A randomized study comparing a patient-directed hypertension management strategy with usual office-based care

Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension: A Secondary Analysis of the ADAMPA Randomized Clinical Trial

Importance

Patient empowerment through pharmacologic self-management is a common strategy for some chronic diseases such as diabetes, but it is rarely used for controlling blood pressure (BP). Several trials have shown its potential for reducing BP in the short term, but evidence in the longer term is scarce.

Objective

To evaluate the longer-term effectiveness of BP self-monitoring plus self-titration of antihypertensive medication vs usual care for patients with poorly controlled hypertension, with passive follow-up and primary-care nursing involvement.

Design, Setting, and Participants

The ADAMPA (Impact of Self-Monitoring of Blood Pressure and Self-Titration of Medication in the Control of Hypertension) study was a randomized, unblinded clinical trial with 2 parallel arms conducted in Valencia, Spain. Included participants were patients 40 years or older, with systolic BP (SBP) over 145 mm Hg and/or diastolic BP (DBP) over 90 mm Hg, recruited from July 21, 2017, to June 30, 2018 (study completion, August 25, 2020). Statistical analysis was conducted on an intention-to-treat basis from August 2022 to February 2024.

Interventions

Participants were randomized 1:1 to usual care vs an individualized, prearranged plan based on BP self-monitoring plus medication self-titration.

Main Outcomes and Measures

The main outome was the adjusted mean difference (AMD) in SBP between groups at 24 months of follow-up. Secondary outcomes were the AMD in DBP between groups at 24 months of follow-up, proportion of patients reaching the BP target (SBP <140 mm Hg and DBP <90 mm Hg), change in behaviors, quality of life, health service use, and adverse events.

Results

Among 312 patients included in main trial, data on BP measurements at 24 months were available for 219 patients (111 in the intervention group and 108 in the control group). The mean (SD) age was 64.3 (10.1) years, and 120 patients (54.8%) were female; the mean (SD) SBP was 155.6 (13.1) mm Hg, and the mean (SD) diastolic BP was 90.8 (7.7) mm Hg. The median follow-up was 23.8 months (IQR, 19.8-24.5 months). The AMD in SBP at the end of follow-up was -3.4 mm Hg (95% CI, -4.7 to -2.1 mm Hg; P < .001), and the AMD in DBP was -2.5 mm Hg (95% CI, -3.5 to -1.6 mm Hg; P < .001). Subgroup analysis for the main outcome showed consistent results. Sensitivity analyses confirmed the robustness of the main findings. No differences were observed between groups in behaviors, quality of life, use of health services, or adverse events.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, BP self-monitoring plus self-titration of antihypertensive medication based on an individualized prearranged plan used in primary care reduced BP in the longer term with passive follow-up compared with usual care, without increasing health care use or adverse events. These results suggest that simple, inexpensive, and easy-to-implement self-management interventions have the potential to improve the long-term control of hypertension in routine clinical practice.

Trial Registration

ClinicalTrials.gov Identifier: NCT03242785.

Implementing a home-based virtual hypertension programme-a pilot feasibility study

INTRODUCTION

Implementing a health system-based hypertension programme may lower blood pressure (BP).

METHODS

We performed a randomized, controlled pilot study to assess feasibility, acceptability, and safety of a home-based virtual hypertension programme integrating evidence-based strategies to overcome current barriers to BP control. Trained clinical pharmacists staffed the virtual collaborative care clinic (vCCC) to remotely manage hypertension using a BP dashboard and phone "visits" to monitor BP, adherence, side effects of medications, and prescribe anti-hypertensives. Patients with uncontrolled hypertension were identified via electronic health records. Enrolled patients were randomized to either vCCC or usual care for 3 months. We assessed patients' home BP monitoring behaviour, and patients', physicians', and pharmacists' perspectives on feasibility and acceptability of individual programme components.

RESULTS

Thirty-one patients (vCCC = 17, usual care = 14) from six physician clinics completed the pilot study. After 3 months, average BP decreased in the vCCC arm (P = 0.01), but not in the control arm (P = 0.45). The vCCC participants measured BP more (9.9 vs. 1.2 per week, P < 0.001). There were no intervention-related adverse events. Participating physicians (n = 6), pharmacists (n = 5), and patients (n = 31) rated all programme components with average scores of >4.0, a pre-specified benchmark. Nine adaptations in vCCC design and delivery were made based on potential barriers to implementing the programme and suggestions.

CONCLUSION

A home-based virtual hypertension programme using team-based care, technology, and a logical integration of evidence-based strategies is safe, acceptable, and feasible to intended users. These pilot data support studies to assess the effectiveness of this programme at a larger scale.

Consumer Devices for Patient-Generated Health Data Using Blood Pressure Monitors for Managing Hypertension: Systematic Review

Background

In the era of digital health information technology, there has been a proliferation of devices that collect patient-generated health data (PGHD), including consumer blood pressure (BP) monitors. Despite their widespread use, it remains unclear whether such devices can improve health outcomes.

Objective

We performed a systematic review of the literature on consumer BP monitors that collect PGHD for managing hypertension to summarize their clinical impact on health and surrogate outcomes. We focused particularly on studies designed to measure the specific effect of using a BP monitor independent of cointerventions. We have also summarized the process and consumer experience outcomes.

Methods

An information specialist searched PubMed, MEDLINE, and Embase for controlled studies on consumer BP monitors published up to May 12, 2020. We assessed the risk of bias using an adapted 9-item appraisal tool and performed a narrative synthesis of the results.

