By James M. McKenney, Blood Pressure William B. Jennings and Eugene V. White Screening in a Community Pharmacy

Recent studies have revealed that hypertensive complications, many of which are disabling or life threatening, can be prevented with antihypertensive drug therapy.1 - 2 Other studies have revealed that approximately one-half of all hypertensive Americans remain undetected.3- 11 These findings have initiated widespread interest in blood pressure screening programs and in related research designed to discover methods to make the health care system more responsive to the problem . The National High Blood Pressure Education Program which has spearheaded much of the work with this and other problems has formed task forces to deal with the various issues involved . The task force working on blood pressure detection and control has recently published its guidelines. 12 Blood pressure screening programs are much more prevalent today- especially in urban centers- and frequently conform to a certain stereotype . These programs are often sponsored by local service or professional organizations and are commonly held over a one to three-day period in shopping centers, grocery stores , churches, local businesses , polling locations , dentists ' offices and industries 3 .4. 7 . 10 No one screening site appears superior to any other in attracting a large number of citizens. However, the limited number of days that the program is offered may limit its availability to the general population . Most screening programs appear to be well publicized and highly organized. Patients found to have an elevated blood pressure on the screening day are generally told to see their physician for further evaluation . This is usuaily done , however, with little assurance that the patient either has a physician, is willing to see him or is able to see him. This may be one of the greatest faults with many screening programs . Hypertensive patients may be detected but the ultimate goal for the screening program may not be reached (Le. , that new hypertensive patients receive the therapy needed to control elevated blood pressure and prevent complications). Effective evaluation , referral or follow-up mechanisms may help solve the problem as recommended by the National High Blood Pressure Education Program . Some authors have suggested that the community pharmacist is a logical person to be involved in this patient service . 13- i5 His practice site has the advantage of being readily accessible to most citizens . This program was supported in part by the Virginia Medical Program, Contract #9 .

Vol. NS 16. No. 4. Apri l 1976

The prior relationship that he has established with patients and physicians may also improve his ability to attract patients for screening and effectively refer them for further evaluation. However, demonstration of these observations is necessary . This article describes a demonstration blood pressure screening program which was conducted in a community pharmacy in a rural setting . The screening procedures employed conform to those recommended by the National High Blood Pressure Education Program. Description of Screening Program Screening Site- The community blood pressure screening program was held in Berryville, Virginia for the citizens of Clarke County. The county has an adult population of appro ximately 5,900 and is located in the northern section of Virginia, one hundred miles west of Washington , D.C. and seven miles east of Winchester, Virginia . Its main business district is located in the town of Berryville and the principal industries in the area include agriculture and manufacturing . The sex, age and race distribution of the citizens from a 1970 census is shown in Table I (at right). Pharmaceutical services for the county are provided by two pharmacies, both located in Berryville . One pharmacy is a typical "corner drug store " offering a wide range of merchandise and prescription drugs. The second pharmacy is a prOfessional office which offers only prescription and non-prescription drugs as well as a wide range of patient care services including patient profile cards and patient consultations . This second pharmacy was chosen as the site of the community blood pressure screening program . Screening Personnel-The screening team consisted of 17 individuals, five professionals and 12 laymen . The program director assumed all responsibilities related to the planning, development and implementation of the program . These responsibilities included solicitation of local physicians and pharmacists ' endorsement and partiCipation in the pmposed program, development of the screening procedures. solicitation and training of program participants. development and implementation of publicity, and development of methods of patient education , referral and follow-up . A second-year hospital pharmacy resident served as the assistant director with primary responsibility for directing the program at the screening site. His responsibilities included the recording of a blood

Age, Sex and Race Distribution of the Target Population

Table I

Age Ra nge

16- 24 25 - 34

Male

Fe mal e

Black

White

Bl ac k

White

98 0.7 %) 75 (1.3 %)

485 (8.2%)

102 (1.7 %)

537 (9. 1%)

55 (0.9 %)

400 (6.8 %) 445 (6 .8%) 40 1 (6.8 %) 394 (6 .7%)

35-44

63 (1. 1%)

45-54

50 (0.8 %)

40 1 (6.8%) 435 (7.4 %) 411 (7.0%)

55 - 64

59 (1. 0%)

362 (6. 1%)

;;:.65

60 (1.0 %)

358 (6. 1%)

52 (0.9 %) 73 (1.2 %)

To tals

405 (6.9%)

245 2 (41.6%)

406 (6.9%)

62 ( 1. 1%) 62 (1. 1%)

