title: From hypertension control to global cardiovascular risk management: an educational intervention in a cluster-randomised controlled trial.
abstract: BACKGROUND
  Guidelines on hypertension management recommend adjusting therapeutic efforts in accordance with global cardiovascular risk (CVR) rather than by blood pressure levels alone. However, this paradigm change has not yet arrived in German General Practice. We have evaluated the effect of an educational outreach visit with general practitioners (GPs), encouraging them to consider CVR in treatment decisions for patients with hypertension.
  
  
  METHODS
  Prospective cluster-randomised trial comprising 3443 patients with known hypertension treated by 87 GPs. Practices were randomly assigned to complex (A) or simple (B) intervention. Both groups received a guideline by mail; group A also received complex peer intervention promoting the concept of global CVR. Clinical data were collected at baseline and 6-9 months after intervention. Main outcome was improvement of calculated CVR in the predefined subpopulation of patients with a high CVR (10-year mortality ≥5%), but no manifest cardiovascular disease.
  
  
  RESULTS
  Adjusted for baseline the follow-up CVR were 13.1% (95% CI 12.6%-13.6%) (A) and 12.6% (95% CI 12.2%-13.1%) (B) with a group difference (A vs. B) of 0.5% (-0.2%-1.1%), p = 0.179. The group difference was -0.05% in patients of GPs familiar with global CVR and 1.1% in patients of GPs not familiar with with global CVR. However, this effect modification was not significant (p = 0.165). Pooled over groups, the absolute CVR reduction from baseline was 1.0%, p < 0.001. The ICC was 0.026 (p = 0.002). Hypertension control (BP <140/90 mmHg) improved in the same subpopulation from 38.1 to 45.9% in the complex intervention group, and from 35.6 to 46.5% in the simple intervention group, with adjusted follow-up control rates of 46.7% (95% CI 40.4%-53.1%) (A) and 46.9% (95% CI 40.3%-53.5% (B) and an adjusted odds ratio (A vs B) of 0.99 (95% CI 0.68-1.45), p = 0.966.
  
  
  CONCLUSIONS
  Our complex educational intervention, including a clinical outreach visit, had no significant effect on CVR of patients with known hypertension at high risk compared to a simple postal intervention.
  
  
  BACKGROUND
  ISRCTN44478543 .
authors.affiliation: Institute of General Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, P.O. Box 101001, 40225, Düsseldorf, Germany. achim.mortsiefer@med.uni-duesseldorf.de.
authors.forename: Achim
authors.initials: A
authors.lastname: Mortsiefer
authors.affiliation: Institute of General Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, P.O. Box 101001, 40225, Düsseldorf, Germany. stefanietobias.meysen@t-online.de.
authors.forename: Tobias
authors.initials: T
authors.lastname: Meysen
authors.affiliation: Institute of General Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, P.O. Box 101001, 40225, Düsseldorf, Germany. martinschumacher81@gmx.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Schumacher
authors.affiliation: Institute of General Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, P.O. Box 101001, 40225, Düsseldorf, Germany. abholz@med.uni-duesseldorf.de.
authors.forename: Heinz-Harald
authors.initials: HH
authors.lastname: Abholz
authors.affiliation: Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. karl.wegscheider@t-online.de.
authors.forename: Karl
authors.initials: K
authors.lastname: Wegscheider
authors.affiliation: Institute of General Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, P.O. Box 101001, 40225, Düsseldorf, Germany. jids@med.uni-duesseldorf.de.
authors.forename: Jürgen
authors.initials: J
authors.lastname: In der Schmitten
mesh_terms: D000368:Aged; D001795:Blood Pressure Determination / Q000379:methods; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000517:prevention & control; D016000:Cluster Analysis; D003695:Delivery of Health Care / Q000379:methods; D019468:Disease Management; D005260:Female; D058006:General Practice / Q000379:methods*; D005858:Germany; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011314:Preventive Health Services / Q000379:methods; D018570:Risk Assessment / Q000379:methods; D040242:Risk Reduction Behavior