Results

We identified 41 different types of BP monitors used in 49 studies included for review. Device engineers judged that 38 (92%) of those devices were similar to the currently available consumer BP monitors. The median sample size was 222 (IQR 101-416) participants, and the median length of follow-up was 6 (IQR 3-12) months. Of the included studies, 18 (36%) were designed to isolate the clinical effects of BP monitors; 6 of the 18 (33%) studies evaluated health outcomes (eg, mortality, hospitalizations, and quality of life), and data on those outcomes were unclear. The lack of clarity was due to low event rates, short follow-up duration, and risk of bias. All 18 studies that isolated the effect of BP monitors measured both systolic and diastolic BP and generally demonstrated a decrease of 2 to 4 mm Hg in systolic BP and 1 to 3 mm Hg in diastolic BP compared with non–BP monitor groups. Adherence to using consumer BP monitors ranged from 38% to 89%, and ease of use and satisfaction ratings were generally high. Adverse events were infrequent, but there were a few technical problems with devices (eg, incorrect device alerts).

Conclusions

Overall, BP monitors offer small benefits in terms of BP reduction; however, the health impact of these devices continues to remain unclear. Future studies are needed to examine the effectiveness of BP monitors that transmit data to health care providers. Additional data from implementation studies may help determine which components are critical for sustained BP improvement, which in turn may improve prescription decisions by clinicians and coverage decisions by policy makers.

Physician perceived barriers and facilitators for self-measured blood pressure monitoring- a qualitative study

INTRODUCTION

Improving hypertension management is a national priority that can decrease morbidity and mortality. Evidence-based hypertension management guidelines advocate self-measured BP (SMBP), but widespread implementation of SMBP is lacking. The purpose of this study was to describe the perspective of primary care physicians (PCPs) on SMBP to identify the barriers and facilitators for implementing SMBP.

METHODS

We collected data from PCPs from a large health system using semi-structured interviews based on the Theoretical Domains Framework (TDF). Responses were recorded, transcribed, and qualitatively analyzed into three overarching TDF domains based on the Behavior Change Wheel (BCW): 1) Motivation 2) Opportunity and 3) Capabilities. The sample size was based on theme saturation.

RESULTS

All 17 participating PCPs believed that SMBP is a useful, but underutilized tool. Although individual practices varied, most physicians felt that the increased data points from SMBP allowed for better hypertension management. Most felt that overcoming existing barriers would be difficult, but identified several facilitators: physician support of SMBP, the possibility of having other trained health professionals to assist with SMBP and patient education; improving patient engagement and empowerment with SMBP, and the interest of the health system in using technology to improve hypertension management.

CONCLUSION

PCPs believe that SMBP can improve hypertension management. There are numerous barriers and facilitators for implementing SMBP. Successful implementation in clinical practice will require implementation strategies targeted at increasing patient acceptability and reducing physician workload. This may need a radical change in the current methods of managing hypertension.

Current challenges for hypertension management: From better hypertension diagnosis to improved patients' adherence and blood pressure control

Hypertension control still remains a largely unmet challenge for public health systems. Despite the progress in blood pressure (BP) measurement techniques, and the availability of effective and safe antihypertensive drugs, a large number of hypertensive patients are not properly identified, and a significant proportion of those who receive antihypertensive treatment fail to achieve satisfactory control of their BP levels. It is thus not surprising that hypertension is still a major contributor to disease burden and disability worlwide, even in developed countries. This paper will address current challenges in hypertension management and potential strategies for an improvement in this field. In its first part relevant issues related to hypertension diagnosis will be addressed, in particular how to improve identification of sustained BP elevation and specific BP phenotypes such as white coat and masked hypertension trough the combined use of office and out-of-office BP monitoring techniques. In its second part focus will be on how to improve achievement of hypertension control in treated patients by optimization and simplification of medication regimens, including more efficient selection and titration of antihypertensive drugs and their combinations, aimed at achieving a more consistent 24hBP control; and by favoring a more active patients' and physicians' involvement in hypertension management also through BP telemonitoring and mobile health technologies.

A Web-Based Self-Titration Program to Control Blood Pressure in Patients With Primary Hypertension: Randomized Controlled Trial

BACKGROUND

Hypertension is a major cause of mortality in cardiac, vascular, and renal disease. Effective control of elevated blood pressure has been shown to reduce target organ damage. A Web-based self-titration program may empower patients to control their own disease, share decisions about antihypertensive dose titration, and improve self-management, ultimately improving health-related quality of life.

OBJECTIVE

Our primary aim was to evaluate the effects of a Web-based self-titration program for improving blood pressure control in patients with primary hypertension. Our secondary aim was to evaluate the effects of that program on improving health-related quality of life.

METHODS

This was a parallel-group, double-blind, randomized controlled trial with assessments at baseline, 3 months, and 6 months. We included patients with primary hypertension (blood pressure>130/80 mm Hg) from a cardiology outpatient department in northern Taiwan and divided them randomly into intervention and control groups. The intervention group received the Web-based self-titration program, while the control group received usual care. The random allocation was concealed from participants and outcome evaluators. Health-related quality of life was measured by the EuroQol five-dimension self-report questionnaire. We used generalized estimating equations to evaluate the effects of the intervention.

RESULTS

We included 222 patients and divided them equally into intervention (n=111) and control (n=111) groups. Patients receiving the Web-based self-titration program showed significantly greater improvement in the systolic and diastolic blood pressure control than those who did not receive this program, at 3 months (-21.4 mm Hg and -5.4 mm Hg, respectively; P<.001) and 6 months (-27.8 mm Hg and -9.7 mm Hg, respectively; P<.001). Compared with the control group, the intervention group showed a significant decrease in the overall defined daily dose at both 3 (-0.202, P=.003) and 6 (-0.236, P=.001) months. Finally, health-related quality of life improved significantly in the intervention group compared with the control group at both 3 and 6 months (both, P<.001).