452 (7.7 %) 2629 (44.6%)

pressure on each patient, directing the activity of screening volunteers, providing patient education , referral and follow-up services, communicating findings to participating physicians and maintaining screening records . The pharmacist-owner provided a space in the pharmacy for blood pressure recording, assisted in the development of the screening procedure and advertising materials, presented the program plans to local physicians for their review and endorsement, and partiCipated in the screening program when possible . He also made available the services of his associate pharmacist and pharmacy student to the program and recruited 12 community volunteers to assist in greeting patients and in completing the program questionnaire . Four physicians in family practice provide medical care to the citizens of Clarke County . They partiCipated in the screening program by assisting in the development of the screening procedure and by cooperating with the screening team in referral and follow-up efforts . Screening Procedure-A written description of the screening procedure was developed by the program director and presented to the local pharmacist for his review . A second written draft was then presented and discussed with each physician practicing in the county. By this means, the screening procedure followed in the program represented the combined thoughts of all major partiCipants . The program provided blood pressure screening for all citizens of the county 16

187

Demonstrating a successful approach which establishes the community pharmacy as an additional site that can contribute significantly to detection of hypertensive patients in a community

years of age or older for a period of 30 days. Patients desiring a screen were greeted and assisted in completing the program questionnaire (Figure 1, at right) by community volunteers. The assistant director recorded all pressures using a Tyco aneroid sphygmomanometer. Pressures were recorded on comfortably seated patients in a private area from the left arm by the technique endorsed by the American Heart Association . 16 Onset and disappearance of sound was interpreted as systolic and diastolic blood pressure respectively . The name of each patient whose primary (initial) screening blood pressure was less than 160 mm Hg but greater than 140 mm Hg, or less than 95 mm Hg but greater than 90 mm Hg diastolic was sent to his physician for annual rescreening . Patients whose primary blood pressure was greater than 160 mm Hg systolic and/or greater than 95 mm Hg diastolic were given an educational program and encouraged to return to the pharmacy on two additional days for screening (rescreening). These patients were given additional counseling and referred to their physician for further observation and management if the average of the blood pressures recorded on three separate visits was found to exceed 160 mm Hg systolic or 95 mm Hg diastolic. Otherwise, the patient 's name and blood pressure results were sent to his physician for annual rescreening . The average of blood pressures recorded on three separate visits was used to minimize the number of false positive referrals to the physician office. Program Methods Program Promotion-Promotion of the program to the public was minimal and required a budget less than $100. The participating pharmacists utilized posters placed in strategic locations within the community, daily radio announcements during the reading of the " Community Calendar " and short weekly advertisements in a daily and a local weekly newspaper to inform the public of the high blood pressure screening program. The newspapers also ran feature articles on the program during the screening month . One of the advertisements used in local newspapers is illustrated in Figure 2 (at right). Note that approximately one-quarter of the population was encouraged to seek blood pressure screening each week . This was done to achieve a more even and orderly flow of screening patients through the busy pharmacy. Educational Program-Two educational

188

Figure 1 - Patient Blood Pressure Screening Questionnaire Please answer the following questions by selecting the most appropriate answer. Then place the number corresponding to your answer in the box to the right of the question . The information contained in this questionnaire wilt help us determine your need for a visit to your physician. Please be advised that the information provided is for the profess ional use of your physicians and pharmacists and will not be released to anyone else without your permission . NAME ___________________________________________ DATE _________ ADDRESS ________________________________________ PHONE ________ FAMILY PHYSICIAN(S) _____________________________________________ 1. AGE

(1) Under 25

2. SEX : (1) Male 3. RACE 4. WEIGHT

(2) 25-34

(3) 35-44

(4) 45-54

(5) 55-64

(1) White (1) Over

(2) Black

(6) Over 65 ......... . . 0 ..................... 0

(2) Female

. ....... 0

(3) Other .

(2) Normal

.. [J

(3) Under.

5. Have you ever been told you have high blood pressure

(1) Yes

6. Have you ever received any medicine for high blood pressure?

(2) No ............ . .. [! (1) Yes

(2) No .

.0

7. Have you ever been told to restrict the use of salt or lose weight because of high blood pressure? (1) Yes (2) No . . ............................ . 0 8. Are you presently receiving any medicine for high blood pressure ? (1) Yes (2) No .... LJ 9. Are you presently on a special diet for high blood pressure?

programs were developed for the screening program. Both used verbal and written means of communication to motivate the patient to comply with recommendations given by the screening team. Patients with an elevated blood pressure during the primary screen received a letter (Figure 3, page 189). Verbal counseling described the points made in the letter. Patients, whose average of three blood pressures was elevated, were given the letter illustrated in Figure 4 (page 189) and a copy of the booklet, " Understanding Your High Blood Pressure ." Verbal counseling emphasized the following points1. High blood pressure causes serious, potentially fatal , complications if left unchecked. 2. High blood pressure produces no symptoms. 3 . Treatment with prescription drugs can lower blood pressure and prevent complications . 4. Evaluation and treatment of high blood pressure starts with a visit to your physician. Referral Mechanism-Referral in this screening program was defined as an organized means of directing a patient from the screening team to his physician . This referral was accomplished in two ways. First, during the educational process, the patient was told that his blood pressure appeared consistently high and that he should see his physician for further evaluation and management. Secondly, all pa-

