Family Practice Advance Access originally published online on October 25, 2007
Family Practice 2007 24(6):547-554; doi:10.1093/fampra/cmm060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Practice and patient characteristics related to blood pressure in patients with type 2 diabetes in primary care: a cross-sectional study
a Department of Diabetes
b Renal Unit, Nottingham University Hospitals, Hucknall Road, Nottingham NG5 1PB
c Division of Primary Care, University of Nottingham, Floor 13, Tower Building, University Park, Nottingham NG7 2RD
d Nottingham Primary Care Research Partnership, Hucknall Health Centre, 54 Curtis Street, Hucknall, Nottingham NG15 5JE
e Division of Epidemiology and Public Health, University of Nottingham Medical School, Queens Medical Centre, Nottingham NG7 2UH, UK
Correspondence to Charlotte Bebb, Renal Unit, City Hospital Campus, Nottingham University Hospitals, Hucknall Road, Nottingham NG5 1PB, UK; Email: charlotte.bebb{at}nuh.nhs.uk
Received 19 September 2006; Revised 11 July 2007; Accepted 23 August 2007.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Background. Good blood pressure control reduces the risk of long-term complications of diabetes; however, most people with diabetes do not achieve recommended blood pressure targets.
Objective. To quantify the relationships between patient and practice factors and blood pressure in patients with type 2 diabetes.
Methods. A cross-sectional study was carried out in 42 general practices in Nottingham. Participants were 1534 people with type 2 diabetes. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by questionnaire. The outcome measures were systolic and diastolic blood pressure.
Results. In all, 46% of participants had well-controlled blood pressure (
145/85 mmHg) and 68% were on anti-hypertensive treatment. Systolic and diastolic blood pressure were significantly higher in males overall, in those with a body mass index 
25 kg/m2, and increased with alcohol consumption. Systolic blood pressure increased whereas diastolic blood pressure decreased with increasing age and duration of diabetes. Current smokers and ex-smokers had a significantly lower diastolic blood pressure than those who had never smoked. Patients from practices where blood pressure targets were negotiated with most patients had significantly lower mean systolic and diastolic blood pressure than those where targets were negotiated with few patients.
Conclusions. A number of patient characteristics are associated with blood pressure. Negotiating individual goals for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore the process of negotiating targets.
Keywords. Blood pressure, hypertension, practice organization, primary care, type 2 diabetes.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Diabetes affects at least 3% of the population in the UK1 and is increasing in prevalence. Cardiovascular disease is the major cause of morbidity and mortality in patients with diabetes.2 Hypertension is more prevalent in patients with type 2 diabetes than in the non-diabetic population and the coexistence of diabetes and hypertension doubles the risk of cardiovascular and total mortality.3 The UK Prospective Diabetes Study4 showed that the risk of diabetic complications was strongly associated with raised blood pressure in patients with type 2 diabetes and a number of studies have shown that tight blood pressure control reduces the risk of macrovascular and microvascular complications.5
Primary care teams provide routine care for about 75% of patients with type 2 diabetes1 and The National Service Framework for diabetes6 aims to improve the management of such patients. A number of guidelines have proposed blood pressure targets for patients with type 2 diabetes,7,8 but there is some concern that these may be unrealistic for many patients.9 The new GP contract includes financial rewards to practices if more than 55% of their patients with type 2 diabetes achieve a blood pressure of 145/85 mmHg or less. Recent findings suggest that approximately 40% of people with type 2 diabetes have blood pressures above this level.10
In spite of the pressing need to improve blood pressure control in patients with type 2 diabetes, little is known about the practice and patient factors that are associated with good control in these patients.11,12 We have therefore undertaken a cross-sectional study to quantify the relationships between a range of practice and patient factors and blood pressure in patients with type 2 diabetes in the primary care setting.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Study design
A cross-sectional study was undertaken using baseline data collected within a cluster randomized controlled trial of an intervention to improve blood pressure control in patients with type 2 diabetes in primary care.13 The trial intervention comprised treatment guidelines including an algorithm for measuring, monitoring and treating hypertension for use by GPs and practice nurses. The algorithm was based on monthly blood pressure checks and increasing specified anti-hypertensive treatment until the target of <140/80 mmHg was obtained. Training in use of the algorithm was provided. The intervention lasted for 1 year. Approval was granted by the Nottingham City Hospital Ethics Committee.