CONCLUSIONS

A Web-based self-titration program can provide immediate feedback to patients about how to control their blood pressure and manage their disease at home. This program not only decreases mean blood pressure but also increases health-related quality of life in patients with primary hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03470974; https://clinicaltrials.gov/ct2/show/NCT03470974.

Effect of Home Medication Titration on Blood Pressure Control in Patients With Hypertension: A Meta-Analysis of Randomized Controlled Trials

Supplemental Digital Content is available in the text.

Background:

Medication titration has been used in home blood pressure (BP) control, with the expectation of enabling patients with hypertension to better manage their BP.

Objective:

The study goal was to estimate the effects of medication titration intervention in lowering the systolic blood pressure and diastolic blood pressure of patients with hypertension.

Methods:

The meta-analysis included randomized controlled trials on adults diagnosed with hypertension and BP≧130/80 mm Hg, having a medication-titration intervention, and using a home BP measurement. We systematically searched PubMed, CINAHL, Ovid-Medline, and the Cochrane Library, for studies published from 1997 to 2017. The quality of the studies was evaluated by the Modified Jadad scale. Statistical heterogeneity among the trials was evaluated using Q statistics and I². Publication bias was assessed with the funnel plot and Rosenthal’s fail-safe N.

Results:

The meta-analysis included 4 studies randomizing 1335 participants. Medication-titration intervention significantly assisted hypertensive patients to improve BP control; systolic blood pressure was reduced by 6.86 mm Hg [95% confidence interval (CI), 4.80-8.93, P<0.0001] and diastolic blood pressure by 3.03 mm Hg (95% CI, 2.07-3.99, P<0.0001), did not significantly affect EQ-5D scores (mean difference, 0.02; 95% CI, −0.01 to 0.04, P=0.13).

Conclusions:

Our findings suggest home medication titration of antihypertensive medication for hypertensive patients significantly improved home BP control. However, the strategy did not enhance quality of life in patients with hypertension.

Intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence- and person-based approach

Background

This paper describes the intervention planning process for the Home and Online Management and Evaluation of Blood Pressure (HOME BP), a digital intervention to promote hypertension self-management. It illustrates how a Person-Based Approach can be integrated with theory- and evidence-based approaches. The Person-Based Approach to intervention development emphasises the use of qualitative research to ensure that the intervention is acceptable, persuasive, engaging and easy to implement.

Methods

Our intervention planning process comprised two parallel, integrated work streams, which combined theory-, evidence- and person-based elements. The first work stream involved collating evidence from a mixed methods feasibility study, a systematic review and a synthesis of qualitative research. This evidence was analysed to identify likely barriers and facilitators to uptake and implementation as well as design features that should be incorporated in the HOME BP intervention. The second work stream used three complementary approaches to theoretical modelling: developing brief guiding principles for intervention design, causal modelling to map behaviour change techniques in the intervention onto the Behaviour Change Wheel and Normalisation Process Theory frameworks, and developing a logic model.

Results

The different elements of our integrated approach to intervention planning yielded important, complementary insights into how to design the intervention to maximise acceptability and ease of implementation by both patients and health professionals. From the primary and secondary evidence, we identified key barriers to overcome (such as patient and health professional concerns about side effects of escalating medication) and effective intervention ingredients (such as providing in-person support for making healthy behaviour changes). Our guiding principles highlighted unique design features that could address these issues (such as online reassurance and procedures for managing concerns). Causal modelling ensured that all relevant behavioural determinants had been addressed, and provided a complete description of the intervention. Our logic model linked the hypothesised mechanisms of action of our intervention to existing psychological theory.

Conclusion

Our integrated approach to intervention development, combining theory-, evidence- and person-based approaches, increased the clarity, comprehensiveness and confidence of our theoretical modelling and enabled us to ground our intervention in an in-depth understanding of the barriers and facilitators most relevant to this specific intervention and user population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0553-4) contains supplementary material, which is available to authorized users.

Role of pharmacist in cardiovascular disease-related health promotion and in hypertension and dyslipidemia management: a cross-sectional study in the State of Qatar

RATIONALE, AIMS AND OBJECTIVES

In Qatar, cardiovascular diseases (CVD) have recently become the leading cause of morbidity and mortality. Prevention, detection and management of CVD risk factors reduce CVD chance. The study objectives were to assess Qatar pharmacists' involvement in CVD health promotion, to identify the activities that they currently provide to patients with CVD risk factors, to describe their attitudes towards their involvement in CVD prevention and to assess their perceived barriers for provision of CVD prevention services

METHOD

We conducted a cross-sectional survey of community and ambulatory pharmacists in Qatar. Pharmacist characteristics, involvement in CVD-related activities along with their attitudes and perceived barriers were analysed using frequency distributions. Bivariate linear regression models were used to test for associations between CVD health promotion activity score and each variable. Variables with a P-value of 0.20 or less were included in the multivariate model.

RESULTS

A total of 141 pharmacists completed the survey (response rate 60%). More than 70% responded with rarely or never to 6 out of the 10 CVD health promotion activities. Eighty-four per cent and 68% always or often describe to patients the appropriate time to take antihypertensive medications and the common medication adverse effects, respectively. Yet, 50% rarely or never review the medication refill history or provide adherence interventions. Lack of CVD educational materials was the top perceived barrier (55%) in addition to lack of having private counselling area (44.6%), and lack of time (38.3%). Females and community pharmacists were more involved in CVD health promotion (P = 0.046 and P = 0.017, respectively) than their counterparts. Health promotion practice increased with increasing attitudes score and decreased with increased barriers score (P = 0.012 and P = 0.001).

CONCLUSION

The scope of pharmacy practice in CVD prevention is limited in Qatar. Efforts need to be exerted to increase pharmacists' involvement in CVD prevention.