(1) Yes

(2) No .......... []

Figure 2-Advertisement Published in Local Newspapers

Do You Have

HIGH BLOOO PRESS. Did You Know That High Blood Pressure affects approximately ONE OUT OF EVERY FIVE adult Americans That people who have High Blood Pressure frequently have NO SYMPTOMS That High Blood Pressure is one of the leading causes of HEART DISEASE, STROKES AND KIDNEY DISEASE and That medicine is now available whi ch can PREVENT the death and disability associated with High Blood Pressure If you reside in Clarke County and are 16 years of age or older HAVE YOUR BLOOD PRESSURE TAKEN Where: The office of Eugene V. White, Pharmacist I W. Main St. Berryville. Va. When: During January Monda)' thru Friday 9 AM to 7 PM 9 AM to I PM Saturday How : First Initial of Last Name A-D E·H ,.Q

R·Z

Screening Dates January Janu ary January Janu ar)'

7-12 14-19 21-26 28-Februar}' 2

Note: No fee will be charged for tbis service. Patients unable to have their blood pressure taken during the weeks designated may be screened a n~,'tim e during the month.

Journal of the American Pharmaceutical Association

McKenney , Jennings and White

Figure 3

Figure 4

lJear Patient,

Dear Patient,

Your bl ood pressure as recorded by us today is high . 111is DOES NOT mcan , however, that you have high blood pressure. Blood pressure may rise i'n re sponse to many things such as an.xiety , r ecent cigarette smoking , stress , exer cise , recent ingestion of food and urge to defecate . In fact , blood pressure in everyone fluctuates each minute throughout ' the day anJ night. Before we would be will i ng to say that you have high blood pressure and recommend that you seek what often i s lifelong treatment we woul d want to be sure t o see a cons i sten t rise in your blood pr essure . Therefore , we want you to retumtoiliis phannacy on two additional days so that we may again take your blood pressure . We will arrange to see you by appointment so that you will not have to wait. Only afte r the third visit wi ll we be ab l e to properly advise you about your need for further evaluat i on and car e by your physician .

You are receiving this letter because your blood pr essure after three vi sits to us appears to be cons i stently above normal. Accordingly , we have strongly recommended that you see your phys i cian for further eva luation and poss i ble t,.eatment. We canno t over emphas i ze how important this Lrip to your physic ian i s . As you read through the literature we have given you , you will see that high blood pressure is associated with many complications including heart attack, heart failure, hardening of the arter ies , stroke, angina and kidney damage . Obvi ously these complica t ions ar e sever e and may cause hosp italizations and early death . Fortunately, t reatment is ava i labl e which can prevent these problems. To receive this treatment you must see your physiciml. Don ' t put the visit to your physician off. You may be adding years to your life .

Please do not he s itate to calJ us if you have any questi ons or pr oblems in making the appointments . Thank you for gi ving us th i s opportwli ty to serve you .

Please do not hesitate to call if you have any questions. you for giv ing us thi s opportunity to serve you.

J

Eugene V. IVbi te Phannacist

Susan Whitacre Phannacist

William C. Jennings Phannacis t , Hi gh Blood Pressure Program

Richard Richards Phannacy Clerkship Student

Eugene V. \\Ihi te Phannacist

Susan IVbi tacre Pharmacist

Wi lliam C. Jennings Phannacist , High Blood Pressure Program

Richard Richards Pharmacy Clerkship Student

James J am~s ~1.

~lcKenney

Blood Pressure Program

Letter given to pa tients with elevated blood p ressure during p rim ary sc reening.

Screening Results During the 30-day screening program , 614 patients (10 .6 percent of the target population) had their blood pressures recorded (Table II, page 190). The age, sex and race distribution of screened patients roughly parallels similar subgroups of the target population (Table III, page 190). The majority of screened patients (65 percent) were female. The lower proportion of male patients screened is disappointing, since hypertensive disease may be of a greater

Vo l. NS 16, No.4, April 1976

"Ie Kenney

Director , High

Di r ector , High Blood Pressurc Program

tients were assisted by the assistant program director in attaining an appointment with their physicians within one week of the screening day. A system of arranging these appointments with physician offices had been previously established through consultation with the local physicians . A form was sent (Figure 5, page 191) to the physician's office before the patient was scheduled to arrive so that the physician would have the advantage of knowing the screening blood pressures. FOllOW-Up Method- Follow-up in this screening program was achieved in two steps. First, the physician 's office informed the screening team of referred patients who were not compliant with scheduled appointments. Secondly, the assistant program director contacted each noncompliant patient by telephone to again emphasize the importance of evaluation and treatment.

~I.

