day. |
Table (2.3) indicates actions following HBPM. Home blood pressure monitoring was offered to the patient with high BP (Systolic BP 140-179 and/or diastolic BP 90-109 mmHg).
| Results | Threshold | Actions Required |
| Normal HBPM | Systolic BP 90-139 And/or
Diastolic BP 60-89 mmHg |
Patient should be advised to continue with their GP in accordance with their usual care pathway |
| High HBPM | Systolic BP 140-179 And/or
Diastolic BP 90-109 mmHg |
These results are consistent with hypertension. They are advised to see their GP for further management within one week. |
| Very High BP | Systolic BP≥180
And/ or Diastolic BP≥110 mmHg |
Inform the patient about their very high blood pressure and advise them to see their GP or seek Urgent Care on the same day |
Table 2.3
Table (2.4) indicates actions following ECG.
| Results | Action Required |
| AF detected
(Using ECG) |
If atrial fibrillation is detected, the patient’s GP will be notified within 24 hours by either Drs. Fok or Khong for further management unless the patient declined this |
| AF not detected
(Using ECG) |
A copy of the ECG will be checked by Drs. Fok and Khong to provide quality assurance for the results. Patient should be advised to continue with their GP in accordance with their usual care pathway. |
Table 2.4
2.8 Data storage and handling
To respect confidentiality of the participants all the gathered documents including surveys, patients details and their recorded screening results were only available to the research team of this project. All the gathered results were strictly confidential and stored in a secure cabinet in the supervisor office at St George’s Hospital. In addition to this, the results which have been stored electronically are kept on a password protected laptop. After the project, the results will then be shredded and disposed of within confidential waste disposal according to the universities guideline.
3. Results
3.1 Pharmacist’s response rate
Regarding on pharmacist survey, 40 questionnaires were distributed to the community pharmacies located within 8 miles from the St Georg’s Hospital. Fourteen surveys had been collected; thirteen completed by pharmacists and one had been completed by pre-registration pharmacist which had been excluded from the results. Nine pharmacists refused to participate in the study. Ten pharmacists confirmed that they will fill, scan, and email the survey to the researcher but the researcher didn’t receive any survey back by email. Seven pharmacists also confirmed that they will fill and post the survey to the researcher but the researcher just received one back. To conclude this result, the respond was calculated and it was (13/40) *100= 32%.
Table 3.1 shows demographic information of participants in the pharmacist’s questionnaire. The average of age was calculated to be 55 years.
| Gender | |
| Percentage % | |
| Male | 54 |
| Female | 46 |
| Age | |
| <30 years | 46 |
| 31-40 years | 23 |
| 41-50 years | 15 |
| 51-60 years | 0 |
| >60 years | 15 |
| Pharmacist experience | |
| <5 years | 30 |
| 5-10 years | 46 |
| 11-20 years | 0 |
| 21-30 years | 8 |
| >31 years | 15 |
| Table 3.1 | |
According to the table 3.1 the percentage of male or female who participate in this study was calculated. Male were participating 8% more compare to female. Regarding on age, 46% of participants were less than 30 years and 15% had been more than 60 years old. In addition to this, 46% of participants had worked as a pharmacist for 5-10 years and just 8% had work experience within 21-30 years.
3.3 Perception- pharmacist
Participants were asked about definition of AF, Figure 3.1 shows that 84% of pharmacists had been familiar with what the AF is and 16% had no understanding of AF.
Figure 3.1
Participants were also asked about risk of AF, Figure 3.2 show that 92% of pharmacists had been familiar with risks of AF and 8% had no understanding of AF risks.
Participants were asked about symptoms of AF, Figure 3.3 show that 69% of pharmacists had been familiar with the AF symptoms and 31% had no understanding of AF symptoms.
Figure 3.3
Figure 3.4 shows potential barriers for pharmacists to setup stroke prevention screening in a community pharmacy. According to this figure level of remuneration or fee for service with 31% had the highest rate of response, followed with time (24%) while the level of knowledge about AF with 3% had lowest rate of response.
Figure 3.4
Regarding on related training for AF screening on a community pharmacy the results show that 39% of participants were agreed that online courses, 32% were agreed evening workshop, 15% of participants were agreed social media and 14% mentioned resource are the ways that can help the pharmacists for AF screening.
Figure 3.5
Pharmacists were asked about how likely is to provide the AF screening service in the future after having related training. The positive response rate for this question was 53% while just 7% were agreed that is slightly unlikely to run the service after the relevant training.
Figure 3.7 shows that pharmacist expectation in value of money for running hypertension/AF screening in a community pharmacy. The available options for pharmacist were 10-15% higher or lower than medicine use review (MUR) as well as the same value of MUR. The achieved results show that 35% of pharmacist are expecting to receive more money than MUR service and just 17% are expecting to receive the same value of MUR for running the AF/hypertension screening service.