The Effect of Self-Monitoring of Blood Pressure on Medication Adherence and Lifestyle Factors: A Systematic Review and Meta-Analysis

BACKGROUND

Self-monitoring of blood pressure (SMBP) can contribute to reduced blood pressure in people with hypertension. Potential mediators include increased medication, improved adherence, and changes in lifestyle factors including dietary change and increased physical activity. The objective of this review was to determine the effect of SMBP on medication adherence, medication persistence, and lifestyle factors in people with hypertension.

METHODS

Electronic bibliographic databases were searched through February 2014 to identify randomized controlled trials that compared SMBP to control/usual care in ambulatory hypertensive patients and reported medication or nonpharmacologic treatment adherence measures.

RESULTS

Twenty-eight trials with 7,021 participants fulfilled the inclusion criteria. Medication adherence was assessed in 25 trials (89%), dietary outcomes in 8 (29%), physical activity in 6 (21%), and medication persistence in 1 (4%). Blood pressure was assessed in 26 studies (93%). Follow-up ranged from 2 weeks to 12 months. Pooled results of 13 studies demonstrated a small but significant overall effect on medication adherence in favor of SMBP interventions (standardized mean difference 0.21, 95% CI 0.08, 0.34), with moderate heterogeneity (I2 = 43%). Standardized mean difference was used to express the size of intervention effect in each study relative to the variability observed, and was used to combine the results of studies where different measures of medication adherence were used. Where SMBP interventions had a significant effect on lifestyle factor change, the effect was unlikely to be clinically significant. Pooled results of 11 studies demonstrate a significant overall effect on diastolic blood pressure in favor of SMBP (weighted mean difference -2.02, 95% CI -2.93, -1.11), with low heterogeneity (I2 = 0%). A test for subgroup differences showed no difference when studies were grouped according to whether medication adherence was significantly improved or not.

CONCLUSIONS

SMBP may contribute to improvements in medication adherence in hypertensives. However, evidence for the effect of SMBP on lifestyle change and medication persistence is scarce, of poor quality, and suggests little clinically relevant benefit.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Self-monitoring of blood pressure for improving adherence to antihypertensive medicines and blood pressure control: a randomized controlled trial

BACKGROUND

Self-monitoring is reported to have limited efficacy for hypertension management in high-income countries. In this study, we aimed to evaluate the effect of self-monitoring on blood pressure (BP) control in an Iranian population.

METHODS

A randomized controlled trial was conducted on 196 mild to moderate hypertensive patients in an outpatient cardiovascular clinic. Patients in the intervention group received a wrist self-monitoring device and were educated to measure and document their BP daily during the study period (24 weeks). Patients in the control group received usual care. Three follow-up visits with the physician were scheduled for all patients (weeks 4, 12, and 24), and the investigator assessed adherence to medications after each visit (pill counting). The primary outcome (BP) was compared between groups using repeated-measure analysis of variance.

RESULTS

One hundred ninety patients completed the study. Systolic BP (144.4±7.4 vs 145.9±6.4mm Hg) and diastolic BP (85.5±6.9 vs. 85.1±7.7mm Hg) were similar between groups at baseline. The trend of BP was not significantly different between groups during the study period. Systolic and diastolic BP decreased significantly in both groups at the first follow-up visit (systolic BP: 132.6 vs. 133.4mm Hg; diastolic BP: 77.4 vs. 77.2mm Hg). In the intervention group, we observed a small continued decrease in diastolic BP up to week 24 BP (P = 0.01). Both groups showed adherence rates >95% during the study period.

CONCLUSIONS

Our study could not confirm that self-monitoring can improve BP control in patients with frequent medical visits.

Simplified therapeutic intervention to control hypertension and hypercholesterolemia: a cluster randomized controlled trial (STITCH2)

BACKGROUND

Notwithstanding improving rates of hypertension control in North America, management of patients with both hypertension and dyslipidemia remains problematic. Based on evidence of improved control utilizing a simplified algorithm for management of hypertension (STITCH), we questioned whether a simplified comprehensive treatment algorithm featuring initial use of single-pill combinations (SPCs) would improve management of participants with both hypertension and dyslipidemia.

METHOD

We randomized 35 primary care practices in Ontario to either Guidelines-care (following current Canadian guidelines) or STITCH2-care (following a treatment algorithm featuring SPCs). Practices each enrolled up to 50 participants with at least one risk factor above target at entry based on Canadian guidelines for BP and LDL-cholesterol control. The primary endpoint was achieving targets for both hypertension and dyslipidemia control after 6 months, assessed at the practice level.

RESULTS

The primary endpoint was achieved in 31.3% of participants in STITCH2-care practices, compared with 28.1% in Guidelines-care practices, yielding a difference of 3.2% (P = 0.63). Notably, STITCH2-care practices had a significantly greater reduction in SBP while LDL-cholesterol reduction was only marginally greater in STITCH2 practices.

CONCLUSION

The STITCH2 algorithm resulted in significantly greater use of any SPC compared with Guidelines-care and greater use of the SPC of calcium channel blocker/statin. Unwillingness of the prescribing physician to advance treatment beyond a monotherapy threshold was found to be an important determinant for failing to achieve blood pressure control. In contrast, the more important determinant for failing to achieve LDL control appeared to be the unwillingness of the prescribing physician to initiate therapy with a statin.

CoCo trial: Color-coded blood pressure Control, a randomized controlled study

BACKGROUND

Inadequate blood pressure (BP) control is a frequent challenge in general practice. The objective of this study was to determine whether a color-coded BP booklet using a traffic light scheme (red, >180 mmHg systolic BP and/or >110 mmHg diastolic BP; yellow, >140-180 mmHg systolic BP or >90-110 mmHg diastolic BP; green, ≤140 mmHg systolic BP and ≤90 mmHg diastolic BP) improves BP control and adherence with home BP measurement.