Thank

Letter given to patients who se average o f three blood p ressures was elevated.

prognostic significance in this group. The black / white ratio of the screened population was similar to that found in the target population . Average blood pressures of subgroups of the screened population divided according to age, sex and race are shown in Table IV (page 191). As may be expected , blood pressures were found to increase with age and were generally higher in blacks and males. Further analysis of the data revealed that 144 of the 614 screened patients had been told previously that they had high blood pressure . Of these, 108 patients reported they had received antihypertensive drug therapy in the past and 65 patients reported they were receiving antihypertensive drug therapy at the time of the blood pressure screen. However, only 30 of the 65 patients receiving drugs were found to have a blood pressure less than 160 mm Hg systolic or 95 mm Hg diastolic after one blood pressure recording. On the basis of the primary blood pressure screen, 97 of 614 patients (15.8 percent) had a blood pressure greater than 160/95. The average blood pressure for this group was 162/ 95. Of these 97 patients, 30 had systolic blood pressure elevations only, 31 diastolic elevation only and 36 diastolic and systolic elevations . Fifty-three (54 .6 percent) of these 97 initially hypertensive patients had been told previously by a physician that they had

high blood pressure and 35 patients (36.1 percent) were receiving antihypertensive medications. It is interesting that five of the 35 patients receiving medications had a diastolic blood pressure greater than 120 mm Hg and admitted under questioning to recently discontinuing prescribed therapy and contact with their physic ian. Each of these 35 patients was given a booklet on hypertension and encouraged by the screening team to see their physician for an evaluation. Follow-up data revealed that the five most severely hypertensive patients were compliant with this referral. No follow-up data were obtained on the remaining 30 patients. After eliminating from further follow-up the 35 patients receiving antihypertensive drugs, four patients living outside the screening area and three patients being closely followed for high blood pressure by their physicians but receiving no drug therapy, 55 patients (8 .9 percent of screened population) with an initial blood pressure greater than 160/95 were rescreened. Each of these patients was given educational instruction as outlined above and requested to return to the pharmacy on succeeding days for two additional blood pressure recordings. Fifty-one of the 55 patients (92 .7 percent) were compliant with this request. Of the four patients not returning for rescreening , one developed an illness and did not recover by the end of the screening period, one died of a stroke

189

Blood Pressure Screening in a Community Pharmacy

Table II

Table III

Summary of Blood Pressure Screening Results

Age, Sex and Race Distribution of 614 Screened Patients

Average

Obse rvations

Numher a nd Perce ntage of Pa tients

Blood Prc ssu re fo r Patie nt Group

Patient s sc re e n ed

6 14 (10.6 ';" o f th e ta rge t p op ul a ti o n)

13 1/79

Patie nt s w ith a b lood pressure greater t ha n 140 I1UI1 Hg systo lic a nd / or 90 IllI11 Hg d iasto li c

270 (44.0'11 of screened p at ie nt s)

14 8/92

Pat ie nt s w ith a blo od p ressure avera ge g reater than 160 I1Ull Hg sys to li c and / o r 95 I1lnl I-I g diat o li c a f ter o n e record in g

97 (1 5.8% scree ne d patie nt s)

Pa t ie nt s w ith a b lood pr essure ave r'lge g reater t h a n 160 111 111 Hg sys to li c and / or 95 I11Ill Hg d ia s to li c after o ne record in g a nd n o t und er tr eat lll e nt

55

Pa ti e nt s w ith an av e rage b lood press ure grea ter t han 160 1111ll Hg systo lic al1d / o r 95 111111 Hg dia sto lic after t hree visits a n d referred

30 (4. 8(;! o f screene d patie nt s)

Patie nt s cO l11p li ant w ith physic ian appoin t Ill e n t

30 (I OO(;! of referre d patient s )

170/ 93

Pati e nt s considere d h y pertens ive by p hys ic ia n

30 (IOO';! of referre d patients)

168 / 93

(8.9 ~1,

of sc ree ne d pati e nt s)

16 2/ 95

168 / 95

Male Age Ran ge

Bl ack

White

Black

White

4 (0.6 %)

19 (3.0%)

II

U· ?'Yr.)

33 (53 %)

25 - 34

7 ( I.I %)

25 (4.0%)

9 (1.4 %)

44 0 .1 %)

35-44

9 (1.4 %)

32 (5.2%)

12 * (I. 9(;!,)

65 (10.5 %)

6 (0.9%)

26 (4.2%)

( 1.7 ';{,)

76 (1 2.3 %)

55-64

7 ( 1.1 (;0

43 (7.0';;',)

14 (2.2 %)

65 ( 10.5';!.)