Practice recruitment
All 123 General Practice surgeries in Nottingham were invited to participate in the trial by letter.
Study participants and eligibility criteria
Patients with type 2 diabetes aged 18–80 years registered with participating practices were eligible to participate whether or not they were previously known to have hypertension. Type 2 diabetes was defined according to the World Health Organization criteria14 and not requiring insulin within 12 months of diagnosis. Exclusion criteria included life expectancy of less than 1 year and inability to give informed consent or to travel to the surgery for appointments.
Recruitment of participants
All eligible patients were invited to take part in the study by letter from their GP. Those agreeing to participate were invited to a consultation with either the research fellow or research nurse at their usual general practice at which written consent was obtained and baseline measurements were made. Patients were recruited between October 1, 2001 and September 30, 2002.
Assessment of baseline characteristics of participants
A standardized clinical interview, examination and case note review was undertaken. The following were recorded: demographic details, postcode (to calculate Townsend deprivation score), duration of diabetes, smoking status, alcohol consumption, family history of vascular disease, past or current evidence of macrovascular and microvascular complications and current medication. Height and weight were measured. Blood pressure was measured using a calibrated semi-automated oscillometric device (Omron HEM-705CP) following a 5-minute rest and while sitting. Two blood pressure readings were taken 1 minute apart; if there was more than a 10% difference between the values, a third reading was taken. The mean of the last two readings was recorded. Glycosylated haemoglobin was measured by the local hospital biochemistry laboratory using a Diabetes Control and Complications Trial aligned assay. Urine albumin creatinine ratio was measured on a random urine sample.
Comparison of participants and non-participants
Anonymized data on participants and non-participants with diabetes were collected using Miquest software which allows General Practice clinical databases to be searched. This comparison could be made for 3488 patients with diabetes at the 36 of the 42 participating practices which were computerized and received electronic pathology results.
Baseline characteristics of practices
Postal questionnaires were sent to the nurse most involved in diabetes care at participating practices. Data were collected on the organization of diabetes services and the use of diabetes guidelines. The nurses were also asked whether their practice had agreed blood pressure targets for patients with diabetes and if so what the agreed target was and were asked how many of their patients with diabetes they negotiate blood pressure targets with (with possible responses of almost all, many, a few and hardly any). The same questionnaire was also sent to all non-participating practices in Nottingham to enable comparison of the characteristics of participating and non-participating practices. Data on list size, practice Townsend score and the proportion of patients from an ethnic minority group were obtained from the former Nottingham Health Authority for all practices in Nottingham.
Statistical analysis
Data were analysed using Stata version 8. The univariate and multivariable relationships between systolic and diastolic blood pressure and patient and practice characteristics were examined using multilevel random effects linear regression to allow for clustering by practice. Variables significant at the 0.20 significance level on univariate analysis were considered for inclusion in the multivariable model. Patient level variables were added to the model first, followed by practice level variables. Variables were retained in the model if the likelihood ratio test was significant at the 5% level. Continuous explanatory variables were categorized if there was non-linearity. We tested for interactions between variables in the model. As treatment for hypertension is a consequence of high blood pressure as well as directly influencing blood pressure, the main analysis excluded hypertensive treatment from the model. Similarly, macrovascular and microvascular complications were not included in the main analyses as they may result from high blood pressure levels, although they may also cause changes in blood pressure. We fitted additional multivariable models to examine the effect of including these three variables if they were statistically significant at the 0.20 significance level on univariate analysis. Models were checked by examining residual plots.
