Authors' objectives:

The objectives were to find out the most effective methods of:

detecting hypertension

improving patient adherence with treatment

improving control of blood pressure

improving professional compliance with standards of good practice.

Authors' results and conclusions: Detection Population screening when compared with usual care or case finding does not appear to increase coverage of the population assessed for hypertension or detection of people with hypertension. Screening programmes in shopping centres or housing blocks do not reach the disadvantaged groups often intended. Case finding appears to be particularly effective when linked with professional training, protocols and reminders to record blood pressure given to both patients and doctors. Labelling of hypertensive patients does not appear to have any long-term effects on sickness absence or psychological well-being provided patients are managed by high-quality, comprehensive services. Ambulatory monitoring does not have any role in the detection of hypertension in the population. Patient adherence No single approach to improving adherence can be recommended based on the evidence reviewed. Complex interventions involving education, easier access to care, and use of protocols may improve adherence and control in some patients. Educational interventions are unlikely to be effective on their own. While simpler drug regimens are likely to improve adherence, simple reminder packaging does not improve adherence or control. Blood pressure control A comprehensive 'stepped-care' approach (i.e. education, free care, specialist clinics, and protocols) achieves the greatest improvements in control. Self-monitoring of blood pressure at home appears to have a small but significant effect on blood pressure control and may be cost-saving. Patient education alone is unlikely to improve blood pressure control. Professional education may make a small contribution to blood pressure control, but is probably due to increased use of drug therapy. Professional standards of care The issuing and use of guidelines does not result in improvements in care. Locally, rather than expert, produced guidelines that are integrated into clinical practice improve both practice and clinical outcomes. The evidence to support nurse-led clinics is surprisingly sparse, and the only British trial found worse control in the nurse-led clinic.

Authors' recommendations: Implications for health care Policy and practice on high blood pressure might best be considered in conjunction with a review of all cardiovascular disease prevention advice to health authorities and general practitioners, as focusing on individual risk factors in isolation is unlikely to produce coherent proposals. Detection Standardisation of methods of blood pressure measurement is essential. Use of Korotkov V (disappearance of sounds) should be widely promoted in primary health care. Facilities for the routine maintenance of sphygmomanometers should be available in all health districts. The British Hypertension Society guidelines on thresholds for starting treatment require review following publication of the New Zealand guidelines and the wider recognition of the importance of absolute disease risk in formulating preventive health care policy. Evidence to support detection and treatment of high blood pressure in older people is very strong. This evidence should be widely disseminated, and professional barriers to treating older people recognised as unacceptable and not consistent with best practice. Ambulatory monitoring methods increase the cost and complexity of blood pressure detection without providing any tangible benefits, and should not be promoted in primary health care. Blood pressure is only one of a number of powerful risk factors which predict the chances of suffering a stroke or ischaemic heart disease. Greater emphasis should be placed on examining risk factor scores (or profiles). Adherence Improving professional adherence to best practice in the management of high blood pressure through a range of mechanisms is required. More direct methods such as financial incentives and penalties require investigation as they may prove more effective than educational or clinical guideline approaches. Evidence is lacking to support any specific approaches to improving patient adherence with antihypertensive drugs or lifestyle changes. Standardisation of methods of measuring and reporting on patient adherence is required. Further research on patient adherence should be linked with the associated question of improving blood pressure control. Control The British Hypertension Society's recommended target blood pressures which should be achieved on drug treatment need to be reviewed. Criteria should take into account co-morbidity, age and level of hypertension. A stepped-care approach to management is supported by American randomised controlled trial evidence, but this is not directly applicable to British practice. Evidence to support nurse-led compared with doctor-led care as a better option in achieving blood pressure control is very sparse.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.hta.ac.uk/881

Year Published: 1998

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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