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

      1 , 2 , 3 , 4 , 5
      Cochrane Hypertension Group
      Cochrane Database of Systematic Reviews
      Wiley

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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 systemsOutcomes 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.

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          Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies

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            Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38

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              Variance imputation for overviews of clinical trials with continuous response.

              Overviews of clinical trials are an efficient and important means of summarizing information about a particular scientific area. When the outcome is a continuous variable, both treatment effect and variance estimates are required to construct a confidence interval for the overall treatment effect. Often, only partial information about the variance is provided in the publication of the clinical trial. This paper provides heuristic suggestions for variance imputation based on partial variance information. Both pretest-posttest (parallel groups) and crossover designs are considered. A key idea is to use separate sources of incomplete information to help choose a better variance estimate. The imputation suggestions are illustrated with a data set.
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                Author and article information

                Journal
                146518
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                March 17 2010
                Affiliations
                [1 ]National University of Ireland; Department of General Practice; No 1, Distillery Road, Galway Ireland
                [2 ]Faculty of Medicine and Health Sciences; Department of General Practice; Clinical Science Institute National University of Ireland Galway Ireland
                [3 ]Trinity College Centre for Health Sciences; Department of Public Health and Primary Care; AMNCH Tallaght Dublin Ireland 24
                [4 ]Department of Community Based Medicine; Academic Unit of Primary Health Care; University of Bristol Cotham House Cotham Hill Bristol UK BS6 6JL
                [5 ]Royal College of Surgeons in Ireland Medical School; Department of Family Medicine and General Practice; Mercer's Medical Centre Lower Stephen Street Dublin Ireland 2
                Article
                10.1002/14651858.CD005182.pub4
                20238338
                4a5d6b1d-4f55-477c-a04a-aec0863d159c
                © 2010
                History

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