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

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Abstract
Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified. To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension. All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980. Randomized 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 Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook. 72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, 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 systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). 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. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73). 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 vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation. 帮助高血压患者控制血压的干预措施 社区高血压患者经常无法达到治疗目标，这被称为顽固性高血压。对高血压患者组织和提供护理的最佳方法尚未得到明确确认。 为了明确干预措施对改善高血压患者血压控制的有效性，以及评估预约提醒对改善高血压患者随访的有效性， 我们检索了Cochrane对照试验中心注册库(CCTR)、Medline（从建库至今）和Embase（1980年1月至今），不限语言。 针对高血压患者的随机对照试验(RCTs)评估以下干预措施: (1)自我监测 (2)针对患者的教育干预 (3)针对卫生专业人士的教育干预 (4)卫生专业人士(护士或药剂师)领导的护理 (5)旨在改善护理服务的组织干预 (6)预约提醒系统。 评估的结局指标为: (1)平均收缩压和舒张压 (2)血压控制水平 (3)临床随访患者比例。 两位作者独立地提取数据,并根据Cochrane手册概述的标准对每项研究进行评估。 72个随机对照试验符合我们的纳入标准。纳入研究的方法学质量参差不齐。一个大样本RCT试验（高血压监测和随访研究）结果显示，使用有组织的定期复查系统与强效降压药联合的疗法，结果显示能降低三组（根据入组时血压分三个组别）的收缩压（加权平均差（WMD）=-8.0mmHg，95％CI=-8.8 - -7.2mmHg）和舒张压（WMD=-4.3mmHg，95％CI=-4.7 - -3.9mmHg），以及5年随访期间全因死亡率（6.4％对7.8％，差异=1.4％）。其他干预措施有不同的效果。自我监测可以适度降低收缩压（WMD=-2.5mmHg，95％CI=-3.7 - -1.3mmHg）和舒张压（WMD=-1.8mmHg，95％CI=-2.4 - -1.2mmHg）。针对患者或健康专业人员的教育干预的随机对照试验存在异质性，似乎也不太可能大幅度降低血压。护士或药剂师领导的护理可能是一个未来有前途的方法，大多数的随机对照试验评估改善血压控制和改善平均收缩压和舒张压指标，但这些干预需要进一步评估。预约提醒系统还需要进一步评估，因为异质性和试验数据量小，但大多数试验增加了随访人员的比例（比值比=0.41，95％CI=0.32 - 0.51），而且两个小试验也改善了血压控制，比值比支持干预组，为0.54（95％CI=0.41 - 0.73）。...