The characteristics of the participating and non-participating patients were compared using multilevel random effects linear regression for continuous variables and multilevel random effects logistic regression for binary variables. Characteristics of participating and non-participating practices were compared using chi-square tests for categorical variables and Mann–Whitney U-tests for non-normally distributed continuous variables.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
A total of 3940 patients were invited to participate and 1534 (38.9%) were recruited. Study participants were significantly older [mean difference: 4.43 years, 95% confidence interval (CI) 3.54 to 5.31], had a significantly lower HbA1c (mean difference: –0.29%, 95% CI –0.17% to –0.42%) and were less likely to be female (42% compared to 48%, odds ratio 0.80, 95% CI 0.71 to 0.91) than non-participants, but did not differ significantly in terms of systolic or diastolic blood pressure, body mass index, serum creatinine or cholesterol. Practice nurses from all 42 participating practices responded to the practice questionnaire and 70% (57/81) of non-participating practices responded. There were no significant differences in list size, Townsend scores or the proportion of registered patients from an ethnic minority group between participating and non-participating practices.
The characteristics of study participants are shown in Table 1. Their median age was 66 years (IQR 58, 72 years), the median number of years since diagnosis of diabetes was 5 (IQR 2, 9), 59% were male and 91% were white. The mean systolic blood pressure was 146 mmHg (SD 20 mmHg) and the mean diastolic blood pressure was 80 mmHg (SD 10 mmHg). In all, 54% of participants had a blood pressure that exceeded the new GP contract target of 145/85 mmHg or less in patients with diabetes.
|
The characteristics of the participating practices are shown in Table 2. The median list size was 5420 patients (IQR 2808, 7012). Most practices had agreed targets for control of blood pressure (83%), but only 13 (31%) negotiated targets with almost all their patients.
|
In the univariate analyses of patient characteristics, systolic blood pressure was significantly associated with age, sex, time since diagnosis and alcohol consumption and was significantly higher in patients on anti-hypertensive medications and with microvascular complications (Table 3). Diastolic blood pressure was significantly negatively associated with age and years since diagnosis and was positively associated with body mass index and alcohol consumption. Females had significantly lower diastolic blood pressure than males. Diastolic blood pressure was significantly lower in patients with macrovascular complications but significantly higher in patients with microvascular complications (Table 3).
|
In univariate analyses of practice characteristics, systolic blood pressure was significantly lower in patients from practices which negotiated blood pressure targets with many or almost all their patients (Table 4). Diastolic blood pressure was significantly negatively associated with practice list size, number of GPs and number of diabetic patients. It was significantly lower in patients from practices where annual reviews were undertaken jointly by the doctor and nurse and from practices which negotiated blood pressure targets with many or almost all their patients.
|
The multivariable analysis for systolic blood pressure (Table 5) showed that females had a lower systolic blood pressure than males at the mean age of 64 years and that systolic blood pressure increased with age, with the increase being more marked in females (0.60 mmHg/year) than males (0.34 mmHg/year). Systolic blood pressure also increased with increasing duration of diabetes, alcohol consumption, and was significantly higher in all body mass index groups
25 kg/m2. Patients in practices where the practice nurse reported that targets were negotiated with almost all or many patients had a lower mean systolic blood pressure (–3.20 mmHg, 95% CI –5.80 to –0.59 mmHg) than those in practices where targets were negotiated with only a few or hardly any patients.