METHODS

In this two-group, randomized controlled trial, general practitioners recruited adult patients with a BP >140 mmHg systolic and/or >90 mmHg diastolic. Patients in the control group received a standard BP booklet and the intervention group used a color-coded booklet for daily home BP measurement. The main outcomes were changes in BP, BP control (treatment goal <140/90 mmHg), and adherence with home BP measurement after 6 months.

RESULTS

One hundred and twenty-one of 137 included patients qualified for analysis. After 6 months, a significant decrease in systolic and diastolic BP was achieved in both groups, with no significant difference between the groups (16.1/7.9 mmHg in the intervention group versus 13.1/8.6 mmHg in the control group, P=0.3/0.7). BP control (treatment target <140/90 mmHg) was achieved significantly more often in the intervention group (43% versus 25%; P=0.037; number needed to treat of 5). Adherence with home BP measurement overall was high, with a trend in favor of the intervention group (98.6% versus 96.2%; P=0.1).

CONCLUSION

Color-coded BP self-monitoring significantly improved BP control (number needed to treat of 5, meaning that every fifth patient utilizing color-coded self-monitoring achieved better BP control after 6 months), but no significant between-group difference was observed in BP change. A markedly higher percentage of patients achieved BP values in the normal range. This simple, inexpensive approach of color-coded BP self-monitoring is user-friendly and applicable in primary care, and should be implemented in the care of patients with arterial hypertension.

From bad behaviour to bad biology: pitfalls and promises in the management of resistant hypertension

Control rates for hypertension have dramatically improved during the past 2 decades-especially in Canada. However, hypertension remains one of the top risk factors for premature death globally. Furthermore, one-third of Canadians with hypertension have not obtained adequate blood pressure control. Most of these patients have resistant hypertension with uncontrolled blood pressure despite therapy. The etiology of resistant hypertension is multifactorial but includes both behavioural and biological factors. Among behavioural factors, nonadherence on the part of patients and especially clinical inertia on the part of health care professionals are contributing causes. An understanding of the root causes underlying the failure to control an individual's blood pressure is central to optimal subsequent management. Further advances in blood pressure control rates in this group of patients will depend on improvements in health care delivery systems and the further development of innovative therapies. Drugs combining multiple antihypertensive agents in a single pill and the development of new technologies to lower blood pressure, primarily by disruption of the sympathetic nervous system, have the potential to be useful strategies in this effort.

Design and rationale for Home Blood Pressure Telemonitoring and Case Management to Control Hypertension (HyperLink): a cluster randomized trial

BACKGROUND

Patients with high blood pressure (BP) visit a physician an average of 4 times or more per year in the U.S., yet BP is controlled in fewer than half. Practical, robust and sustainable models are needed to improve BP in patients with uncontrolled hypertension.

OBJECTIVES

The Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study (HyperLink) is a cluster-randomized trial designed to determine whether an intervention that combines home BP telemonitoring with pharmacist case management improves BP control compared to usual care at 6 and 12 months in patients with uncontrolled hypertension. Secondary outcomes are maintenance of BP control at 18 months, patient satisfaction with their health care, and costs of care.

METHODS

HyperLink enrolled 450 hypertensive patients with uncontrolled BP from 16 primary care clinics. Eight clinics were randomized to provide usual care (UC) to their patients (n=222) and 8 were randomized to provide the telemonitoring intervention (TI) (n=228). TI patients received home BP telemonitors that internally store and electronically transmit BP data to a secure database. Pharmacist case managers adjust antihypertensive therapy based on the home BP data under a collaborative practice agreement with the clinics' primary care teams. The length of the intervention is 12 months, with follow-up to 18 months to determine the durability of the intervention.

CONCLUSIONS

We will test in a real primary care setting whether combining BP telemonitoring and pharmacist case management can achieve and maintain high rates of BP control compared to usual care.

[Prevention of therapeutic inertia in the treatment of arterial hypertension by using a program of home blood pressure monitoring]

OBJECTIVE

To evaluate the efficacy of a program of home blood pressure monitoring (HBPM) on therapeutic Inertia (TI) in mild-to-moderate hypertension (AHT).

DESIGN

Controlled, randomised clinical trial.

SETTING

Forty six clinics in 35 primary care centres. Spain.

PARTICIPANTS

A total of 232 patients with uncontrolled hypertension were included.

INTERVENTION

Two groups with 116 patients were formed: 1) Control group (CG): standard health intervention; 2) Intervention group (IG): patients who were included in the HBPM program.

MAIN MEASUREMENTS

TI was calculated by the ratio: Number of patients whose pharmacological treatment was not changed in each visit/Number of patients with an average BP 140mmHg and/or 90mmHg in the general population or 130 and/or 90 mmHg in diabetics. The mean BPs and the percentage of controlled patients were calculated. The mean number of people that required an intervention in order to avoid TI was calculated (NI).

RESULTS

A total of 209 patients completed the study, with TI in 35.64% (95% CI=29.85%-41.43%) of the sample, and in 71.63% (95% CI=63.9-79.36%) of the uncontrolled hypertensive patients. The TI was 22.42% (95% CI=24.2-37%) in the IG and 50% (95% CI=37.75-62.25) in the CG (p<.05) in visit 2, and 25.23% (95% CI=14.84-35.62) and 46.07% (95% CI=33.85-58.29) in the final visit for IG and CG, respectively (P<.05). The NI was 4.3.

CONCLUSIONS

TI was very significant among the uncontrolled hypertensive patients. The studied interventions are effective for improving TI.

Home blood pressure for the management of hypertension: will it become the new standard of practice?