Figure 3.7
Figure 3.8 shows the pharmacists view regarding on the most effective way to raise AF awareness in the community pharmacy. According to this figure poster with 29% had the highest rate of response, followed with campaign (25%). Leaflet and counselling both with 22% had the lowest rate of response.
Figure 3.8
Regarding on patient AF/hypertension screening, 66 people with average age of 55 years were approached in a community pharmacy. 24 people had declined the service and 8 people declined the ECG. In total 34 people had AF/hypertension screening and 8 people who declined the ECG had just BP measurement. Home blood pressure monitoring was offered for 7 days to four people and all the collected results were normal. The average time
spent in each patient for screening was 15 minutes. To conclude this result, the respond rate was calculated and it was (42/66) *100= 64%. In addition to this, the response rate for BP measurement was 100% while the response rate for ECG was (34/66) *100= 52%.
3.5 Patient’s demographics
Table 3.2 shows demographic information of participants in the AF/hypertension screening.
| Gender | ||
| Percentage % | ||
| Male | 40 | |
| Female | 60 | |
| Age: The average age of participants was 51 years. | ||
| Ethnic group | ||
| White English/Scottish/Northern Irish/ British | 50 | |
| White and Black Caribbean | 8 | |
| White and Asian | 8 | |
| Asian/Asian British | 22 | |
| Other ethnic groups | 11 | |
| Lifestyle | ||
| Smoker | 25 | |
| Drinking alcohol | 50 | |
| Exercise | 61 | |
| Medical conditions | ||
| High blood pressure | 11 | |
| Stroke | 3 | |
| High level of cholesterol | 16 | |
| Asthma | 8 | |
| Diabetes | 13 | |
| COPD | 13 | |
| Pulmonary embolism | 3 | |
| Cancer | 3 | |
| Not known medical conditions | 30 | |
| Table 3.2 | ||
According to the above table female were participating in this study 20% more than men. The average age was 55 years and 50% of participants were White English/Scottish/Northern Irish/ British. In addition to this, the medical conditions which will increase the risk of stroke in the future were not present in 30% of participants in this study.
3.6 Blood pressure measurement results
Figure 3.9 shows the percentage of participants who had normal, high, or very high blood pressure. This figure demonstrates that 89% of participants had normal blood pressure and 11% had blood pressure within, systolic BP 140-179 and/or diastolic BP 90-109 mmHg so they had been offered home blood pressure monitoring for 7 days and the results were collected, all had normal blood pressure. In addition to this, none of the participants had very high blood pressure.
Figure 3.9
Participants in this study were asked about known hypertension, heart conditions or their predication regarding on their low, normal, high, very high blood pressure. Figure 3.10 shows 92% of participants were predicted to have normal blood pressure but according to the achieved results just 88% had normal blood pressure. 4% of participants expecting to have high blood pressure due to known hypertension or other heart conditions but, 8% had high blood pressure and they had been offered home blood pressure monitoring. 2% of participants also were predicted to have low blood pressure but according to the results 4% had low blood pressure.
Figure 3.10
Figure 3.11 show the percentage of smokers, previous smokers, non-smokers, and alcoholic drink users who had been offered home blood pressure monitoring due to high blood pressure. This figure show 83% of patient with high blood pressure were non-smokers and alcoholic drink users, 17% were previous smokers and current smokers were also calculated as 17%.
Figure 3.11
According to the figure 3.12 the percentage of female and male patient who had been offered home blood pressure monitoring were calculated to be 66% for female and 34% for male. The average of age for these patients were also calculated to be 61 years. In addition to this, in 50% of patient who offered home blood pressure monitoring other medical conditions such as previous stroke, asthma, … were present.
Figure 3.12
3.7 ECG monitoring results
Figure 3.10 indicates the ECG monitoring results. Generally, there are 4 ECG classifications on Alive ECG app (Kardia mobile) including: normal, unclassified, no analysis and possible AF. In this study 80% of ECG results were normal means no detection of AF, 14% were unclassified, 2% were no analysis and 2% were possible AF detection. With the cardiologist’s confirmation the unclassified, no analysis and possible AF detection assumed normal.
Figure 3.13
3.8 Overall knowledge & correlating factors
A knowledge section in the pharmacist’s questionnaire was included to test pharmacist’s knowledge on the cause, symptoms, and risk factors of AF/hypertension. The average percentage was calculated to be 81.6%. The mode, median and average age of participants was found to be 31, 53 and 55. Regarding on time which had been spent on screening the mode, median and average time was also found to be 15, 15 and 15 minutes.
4.0 discussion and conclusion
4.1 discussion
4.2 conclusion
4.3 practice implications
5. References
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