|
The multivariable analysis for diastolic blood pressure (Table 5) showed that females had a lower diastolic blood pressure than males at the mean age of 64 years and that diastolic blood pressure decreased with increasing age with the decrease being more marked for males (–0.27 mmHg/year) than for females (–0.08 mmHg/year). Diastolic blood pressure decreased with increasing duration of diabetes and increased with increasing alcohol consumption (0.07 mmHg per unit alcohol/week). Ex-smokers and current smokers had significantly lower diastolic blood pressure than never smokers. Diastolic blood pressure was significantly increased in all body mass index groups
25 kg/m2. Patients in practices where targets were negotiated with almost all or many patients had a lower mean diastolic blood pressure (–2.42 mmHg, 95% CI –3.66 to –1.17 mmHg) compared with those in practices where targets were negotiated with only a few or hardly any patients. When the analysis was repeated including hypertensive treatment and microvascular complications in the model for systolic blood pressure, the effects of duration of diabetes and alcohol consumption were no longer statistically significant (P = 0.18 and P = 0.06, respectively) and the effect of body mass index was less marked. When macrovascular and microvascular complications were added to the model for diastolic blood pressure, the effects of age in females and alcohol consumption were slightly less significant (P = 0.08 and P = 0.06, respectively), but the regression coefficients for the other variables in the model were similar (data not shown).
Practices which negotiated targets with almost all or many patients tended to be larger than practices which negotiated targets with only a few or hardly any patients (median list size 5600 versus 3500), have more patients with diabetes (median 145 versus 118) and were more likely to have annual reviews undertaken jointly by the doctor and nurse (78.3% versus 57.9%).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Principal findings
We have shown that blood pressure control is suboptimal in this population of type 2 diabetic patients in primary care with only 46% of participants meeting the new GP contract target for blood pressure in patients with diabetes. Systolic blood pressure was higher in males overall, but increased more steeply with age in females. A longer duration of diabetes, higher body mass index and increasing alcohol consumption were also associated with higher systolic blood pressure. Diastolic blood pressure was also higher in males but decreased with increasing age in males, whereas in females there was little change. It was higher in those with a body mass index of 25 kg/m2 or above and increased with alcohol consumption; however, it was lower in current and ex-smokers and fell with increasing duration of diabetes. Patients registered at practices where the practice nurse reported that blood pressure targets were negotiated with most patients had significantly lower systolic and diastolic blood pressure compared to those where targets were negotiated with few patients, after adjusting for a range of patient characteristics.
Strengths and weaknesses
This study involved a large number of patients with type 2 diabetes at 42 practices representative of those within the former Nottingham Health Authority. The prevalence of diabetes in participating practices was similar to that found in other recent studies in the UK15 and practice characteristics did not differ between practices participating and those not participating in the study. There were no significant differences in blood pressure between participants and non-participants. There were, however, differences in age, sex and glycaemic control, which may be explained by the fact that as coding of type of diabetes is incomplete in primary care computer databases at present,16 non-participants included type 1 and type 2 diabetic patients. We therefore consider our results should be applicable to the population with type 2 diabetes within Nottingham and to other urban populations within the UK.
All patients were seen individually by a researcher and so data were collected in a standardized manner and there is little missing data. In addition, practice nurses from all participating practices completed the questionnaire on practice characteristics and organization of diabetes care. The extent to which the responses of the practice nurses reflect their personal practice or that of others in the general practice is hard to assess, and no formal validation was undertaken of their responses, although qualitative interviews that explored how nurses worked with patients with type 2 diabetes and hypertension were undertaken with practice nurses at baseline.17
Explanation of findings and comparison to other studies
We have shown that the majority of patients with type 2 diabetes do not achieve the new GP contract target for blood pressure. These results are comparable to those from recent studies of diabetic patients in the UK10,18 and in other countries.11,12,19
Our data confirm previous findings of increasing systolic blood pressure with age.11,20 This is important, as blood pressure control in this group is associated with the most benefit, in view of the higher absolute risk of cardiovascular events.8 Although blood pressure may be more resistant to treatment in the elderly, there is also some evidence that older people with hypertension are managed differently than younger people with hypertension, in terms of frequency of follow-up and the classes of drugs prescribed.21 Previous qualitative research22,23 has also suggested that GPs and practice nurses are more reluctant to aggressively treat hypertension in elderly patients. The differing effect of age on systolic and diastolic blood pressure in males and females has been established in other large-scale population-based studies24,25 which have shown steeper increases in systolic blood pressure with age for women than men and decreases in diastolic blood pressure beyond the age of 50. These changes are likely to be due to arterial stiffening26,27 which is more prevalent in males, increases with age and is accompanied by an increase in systolic blood pressure and pulse pressure.
