Fahey T, Schroeder K, Ebrahim S
University of Dundee,Tayside Centre for General Practice, Kirsty Semple Way, Dundee, UK, DD2 4AD.
Cochrane Database Syst Rev. 2006 Apr 19(2):CD005182. doi: 10.1002/14651858.CD005182.pub2.
It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified.
To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.
All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000.
Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (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) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems. Outcomes assessed were: (1) mean systolic and diastolic blood pressure( 2) control of blood pressure (3) proportion of patients followed up at clinic.
Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.
56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 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. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. 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. Health professional (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.
AUTHORS' CONCLUSIONS: Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels.
众所周知，社区中的高血压患者常常无法达到治疗目标，这种情况被称为“未控制的”高血压。目前尚未明确确定为使高血压患者达到治疗目标而组织和提供护理的最佳方式。
确定干预措施对改善高血压患者血压控制的有效性。评估提醒对改善高血压患者随访情况的有效性。
对2000年6月以来Cochrane对照试验注册库（CCTR）、Medline和Embase中所有年份的所有文章进行全语言检索。
对高血压患者进行的随机对照试验（RCT），评估以下干预措施：（1）自我监测；（2）针对患者的教育干预；（3）针对医护人员的教育干预；（4）医护人员（护士或药剂师）主导的护理；（5）旨在改善护理提供的组织干预；（6）预约提醒系统。评估的结果包括：（1）平均收缩压和舒张压；（2）血压控制情况；（3）诊所随访患者的比例。
两位作者独立且重复地提取数据，并根据Cochrane协作手册概述的标准对每项研究进行评估。
56项RCT符合我们的纳入标准。纳入研究的方法学质量参差不齐。在一项大型RCT——高血压检测与随访研究中，一个与积极的抗高血压药物治疗相结合的有组织的定期复查系统显示，在五年随访中可降低血压（根据三个血压分层，加权平均差分别为-8.2/-4.2 mmHg、-11.7/-6.5 mmHg、-10.6/-7.6 mmHg）以及全因死亡率（6.4%对7.8%，差值1.4%）。其他干预措施效果各异。自我监测与舒张压的适度净降低相关（加权平均差（WMD）：-2.0 mmHg，95%CI：-2.7至-1.4 mmHg）。预约提醒增加了随访就诊个体的比例。针对患者或医护人员的教育干预的RCT结果参差不齐，但单独来看似乎不太可能与血压的大幅净降低相关。医护人员（护士或药剂师）主导的护理可能是一种有前景的护理提供方式，大多数RCT显示与血压控制改善相关，但需要进一步评估。
家庭医疗和社区诊所需要有一个针对高血压患者的有组织的定期随访和复查系统。当患者未达到目标血压水平时，应通过积极的阶梯式护理方法实施抗高血压药物治疗。