Accurate identification of hypertension is crucial for the prevention of cardiovascular disease. Home blood pressure monitoring (HBPM) provides superior prediction of cardiovascular disease, compared with clinic pressures. HBPM can be a valuable resource for the effective treatment of hypertension, when combined with other modalities used to improve patient education, lifestyle enhancement, adherence to medication and reduction of unnecessary clinic visits. In some developed nations, more than half of households with a hypertensive patient have a device for HBPM. The use of HBPM by patients and the acceptance of HBPM measurements by providers is increasing. The long-term effectiveness of HBPM, combined with telemetry for disease prevention, is promising. More research is still needed to establish its full value. It is predicted that HBPM has definite potential for more effective strategies to control hypertension and reduce the need for on-site clinical care.

Management of cardiovascular risk factors is leaving the office: potential impact of telemedicine

Effective control of hypertension and the other cardiovascular risk factors has been dependent on primary medical care as provided by family practitioners and internists. The progressive reduction in availability of primary care for adult populations in the United States threatens the likelihood of better control of the risk factors and potential loss of opportunity for prevention of cardiovascular disease. Recent progress has been made in the use of home blood pressure monitoring for improvement in classification of risk for hypertensive patients. Several studies establish the feasibility of home pressure monitoring combined with telemedicine for improving control of hypertension. Some studies have explored the role of self-care for adjustment of medication, as well. The potential growth of this strategy for effective control of hypertension with reduced need for face-to-face encounter time in primary care is a promising solution to the reduction in primary care providers. Management of hyperlipidemia and diabetes by telemedicine is also being explored, particularly for rural areas, but may also be effective in urban settings. Development of technology for home monitoring together with electronic communication to providers and mechanisms for education, feedback, and warnings offers a promising solution to the possible crisis in prevention of cardiovascular disease due to the loss of traditional primary care.

Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review

BACKGROUND

It is recognized that for the reliable assessment of blood pressure (BP) and the accurate diagnosis of hypertension, out-of-office BP measurement with ambulatory (ABPM) or home BP monitoring (HBPM) is often required. The clinical usefulness of ABPM is well established. However, despite the wide use of HBPM, only in the last decade convincing evidence on its usefulness has accumulated.

METHODS

Systematic review of the evidence on applying HBPM in the diagnosis and treatment of hypertension (PubMed, Cochrane Library, 1970-2010).

RESULTS

Sixteen studies in untreated and treated subjects assessed the diagnostic ability of HBPM by taking ABPM as reference. Seven randomized studies compared HBPM vs. office measurements or ABPM for treatment adjustment, whereas many studies compared HBPM with office measurements in assessing the antihypertensive drug effects. Several studies with different design investigated the role of HBPM vs. office measurements in improving patients' compliance with treatment and hypertension control rates. The evidence on the cost-effectiveness of HBPM is limited. The studies reviewed consistently showed moderate diagnostic agreement between HBPM and ABPM, and superiority of HBPM compared to office measurements in diagnosing uncontrolled hypertension, assessing antihypertensive drug effects and improving patients' compliance and hypertension control. Preliminary evidence suggests that HBPM has the potential for cost savings.

CONCLUSIONS

There is conclusive evidence that HBPM is useful for the initial diagnosis and the long-term follow-up of treated hypertension. These data are useful for the optimal application of HBPM, which is widely used in clinical practice. More studies on the cost-effectiveness of HBPM are needed.

Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review

BACKGROUND

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 organise and deliver care to hypertensive patients has not been clearly identified.

AIM

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension.

DESIGN OF STUDY

Systematic review of randomised controlled trials.

SETTING

Primary and ambulatory care.

METHOD

Interventions were categorised as following: 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. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic.

RESULTS

Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [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). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial.

CONCLUSION

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 is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.

Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis

Hypertension remains the most common modifiable cardiovascular risk factor, yet hypertension control rates remain dismal. Home blood pressure (BP) monitoring has the potential to improve hypertension control. The purpose of this review was to quantify both the magnitude and mechanisms of benefit of home BP monitoring on BP reduction. Using a structured review, studies were selected if they reported either changes in BP or percentage of participants achieving a pre-established BP goal between randomized groups using home-based and office-based BP measurements. A random-effects model was used to estimate the magnitude of benefit and relative risk. The search yielded 37 randomized controlled trials with 9446 participants that contributed data for this meta-analysis. Compared with clinic-based measurements (control group), systolic BP improved with home-based BP monitoring (-2.63 mm Hg; 95% CI, -4.24, -1.02); diastolic BP also showed improvement (-1.68 mm Hg; 95% CI, -2.58, -0.79). Reductions in home BP monitoring-based therapy were greater when telemonitoring was used. Home BP monitoring led to more frequent antihypertensive medication reductions (relative risk, 2.02 [95% CI, 1.32 to 3.11]) and was associated with less therapeutic inertia defined as unchanged medication despite elevated BP (relative risk for unchanged medication, 0.82 [95% CI, 0.68 to 0.99]). Compared with clinic BP monitoring alone, home BP monitoring has the potential to overcome therapeutic inertia and lead to a small but significant reduction in systolic and diastolic BP. Hypertension control with home BP monitoring can be enhanced further when accompanied by plans to monitor and treat elevated BP such as through telemonitoring.

What are the basic self-monitoring components for cardiovascular risk management?

BACKGROUND

Self-monitoring is increasingly recommended as a method of managing cardiovascular disease. However, the design, implementation and reproducibility of the self-monitoring interventions appear to vary considerably. We examined the interventions included in systematic reviews of self-monitoring for four clinical problems that increase cardiovascular disease risk.

METHODS

We searched Medline and Cochrane databases for systematic reviews of self-monitoring for: heart failure, oral anticoagulation therapy, hypertension and type 2 diabetes. We extracted data using a pre-specified template for the identifiable components of the interventions for each disease. Data was also extracted on the theoretical basis of the education provided, the rationale given for the self-monitoring regime adopted and the compliance with the self-monitoring regime by the patients.

