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Cochrane summary

Improving blood pressure control in hypertension

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This review looked at how care for patients with hypertension should be delivered in the community to enhance blood pressure control

Review questions

What interventions are effective in improving the control of blood pressure in patients with hypertension?
Are reminders effective in improving the follow-up of patients with hypertension?

Nursing implications

Hypertension is a significant public health problem as it is associated with stroke and cardiovascular events. These result in increased morbidity and mortality for patients and increased costs for health services.
While evidence has demonstrated the benefits of antihypertension drug therapy in controlling blood pressure, community-based studies throughout the world have shown that blood pressure goals are achieved in only 25-40% of patients who take antihypertensive drugs.
A Cochrane review was warranted to investigate how care for patients with hypertension should be organised and delivered in the community to help improve blood pressure control.

Study characteristics

This summary is based on a Cochrane review of 72 randomised controlled trials. Participants were aged 18 years or over with a diagnosis of essential hypertension that could be treated with or without antihypertensive drugs. They could be from primary care, outpatient or community settings.
Interventions aimed to improve control of blood pressure or clinic attendance. They were classified as self-monitoring, educational interventions directed at the patient, educational interventions directed at the health professional, health professional-led care, organisational interventions that aimed to improve the delivery of care, and appointment reminder systems.
The outcomes of interest were mean systolic blood pressure and/or mean diastolic blood pressure, control of blood pressure, and proportion of patients followed up at clinic.
The methodological quality of included studies was classed as poor to moderate. Meta-analysis was undertaken where possible.

Summary of key evidence

Eighteen studies evaluated self-monitoring. Pooled data from 12 studies showed that self-monitoring was associated with a significant reduction in mean systolic blood pressure compared with controls. Pooled data from 14 studies revealed that self-monitoring was associated with a more modest reduction in mean diastolic blood pressure than controls. In the six studies that reported on control of blood pressure, no significant improvement was shown.
Twenty trials examined educational interventions directed at patients compared with controls. However, due to heterogeneity, the results for mean difference systolic blood pressure and diastolic blood pressure were not valid.
Ten trials investigated educational interventions directed towards physicians compared with controls. There was no significant decrease in mean systolic or diastolic blood pressure. Control of blood pressure produced heterogeneous results.
Twelve trials found that nurse- or pharmacist-led care may be a promising way of delivering care, with the majority of studies being associated with improved blood pressure control. For all three outcomes, however, pooling the results from individual studies produced hetero-geneous results, so the results should be interpreted with caution.
Nine trials compared organisational interventions that aimed to improve the delivery of care with controls. For all three outcomes, pooling of results produced heterogeneous results. The largest study (the Hypertension Detection and Follow-Up Program) produced significant reductions in systolic and diastolic blood pressure across the three groups.
Eight trials evaluated appointment reminder systems compared with controls. In five, reminder systems were associated with an improvement in follow up. However, the pooled results were heterogenous because of one single outlying study and should be treated with caution.

Best-practice recommendations

Self-monitoring was associated with a decline in systolic blood pressure (2.5mmHg) and diastolic blood pressure (1.8mmHg). None of the other interventions were linked with large, clinically important decreases in either systolic or diastolic pressure.
Effective delivery of hypertensive care requires a systematic approach in the community, incorporating regular review of patients and a willingness to intensify antihypertensive drug treatment when blood pressure goals are not being met.

Mengxue He is master’s student, School of Nursing, Fudan University, China, and a member of the Cochrane Nursing Care Field (CNCF)

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