A Cochrane review [Abstract] 1 included 72 studies. The range of interventions used included (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.
An organized system of regular review linked to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (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 3 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 (HDFP). 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 of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires 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 (OR 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control (OR 0.54, 95% CI 0.41 to 0.73).
Comment: The quality of evidence is downgraded by indirectness. The HDFP study was designed as an intervention that would identify newly diagnosed hypertensive patients and then start or modify antihypertensive treatment in those with untreated as well as uncontrolled hypertension. A consequence of this study design is that a differential number of people were receiving antihypertensive drug treatment in the two arms, percentage of patients taking antihypertensive medication - higher for stepped care 81.2%, compared to referred care 64.2% at follow-up in year 5. So though it appears that the systematic follow-up and stepped care approach in HDFP is an important element in effective clinical care and prompts rigorous antihypertensive drug treatment, it is not possible to distinguish between the independent effect of these interventions on blood pressure control.
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