RESULTS

From 52 randomized controlled trials (10,388 patients) we identified four main components in self-monitoring interventions: education, self-measurement, adjustment/adherence and contact with health professionals. Considerable variation in these components occurred across trials and conditions, and often components were poorly described. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted.

CONCLUSIONS

The components of self-monitoring interventions are not well defined despite current guidelines for self-monitoring in cardiovascular disease management. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted. We propose a checklist of factors to be considered in the design of self-monitoring interventions which may aid in the provision of an evidence-based rationale for each component as well as increase the reproducibility of effective interventions for clinicians and researchers.

Physician effectiveness in interventions to improve cardiovascular medication adherence: a systematic review

BACKGROUND

Medications for the prevention and treatment of cardiovascular disease save lives but adherence is often inadequate. The optimal role for physicians in improving adherence remains unclear.

OBJECTIVE

Using existing evidence, we set the goal of evaluating the physician's role in improving medication adherence.

DESIGN

We conducted systematic searches of English-language peer-reviewed publications in MEDLINE and EMBASE from 1966 through 12/31/2008.

SUBJECTS AND INTERVENTIONS

We selected randomized controlled trials of interventions to improve adherence to medications used for preventing or treating cardiovascular disease or diabetes.

MAIN MEASURES

Articles were classified as either (1) physician "active"-a physician participated in designing or implementing the intervention; (2) physician "passive"-physicians treating intervention group patients received patient adherence information while physicians treating controls did not; or (3) physicians noninvolved. We also identified studies in which healthcare professionals helped deliver the intervention. We did a meta-analysis of the studies involving healthcare professionals to determine aggregate Cohen's D effect sizes (ES).

KEY RESULTS

We identified 6,550 articles; 168 were reviewed in full, 82 met inclusion criteria. The majority of all studies (88.9%) showed improved adherence. Physician noninvolved studies were more likely (35.0% of studies) to show a medium or large effect on adherence compared to physician-involved studies (31.3%). Among interventions requiring a healthcare professional, physician-noninvolved interventions were more effective (ES 0.47; 95% CI 0.38-0.56) than physician-involved interventions (ES 0.25; 95% CI 0.21-0.29; p < 0.001). Among physician-involved interventions, physician-passive interventions were marginally more effective (ES 0.29; 95% CI 0.22-0.36) than physician-active interventions (ES 0.23; 95% CI 0.17-0.28; p = 0.2).

CONCLUSIONS

Adherence interventions utilizing non-physician healthcare professionals are effective in improving cardiovascular medication adherence, but further study is needed to identify the optimal role for physicians.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial

BACKGROUND

Control of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care.

METHODS

This randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681.

FINDINGS

527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022).

INTERPRETATION

Self-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care.

FUNDING

Department of Health Policy Research Programme, National Coordinating Centre for Research Capacity Development, and Midlands Research Practices Consortium.

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

BACKGROUND

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.

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 (CCTR) and Medline; and Embase from January 1980.

SELECTION CRITERIA

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 systemsOutcomes 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 Handbook.

MAIN RESULTS

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).

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 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.

The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial

Background

Despite the many antihypertensive medications available, two-thirds of patients with hypertension do not achieve blood pressure control. This is thought to be due to a combination of poor patient education, poor medication adherence, and "clinical inertia." The present trial evaluates an intervention consisting of health coaching, home blood pressure monitoring, and home medication titration as a method to address these three causes of poor hypertension control.

Methods/Design

The randomized controlled trial will include 300 patients with poorly controlled hypertension. Participants will be recruited from a primary care clinic in a teaching hospital that primarily serves low-income populations.

An intervention group of 150 participants will receive health coaching, home blood pressure monitoring, and home-titration of antihypertensive medications during 6 months. The control group (n = 150) will receive health coaching plus home blood pressure monitoring for the same duration. A passive control group will receive usual care. Blood pressure measurements will take place at baseline, and after 6 and 12 months. The primary outcome will be change in systolic blood pressure after 6 and 12 months. Secondary outcomes measured will be change in diastolic blood pressure, adverse events, and patient and provider satisfaction.

Discussion

The present study is designed to assess whether the 3-pronged approach of health coaching, home blood pressure monitoring, and home medication titration can successfully improve blood pressure, and if so, whether this effect persists beyond the period of the intervention.

Trial Registration

ClinicalTrials.gov identifier: NCT01013857

[Control of therapeutic inertia in the treatment of arterial hypertension by using different strategies]

OBJECTIVE

To evaluate the efficacy of different interventions on therapeutic Inertia (TI) in mild-to-moderate hypertension (AHT).

DESIGN

Controlled, randomised clinical trial.

SETTING

Two hundred clinics in 5 primary care centres. Spain.

PARTICIPANTS

A total of 1104 patients with uncontrolled hypertension were included.

INTERVENTION

Four groups with 276 patients were formed: 1) Control group (CG): standard health intervention; 2) Education intervention and a program of home blood pressure monitoring (HBPM) (EG); 3) Card control intervention and HBPM programme (CHG); 4) Education intervention, card control and HBPM programme (ECHG).

MAIN MEASUREMENTS

TI was calculated by the rate: (Number of patients whose pharmacological treatment was not changed in each visit/Number of patients with an average BP 140mmHg and/or 90mmHg in the general population or 130 and/or 90 mmHg in diabetics). The mean BPs and the percentage of controlled patients were calculated. The mean number of people that required an intervention in order to avoid TI was calculated (NI).

