Cochrane for Clinicians
Putting Evidence into Practice
Interventions to Improve Blood Pressure Control in Patients with Hypertension
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Am Fam Physician. 2007 Aug 1;76(3):373-374.
A 53-year-old man with idiopathic hypertension has not achieved blood pressure control after three years of treatment.
What interventions are effective in improving blood pressure control in patients with hypertension?
One large study of adults with hypertension showed that a rigorous, systematic program including regular patient review and aggressive antihypertensive drug therapy improved systolic and diastolic blood pressure and reduced all-cause mortality (7.8 to 6.4 percent at five years; number needed to treat = 71). A pooled analysis of six randomized controlled trials (RCTs) on organizational interventions to improve care showed heterogeneous results. Self-monitoring of blood pressure, educational interventions directed at the patient or health professional, health professional-led care, and appointment reminder systems each had variable and clinically insignificant effects on blood pressure control. Educational interventions alone were unlikely to produce clinically important reductions in blood pressure.1
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 hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.
Search Strategy: All-language search of all articles (any year) in the Cochrane Controlled Trials Register, Medline, and Embase from June 2000.
Selection Criteria: Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions:
Educational interventions directed at the patient
Educational interventions directed at the health professional
Health professional-led care (nurse or pharmacist)
Organizational interventions aimed at improving the delivery of care
Appointment reminder systems
Outcomes assessed were:
Mean systolic and diastolic blood pressure
Control of blood pressure
Proportion of patients followed up at clinics
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: Fifty-six RCTs met inclusion criteria. The methodologic quality of included studies was variable. An organized system of regular review with vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference [WMD] = −8.2/−4.2 mm Hg, −11.7/−6.5 mm Hg, and −10.6/−7.6 mm Hg for three strata of entry blood pressure) and all-cause mortality at five years of follow-up (6.4 versus 7.8 percent, difference 1.4 percent) in a single large RCT (Hypertension Detection and Follow-Up study). Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (WMD = −2.0 mm Hg; 95% confidence interval, −2.7 to −1.4, respectively). Appointment reminders increased the proportion of individuals who attended 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 when used alone. Health professional-led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but this approach requires further evaluation.
Authors' conclusions: Family practices and community-based clinics need to have an organized system of regular follow-up and review of patients with hypertension. Antihypertensive drug therapy should be implemented by means of a vigorous, stepped care approach when patients do not reach target blood pressure levels.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (http://www.cochrane.org)
It is estimated that only 25 to 40 percent of treated patients with hypertension achieve blood pressure goals. Poor compliance with medications and patients not having a primary care physician each have been associated with uncontrolled blood pressure.
This Cochrane review provides some support that an aggressive, stepped approach to providing antihypertensive medications effectively reduces mortality risk. The largest clinical trial on organizational interventions aimed at improving delivery of care in patients with hypertension (Hypertension Detection and Follow-up study) showed a reduction in systolic and diastolic blood pressure and in all-cause mortality. The study's multifaceted intervention included free care, registration, recall, and regular patient review in addition to an aggressive, stepped approach to therapy. However, it is not possible to distinguish the independent effects of organizational interventions or a stepped approach on blood pressure control.2
Other nonpharmacologic interventions to improve outcomes in patients with hypertension (e.g., salt restriction, body weight reduction, stress management, exercise, alcohol intake reduction) have produced heterogeneous or clinically insignificant results.3 Pooled data from 12 RCTs showed that self-monitoring of blood pressure was associated with a statistically significant reduction in diastolic blood pressure (−2.0 mm Hg); however, it is unclear if this is clinically significant. Although the literature shows that in-office blood pressure readings are higher than ambulatory-based or self-monitored readings, several of the studies in the review did not adjust for this discrepancy.
Twenty-five RCTs reported on educational interventions directed at the patient or a health professional. Although health professional education was associated with a small reduction in systolic blood pressure, individual RCTs had heterogeneous results, making pooled data invalid.
Although health professional-led intervention may be a promising method of delivering care, study results on this topic were heterogeneous. Five out of seven RCTs showed a difference in mean systolic blood pressure ranging from −13 to 0 mm Hg with this method; six out of seven RCTs showed a mean difference in the diastolic blood pressure ranging from −8 to 0 mm Hg. One well-conducted RCT showed that nurse-led intervention was also effective at reducing patient body weight and increasing exercise participation. Five RCTs reviewed appointment reminder systems (mail- or computer-based) and showed an improvement in patient follow-up.
Based on the review, effective hypertension management requires a systematic approach to the identification of patients with hypertension, follow-up, and aggressive treatment with antihypertensive medications. This approach likely leads to modest reductions in cardiovascular mortality and morbidity. Supplemental strategies such as self-monitoring of blood pressure and health professional initiatives require further evaluation. Educational interventions (directed at patients or health professionals) alone are unlikely to lead to clinically significant reductions in blood pressure.
Address correspondence to Kathryn K. Holder, Lt Col, USAF, MC, at firstname.lastname@example.org. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
1. Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2006;(4):CD005182.
2. Hypertension Detection and Follow-up Program Cooperative Group. Therapeutic control of blood pressure in the Hypertension Detection and Follow-up Program. Prev Med. 1979;8:2–13.
3. Ebrahim S, Smith GD. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. J Public Health Med. 1998;20:441–8.
The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Holder presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab005182.html.
The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.
Copyright © 2007 by the American Academy of Family Physicians.
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