Educational and organisational interventions used to improve the management of hypertension in primary care: a systematic review.
BACKGROUND
The optimal way in which to organise and deliver care to patients with hypertension has not been clearly identified.


OBJECTIVE
To determine the effectiveness of educational and organisational strategies used to improve control of blood pressure.


METHODS
Systematic review of randomised controlled trials (RCTs).


METHODS
Quantitative pooling of RCT data on 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) organizational interventions that aimed to improve the delivery of care, (6) appointment reminder systems.


RESULTS
Fifty-six RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2mmHg, -11.7/-6.5mmHg, -10.6/-7.6mmHg for three strata of entry blood pressure) and all-cause mortality at 5 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 diastolic blood pressure, weighted mean difference (WMD): -2.03 mmHg, 95% confidence interval (CI) = -2.7 to -1.4 mmHg. Educational interventions directed towards physicians were associated with small reductions in systolic blood pressure (WMD) -2.0mmHg, 95% CI = -3.5 to -0.6mmHg and diastolic blood pressure (WMD) -0.4mmHg, 95% CI -1.1 to 0.3mmHg.


CONCLUSIONS
General practices and community-based clinics need to have an organised 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. These findings have important implications for recommendations concerning implementation of structured delivery of care in hypertension guidelines.
Fahey
Tom
T
University of Dundee, Scotland. t.p.fahey@chs.dundee.ac.uk
Schroeder
Knut
K
Ebrahim
Shah
S
D000328:Adult; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000379:methods; D005194:Family Practice / Q000193:education*; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy*; D010353:Patient Education as Topic; D015397:Program Evaluation; D011569:Psychiatric Status Rating Scales; D011787:Quality of Health Care
D000959:Antihypertensive Agents