RESULTS

A total of 921 patients completed the study, and 1842 visits were made, with TI in 36.8% (IC=5.8%) of the sample and in 82.58% (IC=8.2%) of the uncontrolled hypertensive patients. The TI was 60% (CI=4.2%), 38.4% (CI=4.4%) 30.2 (CI=4.3%) and 14.7 (CI=3.3%) (p=0.001) for CG, EG, CHG and ECHG, respectively. The percentage controlled at the end of study was 35.3% (CI=1.1%), 54.7% (CI=1.8%), 60.2% (CI=2.1%) and 65.1% (CI=2.2%) (p<0.01) for CG, EG, CHG and ECHG, respectively. The NI were 4.6, 3.3 and 2.2 for CG, EG, CHG and ECHG, respectively.

CONCLUSIONS

TI was very significant among the uncontrolled hypertensive patients. The studied interventions are effective for improving TI.

Protocol for a randomised controlled trial of telemonitoring and self-management in the control of hypertension: telemonitoring and self-management in hypertension. [ISRCTN17585681]

Background

Controlling blood pressure with drugs is a key aspect of cardiovascular disease prevention, but until recently has been the sole preserve of health professionals. Self-management of hypertension is an under researched area in which potential benefits for both patients and professionals are great.

Methods and design

The telemonitoring and self-management in hypertension trial (TASMINH2) will be a primary care based randomised controlled trial with embedded economic and qualitative analyses in order to evaluate the costs and effects of increasing patient involvement in blood pressure management, specifically with respect to home monitoring and self titration of antihypertensive medication compared to usual care. Provision of remote monitoring results to participating practices will ensure that practice staff are able to engage with self management and provide assistance where required. 478 patients will be recruited from general practices in the West Midlands, which is sufficient to detect clinically significant differences in systolic blood pressure between self-management and usual care of 5 mmHg with 90% power. Patients will be excluded if they demonstrate an inability to self monitor, their blood pressure is below 140/90 or above 200/100, they are on three or more antihypertensive medications, have a terminal disease or their blood pressure is not managed by their general practitioner.

The primary end point is change in mean systolic blood pressure (mmHg) between baseline and each follow up point (6 months and 12 months). Secondary outcomes will include change in mean diastolic blood pressure, costs, adverse events, health behaviours, illness perceptions, beliefs about medication, medication compliance and anxiety. Modelling will evaluate the impact of costs and effects on a system wide basis. The qualitative analysis will draw upon the views of users, informal carers and professionals regarding the acceptability of self-management and prerequisites for future widespread implementation should the trial show this approach to be efficacious.

Discussion

The TASMINH2 trial will provide important new evidence regarding the costs and effects of self monitoring with telemonitoring in a representative primary care hypertensive population.

Trial Registration

ISRCTN17585681

Proportion and characteristics of patients who measure their blood pressure at home: Nationwide survey in Slovenia

Introduction. Home blood pressure monitoring has several advantages over blood pressure monitoring at a physician's office, and has become a useful instrument in the management of hypertension. Objective. To explore the rate and characteristics of patients who measure their blood pressure at home. Methods. A sample of 2,752 patients with diagnosis of essential arterial hypertension was selected from 12596 consecutive office visitors. Data of 2,639 patients was appropriate for analysis. The data concerning home blood pressure measurement and patients' characteristics were obtained from the patients' case histories. Results 1,835 (69.5%) out of 2,639 patients measured their blood pressure at home. 1,284 (70.0%) of home blood pressure patients had their own blood pressure measurement device. There were some important differences between these two groups: home blood pressure patients were more frequently male, of younger age, better educated, from urban area, mostly non-smokers, more likely to have diabetes mellitus and ischemic heart disease and had higher number of co-morbidities and were on other drugs beside antihypertensive medication. Using the logistic regression analysis we found that the most powerful predictors of home blood pressure monitoring had higher education level than primary school OR=1.80 (95% CI 1.37-2.37), non-smoking OR=2.16 (95% CI 1.40-3.33) and having a physician in urban area OR=1.32 (95% CI 1.02-1.71). Conclusion. Home blood pressure monitoring is popular in Slovenia. Patients who measured blood pressure at home were different from patients who did not. Younger age, higher education, non-smoking, having a physician in urban area and longer duration of hypertension were predictors of home blood pressure monitoring.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >/=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >or=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Self-monitoring of blood pressure and the role of community pharmacists in Kuwait

OBJECTIVE

To determine the types of devices for self-monitoring of blood pressure available to consumers in Kuwait and the pharmacists' knowledge and level of information provided to consumers when purchasing such devices.

MATERIALS AND METHODS

It was possible to contact 196 of the 230 eligible pharmacies from five governorates in Kuwait. Ten of these were used to pretest the questionnaire and six declined to participate. Another six did not carry any blood pressure monitoring devices and hence were excluded. Data was then collected from pharmacists at the 174 remaining community pharmacies via face-to-face structured interview of the respondents at their work sites.

RESULTS

Of the 174 pharmacists, 173 (99.4%) claimed to offer or provide advice to clients at the time of purchasing devices, 117 (67.1%) of them stating that they did so even if the patients did not ask. Although 147 (84.5%) respondents correctly identified the mercury sphygmomanometer as the most reliable device for measuring blood pressure, less than half (86, 49.4%) claimed to know how to check the accuracy of the devices they sold. Only 25 (14.4%) pharmacists could actually identify the correct procedure for checking the accuracy of the devices and only 25 (14.4%) pharmacists could correctly identify cutoff points for systolic and diastolic blood pressure delineating clinical hypertension. Only 1 pharmacist could correctly name a reference source for blood pressure measurement.

CONCLUSION

There is a need for improvement of community pharmacists' competence in supporting patients and in providing them with information regarding devices for measuring blood pressure in Kuwait.

Supporting self-management for patients with complex medical needs: recommendations of a working group

Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.