Effects of a multifaceted intervention on cardiovascular risk factors in high-risk hypertensive patients: the ESCAPE trial, a pragmatic cluster randomized trial in general practice

Abstract

BackgroundSeveral observational studies on hypertensive patients have shown a gap between therapeutic targets recommended in guidelines and those achieved in daily practice. The ESCAPE trial aimed to determine whether a multifaceted intervention focused on general practitioners (GPs), could increase significantly the proportion of hypertensive patients at high risk in primary prevention who achieved all their recommended therapeutic targets.MethodsA pragmatic, cluster randomized trial involving 257 GPs randomized by region. The GPs in the intervention group had a one-day training session and were given an electronic blood pressure measurement device and a short recommendation leaflet. Along with usual follow-up, they focused one consultation on hypertension and other cardiovascular risk factors every six months for two years. They also received feedback at baseline and at one year on their patients’ clinical and biological parameters. Main outcome measures were change in the proportion of patients achieving all their therapeutic targets and each individual therapeutic target at two years, and quality of life.Results1,832 high-risk hypertensive patients were included. After two years, the proportion of patients achieving all their therapeutic targets increased significantly in both groups, but significantly more in the intervention group: OR (odds-ratio) 1.89, (95% confidence interval (CI) 1.09 to 3.27, P = 0.02). Significantly more patients achieved their blood pressure targets in the intervention group than in the usual care group: OR 2.03 (95% CI 1.44 to 2.88, P < 0.0001). Systolic and diastolic blood pressures decreased significantly more in the intervention group than in the usual care group, by 4.8 mmHg and 1.9 mmHg, respectively (P < 0.0001 for both). There were no significant difference changes in physical and mental quality of life between groups.ConclusionAn easy-to-perform, multifaceted intervention targeting only GPs increased significantly the proportion of high-risk hypertensive patients in primary prevention achieving their recommended therapeutic targets.Trial registrationThis trial was registered with ClinicalTrials.gov, number NCT00348855

Hypertension Management in Primary Care: A Cluster Randomized Trial of a Physician-focused Educational Intervention

“…Third, the BP changes observed in our study are within the range of those observed in other CRTs (Figure 1). Like ours, all studies saw improvements in BP within their study populations, but with inconsistent interventional effects (5,6,9,10,14,15).…”

“…While the majority of these interventions used rather costly external support structures, few randomized studies combined internal practice redesign with educational strategies (14,15): Reuther et al (2012) combined physician education about clinical management and practice organization with a clinical decision support system, benchmarking, peer audits, and a specialist hotline: After a 24-month follow-up in 2646 patients from 124 practices, the interventional effects amounted to -1.75 mmHg systolic [95% confidence interval (CI) 4.02 to 0.53] and +0.14 mmHg diastolic [95% CI: -1.16 to 1.44] (15).…”

ESCAPE ancillary blood pressure measurement study 2

“…The inclusion criteria and a description of the intervention have been detailed elsewhere [7]. Practitioners in the IG were supplied with a validated electronic device to measure BP (Spengler TB 101; Spengler SAS, Antony, France).…”

“…ESCAPE (EffetS d'une intervention multifaCtorielle sur les fActeurs de risque des patients hyPErtendus) was a pragmatic cluster randomized-controlled trial [7]. Its primary aim was to show that a multifactorial intervention targeting general practitioners increased the number of high cardiovascular risk hypertensive patients in primary prevention achieving the recommended targets [8] without altering their quality of life.…”

Hypertension management in primary care: study protocol for a cluster randomized controlled trial

“…introduced calibrated 24-hour blood pressure monitor devices in primary care practices, while Reuther et al . introduced strategies to organize hypertension management in primary care [ 23 , 24 ]. The mean group differences were −4.76/-1.88 mmHg [ 23 ] and −1.75/+0.14 mmHg [ 24 ].…”