Family Practice Vol. 20, No. 4, 469-473
© Oxford University Press 2003
International Health Care Research |
Is there a role for nurse-led blood pressure management in primary care?
Department of General Practice and Primary Care, St George’s Hospital Medical School, London SW17 0RE and
a Battersea Research Group, Bolingbroke Hospital, London SW11 6HN, UK.
Correspondence to Pippa Oakeshott; E-mail: oakeshot{at}sghms.ac.uk
Oakeshott P, Kerry S, Austin A and Cappuccio F. Is there a role for nurse-led blood pressure management in primary care? Family Practice 2003; 20: 469–473.
Received 18 November 2002; Revised 28 March 2003; Accepted 28 March 2003.
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Abstract |
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 Top Abstract IntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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Adequate treatment of high blood pressure reduces the risk of strokes and other cardiovascular events, but current treatment in UK general practice is often inadequate. Nurse-led management of people with high blood pressure could lead to improvements due to strict adherence to protocols, agreed target blood pressure, better prescribing and compliance, and regular follow-up. However, a review of the literature shows a lack of robust evidence of the effectiveness of nurse-led hypertension management in primary care. There is a clear need for randomized controlled trials to see if nurse-led management is associated with better blood pressure control than routine care.
Keywords. Blood pressure, nurse-led management, primary care, review.
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Introduction |
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TopAbstractIntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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Evidence of the benefit of antihypertensive treatment in people with high blood pressure is overwhelming. Effective treatment reduces risk of stroke by 40%1 and of any cardiovascular event by 25%.2 The benefits are greater in elderly people because they have a higher absolute risk of cardiovascular disease.3 It is estimated that while 168 young and middle-aged people with hypertension would need to be treated for 5 years to save one major fatal or non-fatal cardiovascular event, only 46 patients aged
60 years would need to be treated for the same benefit.4 Furthermore, research on isolated systolic hypertension in the elderly suggests that the number needed to treat for 5 years to prevent one major cardiovascular event in people aged 70 years is less than 20.2 Reducing high blood pressure is therefore highly cost effective.
In the UK, around half the population aged >65 years has high blood pressure (defined as blood pressure 160/95 mmHg), and 125 000 people suffer a stroke each year at a cost of £2.3 billion to the NHS and Social Services.5 Most strokes are not fatal, and the major burden of stroke is chronic disability. Even a small reduction in incidence by improved blood pressure control would yield substantial cost savings.1
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Blood pressure management in UK general practice needs improvement |
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TopAbstractIntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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Most people with high blood pressure are managed in general practice. Unfortunately, quality of care is often inadequate. Since Tudor Hart’s groundbreaking work in the 1970s,6 subsequent surveys have continued to show incomplete detection, treatment and control.4,7–10 Probably only about a quarter of hypertensive patients have their blood pressure adequately treated, and this has major implications for cardiovascular morbidity and mortality. For example, a large observational study from Merseyside of 6139 patients aged >65 years from 76 general practices found that only 64% of hypertensives were receiving treatment, of whom only 54% had a blood pressure of <160/90 mmHg (which is above current targets of 140/85 mmg).11 In addition, little attention has been given to blood pressure management among people from lower socio-economic groups1 and those from ethnic minorities such as South Asians and people of African or Caribbean origin who have an increased risk of hypertension and diabetes.9,12 One UK primary care-based study found that although people of African origin were more likely to be on antihypertensive treatment, they were also more likely to have blood pressure levels above the guidelines.10 Interventions are needed to reduce such health inequalities.