;;,65

5 (0.8 %)

32 (5.2 %)

8 ( 1.3%)

(8 . 3')1, )

38 (5.970 )

177

(2 8.6%)

65 (10.2%)

334 (54.0%)

< 25

45-54

170 /93 Tota ls

and two wished to go directly to their physician for further evaluation. Follow-up data on the latter two patients indicate that they saw their physician and were given . therapy. Of the 51 patients returning to the pharmacy for secondary screening , 30 were found to have an average blood pressure greater than 160/95. These patients were counselled , assisted in obtaining a physician appointment and referred to their physician for further evaluation and management. Of these 30 referred patients, 10 had an elevated systolic blood pressure only, 7 a diastolic blood pressure elevation only and 13 an elevation in both systolic and diastolic pressures . The average blood pressure of the 30 patients was 170/93. A systolic pressure range ()f 133 to 200 and diastolic pressure range of 81 to 110 was found . Only seven of the 30 hypertensive patients had been told previously that they had high blood pressure and none were receiving drug treatment. Follow-up data revealed that all of the 30 patients referred were compliant with their physician appointments (Table If). The physiCians found all 30 of the referred patients hypertensive on the basis of their evaluation. The average blood pressure of the group of referred patients , 168/93, as recorded by the physician was similar to the average blood pressure of 170/ 93 obtained by the screening team.

190

It is interesting to observe what would have happened if systolic blood pressures above 140 mm Hg or diastolic blood pressures above 90 mm Hg after the primary screen had been defined as high prior to the screening program . As shown in Table II , 270 of the 614 screened patients (44.0 percent) would have been referred to the physician for further evaluation and treatment. Using the lower blood pressure definition would have increased the average number of patients referred to the physicians from 1.3 to approximately 11 per day . The size of the patient load per day in the pharmacy for this screening program was very manageable. Our data revealed that an average of 25.6 patients were screened per day with the largest number, 49 patients, screened on the first day and lowest number , 5 patients, screened on the last day . During the first week, 33.3 percent of the patients were screened; 24 .6 percent were screened during the second week; 23.8 percent during the third week and 18 percent during the final week. This data would appear to indicate that the public 's enthusiasm in the screening effort diminished during the course of the screening period. The data also appear to coincide with the reduction in promotion of the program . Screened patients also were questioned about the regularity with which they came

female

II

51

* O n e patient had " o ther" race.

into contact with a health care provider. Responses showed that 87 percent of the 614 screened patients had visited their phYSician at least once in the previous 12 months . Approximately 91 percent of the patients had visited their pharmacist at least once during this same period and 84 .7 percent of the patients had visited the pharmacy at least once monthly . This data may indicate that either the screened patients were conscientious in ,regularly seeking health care or had an unusually high contact with the health care system in the area.

Screening Program Critique We believe that this study demonstrates a successful blood pressure screening approach and establishes the community pharmacy as an additional site that may contribute significantly to the detection of hypertensive patients in a community. Of particular note was the successful referral of patients to the physician for evaluation and treatment. There appear to be at least three explanations for this finding. First. the educational/counseling services provided by pharmacists appeared successful in motivating patients to accept referral recommendations from the screening team. The written material and verbal instruction given the patient were factual and emphasized the positive benefit of being detected and treated for high blood pressure. Second , the preestablished relationship between the pharmaCist and the patient may have contributed to the suc-

Journ al of the Ameri can Pharmaceutical Assoc iation

McKenney , Jennings and White

Table IV

Average Blood Pressures for 614 Screened Patients* Male

Age Range

< 25 25 - 34 35-44 45- 54 55-64 ;,65

Bl ac k

White

11 6/ 69 126/75 130/77 125/78 136/88 128/8 3 11 8/8 1 138/8 4 152/88 139/84 157/92 145 /8 2

Fe male Bla c k

11 0/70 11 5/73 138/8 4 141 /9 1 154/90 148 /8 6

White

11 4/7 1 1 16/75 126/79 ** 134/8 2 142 /8 2 149/7 9

Figure 5 - Blood Pressure Screening Program Referral Form

Physician

Referring Pharmacist _

Patient's Name

Address

Blood Pressure (1 )

Date _.

(2)

Date

(3)

Date _ _ ._

Average Blood Pressure Patient Appointment Scheduled for (Date) Patient Kept Appointment

If no, appointment rescheduled for __ j Yes No )

(Date )

_ _ _ __ Sitting _-::-_ _ Arm

Physician Bl ood Pressure

IR. LI

* I n groups divided by age, sex, and r ace

**

One patient was " other" race

cessful referral. Patients frequenting the screening pharmacy had come to expect clinical services and looked to the pharmacist as a dispenser of not only prescription drugs but of drug and health-related information as well. Finally , the cooperativeness of the participating physicians may have contributed to the succ ess of referrals . The physicians serving this target population agreed to have their office personnel arrange an appointment with the patient within one week after the screening procedure was complete . If they had not been so willing to cooperate and patients had to wait weeks or months for appointments , it is likely that few patients would have complied with the referral. An additional positive aspect of this screening approach was the success of having patients initially found to have an elevated blood pressure return to the pharmacy two additional times for rescreening. This success again can be attributed partly to the educational/counseling services provided by the pharmacist and the preestablished relationship between the patient and pharmacist. In addition , this success may have been partly the result of the accessibility and convenience afforded patients who were returning for additional blood pressure recordings . These patients were given return appointments with the pharmacist so that they did not have to wait an excessive period of time. It should be noted that the patient was not charged . a fee for screening- a fact that may have contributed to the patient's compliance to secondary screening. Another interesting aspect of this study was the relatively small number of patients found to have a sustained blood pressure elevation . Our results showed that 44 percent of the screened population would have been referred to the physician if only

