Interventions used to improve control of blood pressure in patients with hypertension
Abstract
Background
It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals‐ a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.
Objectives
To determine the effectiveness of interventions to improve control of blood pressure in patients with elevated blood pressure.
To evaluate the ability of reminders to improve the follow‐up of patients with elevated blood pressure.
Search methods
All‐language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.
Selection criteria
Randomised controlled trials (RCTs) of patients with hypertension that evaluated the following interventions:
(1) self‐monitoring
(2) educational interventions directed to the patient
(3) educational interventions directed to the health professional
(4) health professional (nurse or pharmacist) led care
(5) organisational interventions that aimed to improve the delivery of care
(6) appointment reminder systems
Outcomes assessed were:
(1) mean systolic and diastolic blood pressure
(2) control of blood pressure
(3) proportion of patients followed up at clinic
Data collection and analysis
Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.
Main results
59 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review linked to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference ‐8.2/‐4.2 mmHg, ‐11.7/‐6.5 mmHg, ‐10.6/‐7.6 mmHg for 3 strata of entry blood pressure) and all‐cause mortality at five years follow‐up (6.38% versus 7.78%, difference 1.4%) in a single large RCT‐ the Hypertension Detection and Follow‐Up study. Other interventions had variable effects. Self‐monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): ‐2.03 mmHg, 95%CI: ‐2.69 to ‐1.38 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow‐up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.
Authors' conclusions
Family practices and community‐based clinics need to have an organized system of regular follow‐up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a systematic stepped care approach when patients do not reach target blood pressure levels.
PICOs
Plain language summary
There is a lack of evidence about how care for hypertensive patients should be organized and delivered in the community to improve blood pressure control. This review was aimed to determine the effectiveness of interventions whose objective was to improve follow‐up and control of blood pressure in patients taking blood pressure lowering drugs. We included studies that had as populations of interest adult patients with primary elevations of blood pressure in an ambulatory setting. The interventions included all those that aimed to improve blood pressure control. The outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and the proportion of patients followed up at clinic.
Fifty nine randomised controlled trials met our inclusion criteria. The range of interventions used included (1) self‐monitoring, (2) educational interventions directed to the patient, (3) educational interventions directed to the health professional, (4) health professional (nurse or pharmacist) led care, (5) organizational interventions that aimed to improve the delivery of care, (6) appointment reminder systems. The trials were very different in methodological quality, part of which was due to poor reporting. An organized system of regular review linked to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all‐cause mortality in a single large RCT‐ the Hypertension Detection and Follow‐Up study. Other interventions had variable effects. Self‐monitoring was associated with moderate net reductions in diastolic blood pressure (weighted mean difference (WMD): ‐2.03 mmHg, 95% confidence interval (CI): ‐2.69 to ‐1.38 mmHg. Appointment reminders increased the proportion of individuals who attended for follow‐up (absolute difference 16%, but this pooled result should be treated with caution because of the heterogeneous results from individual RCTs). Trials of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care appears to be a promising way of delivering care but requires further evaluation.
We conclude that an organized system of registration, recall and regular review linked to a vigorous stepped care approach to antihypertensive drug treatment appears the most likely way to improve the control of elevated blood pressure. Health professional (nurse or pharmacist) led care requires further evaluation. Education alone, either to health professionals or patients, does not appear to be associated with large net reductions in blood pressure.