Studies have examined obstacles to effective treatment of hypertension. Physician barriers include a willingness to accept blood pressure outside national guidelines, reluctance to change or initiate treatment, workload and lack of resources to organize regular follow-up.13,14 Patient barriers include lack of knowledge about the risks of uncontrolled hypertension, poor compliance, loss to follow-up and cost of treatment.14
The British Hypertension Society, joint British recommendations and the National Service Framework for Coronary Heart Disease (CHD) have produced guidelines for the management of people with raised blood pressure.15–17 The aim is to lower absolute CHD risk, not just blood pressure, with the patient feeling well.3,18 Treatment should be effective, convenient and well tolerated.19 The major task in general practice is to apply the evidence.1,8
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Little research on nurse-led blood pressure management in primary care |
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TopAbstractIntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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Nurse-led management of people with high blood pressure could lead to improvements due to strict adherence to protocols, agreed target blood pressure, improved prescribing and compliance, and regular follow-up.20,21 In addition, most patients prefer general practice-based to hospital-based blood pressure care due to greater accessibility and continuity.13 However, as Ebrahim pointed out in 1998,1 there is an urgent need for robust evidence for the effectiveness of nurse-led hypertension management in primary care.
In Spring 2002, we conducted a review of trials of nurse-led clinics in UK general practices which included some evaluation of blood pressure. We searched Medline, EMBASE, CINAHL, The Cochrane Library and UK HTA reports from 1990 to 2001. We also added trials identified from citations. Search terms used included hypertension, nursing and family practice. We selected studies to review if the setting was UK primary care, the interventions were conducted by nurses, and the studies were randomized controlled trials with a contemporaneous control group receiving no intervention.
Ten studies met all the inclusion criteria (Table 1)
.22–31 Their methodological quality in terms of the Jadad criteria32 of randomization, blinding and reports of losses to follow-up was generally good. However, the nature of a health promotion intervention meant patients could not be blind as to whether or not they received it, and it was often difficult for the outcome assessors to remain blind. Losses to follow-up were well documented in all but one study.23
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Most studies found that nurse-led management and cardiovascular health promotion without change in prescribing had little or no effect on blood pressure.22–31 In the only trial to show an important difference,30 patients with blood pressure outside the guidelines were referred to their GP for drug treatment. However, this was a small trial (n = 98), and was of poorer methodological quality with unblinded outcome assessment by the cardiac liaison nurse who conducted the intervention. Finally, since this review was completed, further analysis of the trial by Campbell and colleagues27 has just been published.33 This showed a greater improvement in the percentage of CHD patients with blood pressure managed according to British Hypertension Society guidelines after 1 year in practices with nurse-led secondary prevention clinics (adjusted odds ratio 5.32, 3.01–9.41).
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Is there any evidence supporting nurse-led management? |
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TopAbstractIntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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Evidence suggesting potential benefits comes from trials of nurse-led management for smoking cessation,34 non-primary care-based hypertension management20 and cholesterol lowering.21 All showed significant improvement mainly due to rigorous application of national guidelines and increased or more appropriate use of medication. A Canadian trial in 457 untreated hypertensive patients aged 18–69 years compared worksite treatment of hypertension by specially trained nurses with care by GPs.20 Patients in the nurse group were more likely to be put on antihypertensive treatment (95 versus 63%), to achieve agreed target blood pressure (49 versus 28%) and to take the drugs prescribed (68 versus 49%). Similarly, trained nurses were more likely than primary care physicians to achieve target low-density lipoprotein (LDL) cholesterol levels in siblings of individuals with premature CHD.21 This was due to increased pharmacotherapy and greater adherence to application of national guidelines. Finally, use of CHD risk charts by trained practice nurses and GPs in UK primary care was associated with a reduction in systolic blood pressure related to increased prescribing.35
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Conclusion |
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TopAbstractIntroductionBlood pressure management in...Little research on nurse-led...Is there any evidence...ConclusionReferences |
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After initial evaluation and treatment, most hypertensive patients in primary care with well-controlled blood pressure do not need to see a doctor for routine blood pressure management. In line with government policy, there is an increasing role for trained practice nurses and nurse practitioners.8 Compared with general practice care, nurse-led care may benefit from more reliable blood pressure assessment, being more user friendly, accessible and less hurried, and improving understanding, encouraging healthy living and forming an alliance with the patient.36–38 However, the most important difference with current practice is likely to be due to improved antihypertensive prescribing, compliance with treatment and regular follow-up due to rigorous application of national guidelines. There is now a need for randomized controlled trials based in general practice to see if management of people with hypertension by specially trained practice nurses is associated with better blood pressure control than routine care.1
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References |
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