Using digital tools to support clinical pharmacist HRT reviews in primary care

A three-monthly review is recommended after starting hormone replacement therapy (HRT) to assess menopausal symptom control, side effects and bleeding patterns. These factors are also evaluated during an annual review, as well as any changes in medical history^​1​. 

A programme was designed using digital tools that allowed women to provide information prior to a telephone HRT review — this encouraged woman to engage with HRT reviews to allow the continuation of safe prescribing.

Women taking HRT aged between 45–70 years, who had not received an annual review of their HRT or a blood pressure (BP) check in the past year, were identified as the patient cohort. These women were invited for their three-monthly or annual HRT review with a clinical pharmacist after completing a questionnaire that included BP and weight measurements.

The work was carried out in a GP surgery in Bexhill-on-Sea, East Sussex, and women using topical HRT were excluded from this study. A total of 168 women were identified who required a HRT review and BP check. From this cohort, 142 women were sent HRT questionnaires using Accurx text messaging and the remaining 26 women were not contacted using this method as they either did not have a mobile telephone number or there was no consent to contact using this method^​2​. At any point, if a patient opted out of the pathway, once a participant, their GP was informed.

From the 142 participants in this study, there was a high response rate to contact: 115 (81.0%) completed the HRT questionnaire, which included a BP check and weight measurement. There was no response from 13 patients (9.2%), and ten patients submitted incomplete questionnaires. The non-responders will be further contacted and those patients that submitted incomplete questionnaires will be supported further so that a complete HRT review can be carried out. 

Following completion of the HRT questionnaire, patients were contacted by telephone to complete their HRT review with a clinical pharmacist.

Most women used home BP monitors to submit readings — 22 women preferred to be booked into clinic to have this done and 19 of these patients subsequently attended clinic.

Detailed instructions were given to patients on how to monitor their BP at home and how and where to escalate concerns. The frequency of BP monitoring was patient specific. Also if there was a pre-existing diagnosis of hypertension, then four days of readings were requested. Alternatively, if there was not a pre-existing diagnosis of hypertension, then seven days of readings were needed. All BP readings were submitted to the project team using Accurx, and there were options to submit readings via email or a paper diary. Patients were advised on BP thresholds and safety-netting advice was given to patients about low or very high BP readings.

From the 115 women that completed HRT questionnaires in full, eight patients had raised BP readings. Therefore, seven days of home BP monitoring was requested. In addition, seven patients had normal home BP readings, with one diagnosed with hypertension and subsequently treated to target.

There were 12 women with a BMI of 30–40 and three women with BMI >40 that were aged 45–60 years inclusive. Of the women that were aged over 60–70 years, none had a BMI that was 30–40, and one woman had a BMI that was >40. These figures were important to note when discussing the risks and benefits of HRT, since an increased BMI is associated with an increased risk of malignancy and venous thromboembolism¹. During reviews, signposting to weight management services and lifestyle advice should be given as appropriate.

A total of 92 HRT reviews were completed in full by the clinical pharmacist. From the completed reviews, women were aged 45–60 years inclusive (82.6%) and 16 women were over the age of 60–70 years (17.3%). In the first group, there were nine medicine changes, one woman was switched from sequential HRT to a continuous preparation, three women were co-prescribed topical oestrogen for genitourinary syndrome of menopause and five women were switched from patches to gel formulations owing to issues with patch adherence. In the latter group, there were three medicine changes, two women were switched from oral HRT to a transdermal preparation to reduce the risk of venous thromboembolism and one woman had a dose reduction of her HRT.

In addition, nine women aged 45–60 years were referred to the GP, two were referred owing to a breast lump — one of which was referred for an urgent suspected cancer — two were referred for bleeding on HRT requiring further investigation and five were referred to the GP for unrelated non-gynaecological health issues. In the older cohort, three patients were referred back to the GP for unrelated non-gynaecological health issues. Furthermore, patients were signposted to services to promote healthy behaviours — for example, smoking cessation services and cervical screening.

The project team took responsibility for completed HRT questionnaires, reviewing BP readings and was the point of contact for patient queries or concerns. If hypertension was newly diagnosed, or it was demonstrated that a patient with known hypertension was not treated to target, the patient’s care was managed by the clinical pharmacist then handed over back to the GP practice for review and medicines advice. Written communication was sent to the patients’ registered GP following verbal advice to the patients, which was important to ensure that there was a safe transfer of care. During the project, patients were followed up to ensure relevant actions had taken place.

Patient feedback was sought from the 92 patients that had undergone full HRT reviews. Of the 46 patients who responded (50%), 19 described their ethnic origin as White, 20 identified as English/Welsh/Scottish/British, two patients identified as Asian or Asian British, one identified as South Asian and one identified as Black. Patients were very positive when asked ‘how satisfied they were with the care received’ (rating it on average 4.5 out of 5) and rated ‘the overall experience with the clinical pharmacist’ an average 4.4 out of 5. Comments indicated that patients valued the opportunity to review their HRT. There was also positive feedback of the communication back to GP surgeries. In addition, feedback from GPs indicated that the pathway reduced workload at the GP surgeries.

The pathway had a high response rate — reasons for this could be that women wished to continue with their HRT prescriptions and, therefore, engaged in reviews as part of the ongoing safe prescribing and assessment of HRT medicine. There were, however, some non-responders, which could be because this cohort of patients is generally well, and they may not feel compelled to participate in this pilot. It was noted that telephone call reminders may be helpful in engaging with these patients.

Our pathway aligns with the principles of personalised care, including shared decision-making and supported self-management. It may be that the findings of this study may be applied to test the delivery of community pharmacy independent prescribing for HRT reviews. The Women’s Health Strategy for England aims to improve health outcomes and reduce inequalities across groups of women. Specifically, we anticipate that this pathway will improve information provision on women’s health, perform HRT medication reviews, as well as support incidental case finding of hypertension, and promote treatment to target of hypertension as necessary. 

Suneeta Kochhar, clinical director and clinical lead for cardiovascular disease prevention and women’s health, NHS Sussex

Sascha Trani, clinical pharmacist in Bexhill-on-Sea, East Sussex