Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review

BACKGROUND: Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as 'uncontrolled' hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified. AIM: To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. DESIGN OF STUDY: Systematic review of randomised controlled trials. SETTING: Primary and ambulatory care. METHOD: Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic. RESULTS: Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference WMD -2.5 mmHg, 95%CI = -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95%CI = -2.4 to -1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial. CONCLUSION: Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.