Vol. NS 16, No. 4, April 1976

Phys ician Assessmen t (Please circle one)

Patient Hypertensive

Patient Normotensi ve

Comments. No te : Please re tain this form for th e referring pharmacist.

one blood pressure recording and pressures over 140/ 90 were used as referral criteria. Even if all patients with blood pressures over 160/ 95 after one blood pressure recording were referred to their physician , approximately 16 percent of the screened population would have been referred . By recording blood pressures on three consecutive visits and referring patients whose blood pressure averaged more than 160/ 95 , only five percent of the screened population were referred. This represents a nine-fold decrease in the number of patients with an initial blood pressure over 160/ 95. It may be argued that this procedure eliminated some patients with high blood pressure who should have been evaluated by a physiCian. To avoid this possibility, our screen ing team supplied each physician with the names of his patients who showed an initial blood pressure recording over 140/ 90 and 160/ 95 . In this manner, the physician was alerted to patients needing annual rescreening during routine yearly examinations or visits to his office for other medical complaints. The major negative result in this blood pressure screening program was the small percentage of the population screened . The main explanation for this finding probably relates to the patient scheduling system . As indicated previously, only onefourth of the population was encouraged to come to the pharmacy for blood pressure recording each week . This was done to avoid large crowds which could have completely disrupted the normal distribution of health services in the pharmacy . In retrospect, this restriction was probably a barrier to at least a portion of the population

wishing to have their blood pre.ssures recorded . It should also be noted that the screening month of January is a period of cold and inclement weather in this area of Virginia and may have affected the population 's response to the screening effort. Even with a correction of these barriers, however, every person in the target population could not be attracted to the community pharmacy screening program. Other screening efforts and approaches will be required in order for the entire community to be reached . Therefore , the community pharmacy, while providing an additional viable site and approach for screening , should not be thought of as the only site for a community blood pressure screening effort. The single largest barrier for the pharmacist who wishes to conduct a blood pressure screening program in his practice site is the time required for this effort. Most pharmacists are busy attempting to properly serve the pharmaceutical needs of their patients and are reluctant to Gommit themselves to programs , however needed and worthy, which may jeopardize ongoing practice responsibilities. Our experience in this screening program revealed that a minimum of three minutes per patient would be required of the practitioner who offers this blood pressure screening service . The use of volunteers to greet patients, assist them in completing the necessary forms and directing them to the screening area would be of great assistance in lessening the personal time commitment of the pharmacist. The pharmacist may concentrate his efforts on recording blood pressures on all screened

19 1

Blood Pressure Screening in a Community Pharmacy

patients , although this could be done by nurses or technicians under his employ. At the very least, the pharmacist should be personally involved in counseling patients who are requested to return to the pharmacy for additional blood pressure recordings or referred to their physician . • Acknowledgment The authors wish to express their sincere gratitude to Drs. Beverly N. Chambers, Carroll H. Iden, Thomas C. Iden and James R. York; to Susan B. Whitacre , pharmacist; to Fleet Richards, pharmaCist extern, and to community volunteers Margaret Ames (coordinator), Anna La Velie, Myrl Barfield, Nellie Dillow, Violet Sherman, Effie Kline, Dolly Enders, Nell Jane Hardesty, Virginia Carlisle, Ann Raikes and Georgianna Glasscock for making this study possible.

