Quality-improvement strategies for the management of hypertension in chronic kidney disease in primary care: a systematic review

BACKGROUND: Chronic kidney disease (CKD) is a relatively recently recognised condition. People with CKD are much more likely to suffer from cardiovascular events than progress to established renal failure. Controlling systolic blood pressure should slow the progression of disease and reduce mortality and morbidity. However, no systematic review has been conducted to explore the effectiveness of quality-improvement interventions to lower blood pressure in people with CKD. AIM: To assess the effectiveness of quality-improvement interventions to reduce systolic blood pressure in people with CKD in primary care, in order to reduce cardiovascular risk and slow the progression of renal disease. METHOD: Papers were identified from the trial data bases of the Cochrane Effective Practice and Organisation of Care Group (EPOC) and Cochrane renal groups. In a three-round process, at least two investigators read the papers independently. Studies were initially excluded based on their abstracts, if these were not relevant to primary care. Next, full papers were read, and again excluded on relevance. Quantitative and, where this was not possible, qualitative analyses of the findings were performed. RESULTS: The selected studies were usually carried out on high-risk populations including ethnic minorities. The interventions were most often led by nurses or pharmacists. Three randomised trials showed a combined effect of a reduction in systolic blood pressure of 10.50 mmHg (95% confidence interval [CI] = 5.34 to 18.41 mmHg). One non-randomised study showed a reduction in systolic blood pressure of 9.30 mmHg (95% CI = 3.01 to 15.58 mmHg). CONCLUSION: Quality-improvement interventions can be effective in lowing blood pressure, and potentially in reducing cardiovascular risk and slowing progression in CKD. Trials are needed in low-risk populations to see if the same improvements can be achieved.