Closing the hypertension gap with ABPM: a primary care quality-improvement study

Hypertension remains substantially underdiagnosed and undertreated globally, with ambulatory blood pressure monitoring (ABPM) - the gold standard for hypertension diagnosis - significantly underutilised in primary care. Nurse-led protocols offer a scalable approach to closing these gaps, yet evidence from rural Irish general practice is limited. This retrospective paired clinical audit reviewed electronic health records of 706 adults aged ≥ 25 years with clinic systolic blood pressure ≥ 150 mmHg or a coded ICPC-2 diagnosis of hypertension at a single rural Irish general practice. In November 2019, a nurse-led clinical practice pathway based on ESH and NICE guidelines was implemented in the practice, empowering practice nurses to independently initiate ABPM referrals, deliver lifestyle counselling, and coordinate follow-up. Data were then collected pre-protocol (November 2017 to 2019) and post-protocol (November 2019 to 2022) to assess changes in HTN diagnosis and management. Paired categorical outcomes were compared using McNemar’s test with Bonferroni correction; continuous outcomes were compared using the Wilcoxon signed-rank test. ABPM utilisation rose by more than 10% (57.1% to 69.0%), enabling more accurate diagnosis and treatment decisions. Coded hypertension diagnoses rose from 78.9% to 83.9%, and the proportion achieving guideline-recommended BP targets improved from 37.7% to 44.1%. Antihypertensive therapy was meaningfully intensified: ACEi/ARB and calcium channel blocker prescribing increased significantly, and the mean number of medication classes rose from 1.88 to 2.18. Post-protocol analysis identified a sequence of associations linking ABPM uptake to new hypertension diagnosis (OR 6.60) and new diagnosis to antihypertensive prescribing (OR 5.45). A nurse-led protocol centred on ABPM as the diagnostic cornerstone was associated with significant improvements in hypertension diagnosis and treatment in a rural Irish primary care setting, sustained throughout the COVID-19 pandemic. These findings support wider evaluation of nurse-led, ABPM-integrated models as a practical approach to closing the hypertension treatment gap in primary care.