References 1. Veterans Administrati on Cooperat ive Study Group on Antihypertens ive Agents, "E ffects of Treatment on Morbidity in Hypertension . Results in Patients with Diastolic Blood Pressures Averaging 115 through 129 mm Hg .... JA MA. 202, 116 ( 1967) Veterans Admini strat io n Cooperative Study Group o n Antihypertensive Agents, "E ffects of Treatment on Morbidit y in Hypertension . II Results in Patients w ith Diastolic Blood Pressure Averaging 90 through 114 mm Hg.," JAMA. 213, 1143 (1970) 3. Schoenberger, ,J . A .. Stam ler, J., Shekeli e , R. B .. and Sheke ll e, S .. "Current Status of Hyperte nsion Contro l in an Industrial Popu lat io n ," JAMA. 222, 559 (1972) 4 Wi lber. J . A., and Barrow. J. G ... Hypertens ion - A Community Prob lem, " Am. J Med, 52 , 653( 1972) 5. Wi lber, J. A .. Millward, P., Baldwin , A., Capron. B., Sil verman, 0., James. L M. , Wolbert. T., and McCombs. N. J .. "Atlanta Community Hi gh Blood Pressure Program Methods of Community Hypertension Screening. " Circulation, 30, 11- 101(1972) 6. Wood. J. E .. Va rrow, J . G .. Freis, E. D., Gifford, R. W .. Kirkendall. W . M., Lee, R E., W illiamson . H., W ilber, J . A .. and Stamler, J., "Gu ideline s for the Detection, Diagnosis and Management o f Hypertensive Popu lations," Circulation. 44, A-263 ( 197 1) 7. Finnerty, F. A., Jr., Shaw, L W.o and Himmelsbach, C. K., " Hypertension in the Inner City," II Detection and Fol low-Up, Circulation. 47, 76 ( 1973) 8. Kannel. W. 8., Wo lf, P. A., VerIe r , J ., a nd Mc Namarra. P. M., "Epidemio logic Assessm e nt o f the Role of Blood Pressure in Stroke. " JAMA. 214, 301 ( 1970) 9. Kannel, W. B., Caste lli , W . P., McNamara , P. M ., McKee, P. A., and Feinleib, M., "Role of Blood Pressure in the Development of Congestive Heart Fai lure," N. Eng!. J. Med .. 287, 781 ( 1972) 10. Berman, C . L .. Guarin o, M . A., and Giovannoli, S. M., " High Blood Pressure Detection By Dentists ," JADA. 87 , 359( 1971) 11. Charm an. R. C .. " Hypertension Management Program in an Industrial Commu nity." JA MA. 227 , 287 (1974) 12. National High Blood Pressure Program, "Guidel ines for the Use of Volu nteers for High Blood Pressure Educadon and Detection Contro l, Programs," DHEW Publication , Bethesda, Md. ( 1975) 13. Wi lli ams, R. L. , " Should the Pharmacist Take the Pati ent's Blood Press ure? " JA PhA , NS14 , 202( 197 4) 14, Skhal, J . T .. "California Pharmaceut ica l Associat ion's Hypertension Program ." JAPhA. NS14, 197(1974) 15 McKenney, J. M., " The Challe nge of Hypertension: Turning Professional Inventory Into Action," Am. J. Hasp. Pharm.. 32, 465 ( 1975) 16, Kirk e ndall. W. M., Burton, A . C., Epstein, F. H. , and Fre is, E. D .. "Recommendations for Human Blood Pressure Determ inatio n by Sphygmomanometers," American Heart Association (booklet) New York ( 1967)

192

Guidelines for High Blood Pressure Screening in Community Pharmacies Planning Some of the steps that should be taken when planning a blood pressure screening program in a community pharmacy are listed below . Some of them are discussed in the following sections: Select screening date(s) and time(s). Design patient logistics Design and procure interview records Solicit and schedule volunteers Select screening methods Meet with local MD 's for endorsement Design and initiate publicity Select and procure equipment Standardize equipment Plan and procure educational material Train recorders, interviewers , educators Arrange referral mechanism Plan follow-up system Screening Site 1. An area in the pharmacy that is removed from the normal flow of patients should be identified for blood pressure screening . 2. The screening area should be as private and comfortable as possible . Screening Personnel 1. Screening personnel should be carefully selected and trained for the function they are to assume in the screening program. pharmacy receptionists, 2. Generally, pharmacy technicians or community volunteers can easily assume responsi-

bility for greeting patients, collecting screening information and directing patient logistiCS in the pharmacy. 3. Responsibility for blood pressure recording and education of patients should be performed either by individuals with prior established competence or by those given appropriate training. Nurses and pharmacists may more easily perform these functions . Recording Equipment 1. Blood pressure recording equipment should offer recording accuracy and durability. (See sources listed below.) 2. Mercury manometers may provide more recording accuracy but aneroid manometers are acceptable. 3. Aneroid recording equipment should be periodically standardized. Recording Technique 1. All personnel to be involved in recording blood pressures should be thoroughly trained and/or evaluated in the proper recording technique prior to the initiation of the program. 2. The recording methods endorsed by the American Heart Association may be accepted as the standard. 16 3. Interpretation of appearance and disappearance of sound as systolic and diastolic blood pressure respectively is acceptable for screening purposes. 4. Blood pressures should be taken in either arm (although the left arm is usually chosen) from the sitting position after a few minutes of rest. Blood Pressure Definition The definition of high blood pressure and its use in screening programs is illustrated

Some of th e sphygmomanom e ters w hi ch have been tes te d and recomm e nd ed by H ealth DCl'iccs arc listed bc low Source Anc ho r Hosp ita l Suppl y P. O. Box 699 Last Orange, N.I 070 19

Sl'hygll1oll1allOI1l!'fcrs Available Anch or Desk Me rcury Manom ctcr Anchor Pocket Anero id Mano me ter

Milt ex In str um ents 300 Pa rk Avcn u e, So u t h New York, NY 100 10

Erka m cter Desk Mercu ry M:J nomcte r Lrka C lini cll s Pock e t Aneroid Man o m eter

