Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial.
BACKGROUND
First Nations people with diabetes mellitus and hypertension are at greater risk of renal and cardiovascular complications than are non-native patients because of barriers to health care services. We conducted this randomized controlled trial to assess whether a community-based treatment strategy implemented by home care nurses would be effective in controlling hypertension in First Nations people with existing hypertension and type 2 diabetes.


METHODS
We compared 2 community-based strategies for controlling hypertension in First Nations people with existing hypertension and diabetes. In the intervention group, a home care nurse followed a predefined treatment algorithm of pharmacologic antihypertensive therapy. In the control group, treatment decisions were made by each subject's primary care physician. The primary outcome measure was the difference between the 2 groups in the change in systolic blood pressure after 12 months. Secondary outcome measures were the change in diastolic blood pressure over time, the change in urine albumin status and the incidence of adverse events.


RESULTS
Both groups experienced a significant reduction in systolic blood pressure by the final visit (by 24.0 [standard deviation (SD) 13.5] mm Hg in the intervention group and by 17.0 [SD 18.6] mm Hg in the control group); p < 0.001 in each case). However, the difference between the 2 groups in this change was not significant. Patients in the intervention group had a larger decrease in diastolic blood pressure over time than did those in the control group (by 11.6 [SD 10.6] mm Hg v. 6.8 [SD 11.1] mm Hg respectively; p = 0.05). The groups did not differ significantly in terms of changes in urine albumin excretion or incidence of adverse events.


CONCLUSIONS
High rates of blood pressure control in the community were achieved in both groups in the DREAM 3 study. The addition of a home care nurse to implement a treatment strategy for blood pressure control was more effective in lowering diastolic than systolic blood pressure compared with home care visits for blood pressure monitoring alone and follow-up treatment by a family physician.
Tobe
Sheldon W
SW
Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ont. sheldon.tobe@sw.ca
Pylypchuk
George
G
Wentworth
Joan
J
Kiss
Alexander
A
Szalai
John Paul
JP
Perkins
Nancy
N
Hartman
Susan
S
Ironstand
Laurie
L
Hoppe
Jacqueline
J
D000328:Adult; D000368:Aged; D000465:Algorithms; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002170:Canada; D048909:Diabetes Complications / Q000208:ethnology / Q000517:prevention & control; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000208:ethnology* / Q000517:prevention & control*; D005260:Female; D006699:Home Care Services; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology*; D007198:Indians, North American; D004930:Inuit; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D019035:Rural Health Services; D012424:Rural Population
D000959:Antihypertensive Agents