BackgroundSelf-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension.Methods and findingsMedline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes—change in mean clinic or ambulatory BP and proportion controlled below target at 12 months—were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (−3.2 mmHg, [95% CI −4.9, −1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (−1.0 mmHg [−3.3, 1.2]), to a 6.1 mmHg (−9.0, −3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic −0.2 mmHg [−2.2, 1.8]; ambulatory 1.1 mmHg [−0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies.ConclusionsSelf-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.
OBJECTIVE -To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) Ն140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA 1c , UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores.RESULTS -The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9 -19.3) (P ϭ 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP Ͻ140 mmHg compared with conventional care (P ϭ 0.003). A significant fall in 10-year CHD (P ϭ 0.004) and stroke risk (P ϭ 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months.CONCLUSIONS -Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP Ͻ140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores. Diabetes Care 26:2256 -2260, 2003H ypertension is a major and modifiable risk factor for cardiovascular disease that frequently coexists with diabetes (1). A progressive rise in blood pressure (BP) is also a promoter of renal dysfunction and the development of end-stage renal failure (2). The presence of proteinuria and hypertension also increases the risk of premature death from cardiovascular disease eightfold compared with unaffected patients (3,4). A large evidence base of randomized controlled trials have demonstrated that treating hypertension reduces morbidity and mortality from hypertension-related diseases (5,6). More recently, the use of antihypertensive agents that interrupt the renin-angiotensin system has been shown to be an effective strategy to retard the progression of nephropathy and reduce cardiovascular events in people with diabetes (7-9). Throughout the western world, expert committees on hypertension recommend that treatment to lower BP is warranted in patients with diabetes who have a systolic BP Ն140 mmHg (10,11). Currently, hypertension is poorly managed. The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the maj...
We conducted a randomized controlled trial using mobile health technology in an ethnically diverse sample of 137 patients with complicated diabetes. Patients in the intervention group (n = 72) were trained to measure their blood glucose with a sensor which transmitted the readings to a mobile phone via a Bluetooth wireless link. Clinicians were then able to examine and respond to the readings which were viewed with a web-based application. Patients in the control arm of the study (n = 65) did not transmit their readings and received care with their usual doctor in the outpatient and/or primary care setting. The mean follow-up period was 9 months in each group. The default rate was higher in the patients in the intervention arm due to technical problems. In an intention-to-treat analysis there were no differences in HbA(1c) between the intervention and control groups. In a sub-group analysis of the patients who completed the study, the telemonitoring group had a lower HbA(1c) than those in the control group: 7.76% and 8.40%, respectively (P = 0.06).
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