There is little evidence as to how care for hypertensive patients should be organized and delivered in the community to help improve blood pressure control. This review aimed to determine the effectiveness of interventions whose objective was to improve follow-up and control of blood pressure in patients taking blood pressure lowering drugs. We included studies that had as population of interest adult patients with essential hypertension in an ambulatory setting. The interventions included all those that aimed to improve blood pressure control. The outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and the proportion of patients followed up at clinic.
Seventy two randomised controlled trials met our inclusion criteria. 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. The trials showed a wide variety of methodological quality, part of which may be attributed to poor reporting. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Weighted data analysis showed that self-monitoring was associated with moderate net reductions in systolic blood pressure (weighted mean difference -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (weighted mean difference -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). Trials 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 improving control in patients with hypertension, with the majority of RCTs being associated with improved blood pressure control, improved systolic blood pressure and more modestly improved diastolic blood pressure, but these interventions require further evaluation. Appointment reminder systems increased the proportion of individuals who attended for follow-up (absolute difference 16%, but this pooled result should be treated with caution because of the heterogeneous results from individual RCTs) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73).
We conclude that an organized system of registration, recall and regular review allied to a vigorous stepped care approach to antihypertensive drug treatment appears the most likely way to improve the control of high blood pressure. Health professional (nurse or pharmacist) led care and appointment reminder systems requires further evaluation. Education alone, either to health professionals or patients, does not appear to be associated with large net reductions in blood pressure.