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Systematic Review

Interventions used to improve control of blood pressure in patients with hypertension.

Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database of Systematic Reviews 2010 3:CD005182. [PubMed]

Sources of funding: National Health Service (NHS) R&D Primary Care Career Scientist Award, UK, Medical Research Council Health Services Research Training Fellowship Scheme, UK, Health Research Board, Cochrane Fellowship Scheme, Ireland. No perceived conflict of interest.

Main author affiliation: Glynn LG, Department of General Practice, National University of Ireland, No 1, Distillery Road„ Galway, Ireland.

Q: What is the effectiveness of interventions to improve control of blood pressure in patients with hypertension and how effective are reminders for improving the follow-up of patients with hypertension?

BACKGROUND

This is an update to Fahey 2006 (PMID:17054244). The objective of this review was to determine the effectiveness of interventions intended to improve follow-up and control of blood pressure in patients with essential hypertension taking blood pressure lowering drugs. Interventions considered included: self-monitoring, educational interventions directed to the patient, educational interventions directed to the health professional, health professional (nurse or pharmacist) led care, organisational interventions that aimed to improve the delivery of care and appointment reminder systems.

INCLUSION

Individual studies from systematic review

SEARCH FOR EVIDENCE: 1950 to February 2008

INCLUDED STUDIES: 72 studies in 78 papers

STUDIES RELATED TO PRESCRIBING: 12

STUDY DESIGN: RCT, Other (cluster RCT).

STUDY CHARACTERISTICS:

  • Target Population: Physicians, Nurses, Pharmacists, Other (Nurse practitioners, Health practitioners).
  • Intervention(s): Reminders - general, Nurse-led care, Pharmacy-led care, Multifaceted, Continuity of care, Reminders - CDSS, Audit and feedback, Patient-mediated, Change to setting/site of service delivery, Distribution of educational materials
  • Setting: Location - Primary care practices, Outpatient clinics, Hospitals, Communities, Other (Health/medical centers, Homes, Work-site, HDFP centers); Ownership - Public, Other (Not specified); Institution - Teaching, Not specified.
  • Patients Reviewed: Age - Adults, Elderly, Not specified; Diagnosis/Clinical condition - Essential hypertension, uncontrolled hypertension, diabetes.
  • Drug Related Outcome Categories: Choice, Cost containment, Concordance, Other appropriate use.
  • Other Outcome Categories: Diagnosis, Record-keeping, patient-provider communication, procedures, other resource use.

AUTHORS' ANALYSIS OF DATA:

Meta-analysis, Effect size, Descriptive

REVIEW QUALITY: 7

RESULTS - OVERALL

All of the included studies were RCTs. 14 used a cluster design and the review authors reported that in four trials, no adjustment was made for clustering. Reminders - general (n=4), pharmacy led care (n=3), nurse-led care (n=3) and patient-mediated (n=2) were found to be generally effective for improving appropriate care behaviour, while multifaceted interventions (n=2)had mixed effects for improving appropriate care. There was insufficient evidence to determine the effectiveness of audit and feedback, changes to setting/site of service delivery, continuity of care, reminders - CDSS and distribution of educational materials on appropriate care behaviour. Primary outcomes of interest included changes in patients' clinical values (blood pressure) and studies that only reported on this outcome were excluded from our analysis (n=56).

RESULTS - RELATED TO PRESCRIBING

Nurse led (n=2) and pharmacy led (n=3)care were both found to be generally effective for improving concordance outcomes but there was insufficient evidence to determine the effectiveness of these intervention on improving cost containment and choice. There was also insufficient evidence to determine the effectiveness of the following interventions on improving prescribing behaviour: patient mediated, multifaceted, change to site of service delivery, continuity of care, reminders - general and reminders- CDSS.

CONCLUSIONS - OVERALL

Medium quality review. Too few studies were located to make firm conclusions on the effectiveness of these interventions on appropriate care outcomes.

CONCLUSIONS - RELATED TO PRESCRIBING

Medium quality review. Too few studies were located to make firm conclusions on the effectiveness of these interventions on prescribing behaviours.


Table of Results

Comparison Outcome N Analysis Results
Audit and feedback vs control Appropriate care 1 Vote counting based on direction of effect Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Distribution of educational materials vs control Appropriate care 1 Vote counting based on direction of effect Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Multifaceted (educational) vs control Appropriate care 2 Vote counting based statistical significance Vote counting 1/2 RCTs favoured intervention: mixed effects.

Other Prescribing outcomes:
Choice:
Vote counting 0/1 RCT favoured intervention: insufficient evidence.
Patient-mediated vs control Appropriate care 2 Vote counting based on direction of effect Vote counting 2/2 RCTs favoured intervention: generally effective.

Prescribing related outcomes
Other appropriate use:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Reminders - general vs control Appropriate care 4 Vote counting based on direction of effect Vote counting 3/3 RCTs favoured intervention: generally effective.

Prescribing related outcomes
Choice:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.

Other appropriate use:
Vote counting 0/1 RCT favoured intervention: insufficient evidence.
Reminders - CDSS vs control Appropriate use 1 Vote counting based on direction of effect Choice:
Vote counting 0/1 RCT favoured intervention: insufficient evidence.
Continuity of care (stepped care) vs control (referred care) Appropriate use 1 Vote counting based on direction of effect Choice:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Changes in setting/site of service delivery vs control Appropriate use 1 Vote counting based on direction of effect Choice:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.

Concordance:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Revision of professional roles - pharmacy led care vs control Appropriate use 3 Vote counting based on direction of effect Concordance:
Vote counting 2/3 RCT comparisons favoured: generally effective.

Cost containment:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.
Revision of professional roles - nurse led care vs control Appropriate use 2 Vote counting based on direction of effect Concordance:
Vote counting 5/5 RCT comparisons (from 2 studies) favoured intervention: generally effective.

Choice:
Vote counting 1/1 RCT favoured intervention: insufficient evidence.