Propper Man u fact uring Co. In c. 10- 34 44th Drive Lo ng Island, NY 1110]

Pr opper Me rcurette and Mercur i, Desk !'v!:Jnom ete r Pr opper Pre cisomcter and other mode ls of Pocket Anero id Manom eters Propp er Manu e ll Sera-Sp h yg A nero id Hand Manometer

Py Ma H Corpora tion Box 302 Sommerville . N.I 08876

PyMa H Tr im lin c Mercur y Manomete r

Tay lor Instr u ment Consume r Prod uct s Di vision Syborn Corpor,ltion A rden, NC 28704

Tycos Desk Mercury Manomete r T ycos Pocket Anero id Ma no m eter T ycos Ha nd Aneroid Ma nometer

Journal o f th e American Pharm aceutical Assoc iation

McKenney, Jennings and White

on the accompanying chart. This is similar to the recommendations endorsed by the National High Blood Pressure Program. It should be noted that data in the literature are insufficient to clearly establish only pressures above 160/95 as high.

BP greater than 160 mm Hg and/or 95 mm Hg

BP less than 160 mm Hg and 95 mm Hg

Primary (initial) screen

I Record Pressure on th ree separate visits and average

Patient Education

1. All patients referred for medical evaluation or rescreening should be given an educational program. 2. The most efficient patient education program utilizes both the person-toperson approach and supplemental written or audio-visual materials for reinforcement. 3. The information provided patients need not be extensive but should include the following minimal points-High blood pressure causes serious, potentially fatal, complications if left unchecked. -High blood pressure produces no symptoms. -Treatment with prescription drugs can lower blood pressure and prevent complications. -Evaluation and treatment of high blood pressure starts with a visit to your physician.

~

~--------------~

BP average less than 160 mm Hg and 95 mm Hg

Vol. NS 16, No. 4, April 1976

/

BP average greater than 160 mm Hg and/ or95 mm Hg

Diastolic BP greater than 120 mm Hg on any visit

Follow-Up 1. A method of identifying patients who were not compliant with the referral should be devised prior to the initiation of the screening program with cooperating physicians or clinics. This ·may be done by either (1) having the screening team contact the medical referral center after the date the patient was to be seen or (2) having the medical referral center contact the screening team to

report missed appointments. 2. Referred patients who were not compliant with the referral should be contacted by the screening team and given additional counseling regarding the importance of evaluation and treatment. Methods of contacting patients in order of decreasing preference are-person-to-person -telephone -mail

James M. McKenney

James M. McKenney, PharmD, is coordinator of ambulatory clinical services for the department of pharmacy, Medical College of Virginia Hospitals, and assistant professor at the Virginia Commonwealth University school of pharmacy. He also directs the Virginia Pharmacists' High Blood Pressure Program. He received a BS in mathematics from Hampden Sydney College, a BS in pharmacy from the Medical College of Virginia and a PharmD from Wayne State University. His memberships include APhA and its Academy of Pharmacy Practice, Virginia Pharmaceutical Association, Virginia Society of Hospital Pharmacists, Rho Chi, Sigma Zeta and Kappa Psi.

Eugene V. White

Eugene V. White, BS, has been a community pharmacist in Berryville, Virginia, since 1950 when he received his BS from the Medical College of Virginia. The originator of the patient-oriented practice of pharmacy concept, White has long been active in pharmacy organizations . He was the first recipient of the APhA Academy of Pharmacy Practice Daniel B. Smith Award (1965). In 1966 the Philadelphia College of Pharmacy and Science awarded him an honorary master of pharmacy degree. Other honors include the Pharmacist of the Year award from Virginia Pharmaceutical Association and the 1973 ACA J. Leon Lascoff Award . He is a member of APhA and ACA .

William B. Jennings

William B. Jennings, BS, is a community pharmacy practitioner in northern Virginia. He received a BS in pharmacy and is currently completing his MS degree program at Virginia Commonwealth University school of pharmacy . He also has completed an ASHP residency from the Medical College of Virginia Hospitals. His memberships include the American Pharmaceutical Association, APhA Academy of Pharmacy Practice, Virginia Pharmaceutical Association and Kappa Psi.

Referral 1. An organized and structured method that enhances .the success of referring patients from the screening team to the physician should be devised and followed. 2. The referral mechanism should be arranged with participating physicians or clinics prior to the initiation of the screening program. 3. Some methods that may enhance the success of referral are listed below: -Insure medical evaluation of referred patients within one week of the final ·screening date -Assist referred patients in obtaining an appointment with their physician or clinic -Provide referred patients who do not have a private physician with the names and addresses of physicians or clinics willing to evaluate new hypertensive patients. (These lists may be obtained from medical societies, local heart associations, health departments, and other public and private institutions and clinics.) -Provide a list of financial assistance resources to patients.

Diastolic BP greater than 120 MM Hg

193