Bosworth Hayden B, Powers Benjamin J, Olsen Maren K, McCant Felicia, Grubber Janet, Smith Valerie, Gentry Pamela W, Rose Cynthia, Van Houtven Courtney, Wang Virginia, Goldstein Mary K, Oddone Eugene Z
Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA.
Arch Intern Med. 2011 Jul 11;171(13):1173-80. doi: 10.1001/archinternmed.2011.276.
To determine which of 3 interventions was most effective in improving blood pressure (BP) control, we performed a 4-arm randomized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center.
Eligible patients were randomized to either usual care or 1 of 3 telephone-based intervention groups: (1) nurse-administered behavioral management, (2) nurse- and physician-administered medication management, or (3) a combination of both. Of the 1551 eligible patients, 593 individuals were randomized; 48% were African American. The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices. Behavioral management involved promotion of health behaviors. Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines.
The primary outcome was change in BP control measured at 6-month intervals over 18 months. Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8% (95% confidence interval [CI], 1.6%-24.1%) and 12.5% (95% CI, 1.3%-23.6%), respectively-but not at 18 months. In subgroup analyses, among those with poor baseline BP control, systolic BP decreased in the combined intervention group by 14.8 mm Hg (95% CI, -21.8 to -7.8 mm Hg) at 12 months and 8.0 mm Hg (95% CI, -15.5 to -0.5 mm Hg) at 18 months, relative to usual care.
Overall intervention effects were moderate, but among individuals with poor BP control at baseline, the effects were larger. This study indicates the importance of identifying individuals most likely to benefit from potentially resource intensive programs.
clinicaltrials.gov Identifier: NCT00237692.
为确定三种干预措施中哪种在改善血压（BP）控制方面最有效，我们在一家退伍军人事务医疗中心的基层医疗诊所进行了一项四臂随机试验，并进行了18个月的随访。
符合条件的患者被随机分配至常规护理组或三个基于电话的干预组之一：（1）护士实施的行为管理组，（2）护士和医生实施的药物管理组，或（3）两者结合组。在1551名符合条件的患者中，593人被随机分组；48%为非裔美国人。干预电话根据通过远程监测设备传输的家庭血压值触发。行为管理包括促进健康行为。药物管理包括研究医生和护士根据高血压治疗指南调整药物。
主要结局是在18个月内每隔6个月测量的血压控制变化。单独的行为管理和药物管理在12个月时均显示出显著改善——分别为12.8%（95%置信区间[CI]，1.6%-24.1%）和12.5%（95%CI，1.3%-23.6%）——但在18个月时未显示出改善。在亚组分析中，在基线血压控制不佳的患者中，与常规护理相比，联合干预组的收缩压在12个月时下降了14.8 mmHg（95%CI，-21.8至-7.8 mmHg），在18个月时下降了8.0 mmHg（95%CI，-15.5至-0.5 mmHg）。
总体干预效果中等，但在基线血压控制不佳的个体中，效果更大。本研究表明识别最有可能从潜在资源密集型项目中受益的个体的重要性。
clinicaltrials.gov标识符：NCT00237692。