Few previous studies have looked at physician and organizational factors associated with blood pressure control.11,12 One study found improved blood pressure control was associated with being treated by a female physician and being seen more frequently,12 but a second study found no association between blood pressure control and practice size or physician factors.11 The only practice factor we found to be significantly associated with blood pressure control was negotiating targets with patients. It should be noted that negotiating blood pressure targets was not a component of the intervention in the trial. The responses to this question were provided by the practice nurses who may have interpreted the question in different ways and their responses may not accurately reflect the practice of the GPs' or the patients' perceptions. We do not know how much time negotiating targets takes when it occurs, nor the extent to which this differs between practices and practitioners. The qualitative study of practice nurses17 found that nurses who reported negotiating targets with almost all or many patients (i.e. they discussed and agreed a personalized target for the individual patient) were much more likely to describe working in other patient-centred ways and to demonstrate an awareness of models of behaviour change. They were also less likely to express concern about making people anxious when discussing blood pressure targets. This implies that practices which report negotiating targets with a greater proportion of patients do differ in other ways in the care they provide for their patients with diabetes and hypertension. If, however, negotiating targets specifically does lead to better control of blood pressure, then this is an interesting and potentially important finding particularly in the light of the increased importance being placed on nationally set targets within the National Health Service. It has previously been suggested that targets are more likely to be effective if they are attainable, believed in, negotiated and flexible.28 There is some evidence that the setting of more realistic targets,29 shared decision making, patient empowerment30 and improved communication with patients31 may impact on patient functioning and health outcomes, although this has yet to be demonstrated for blood pressure control among people with diabetes.32 Our findings go some way to supporting work that demonstrates more patient-centred ways of working have a positive impact on patient outcomes, although as our study is cross-sectional in design, we can only identify associations and not causal relationships, and so are unable to conclude that these practice factors directly result in better blood pressure control.
Implications for practice and further research
Our findings suggest that there is scope for improvement in the control of blood pressure among patients with diabetes in primary care. Negotiating individual targets for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore in detail the process of negotiating targets and associated practice factors.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Funding: National Health Service Executive, Trent (RGB00XX7). All researchers are independent from the funding body.
Ethical approval: Nottingham City Hospital Ethics Committee.
Conflict of interest: None.
|
Acknowledgments |
|---|
We thank Maureen Smith and Diane Havard for help with data collection, Viv Savage and Joanne Daws for secretarial support, Neil Pound for help with database design, Vicky Hammersley for help with Miquest searches and particular thanks to the staff at the participating surgeries for all their help and to all the patients who took part in the study and to the Trent Collaborative Research Network for helping to recruit practices.
|
Notes |
|---|
Bebb C, Coupland C, Stewart J, Kendrick D, Madeley R, Sturrock N and Burden R, for the Nottingham Diabetes Blood Pressure Study. Practice and patient characteristics related to blood pressure in patients with type 2 diabetes in primary care: a cross-sectional study. Family Practice 2007; 24: 547–554.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
1 Audit Commission. Testing Times: A Review of Diabetic Services in England and Wales (2002) London: Audit Commission.
2 Scottish Intercollegiate Guidelines Network. Management of Diabetes (2001) Edinburgh: Scottish Intercollegiate Guidelines Network.
3 Grossman E, Messerli FH, Goldbourt U. High blood pressure and diabetes mellitus: are all antihypertensive drugs created equal? Arch Intern Med (2000) 160:2447–2452.
4 Adler AI, Stratton IM, Neil AW, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ (2000) 321:412–419.
5 UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ (1998) 317:703–713.
6 Department of Health. National Service Framework for Diabetes: Standards (2001) London: Department of Health.
7 National Institute for Clinical Excellence. Blood Pressure Management. Management of Type 2 Diabetes (2002) London: National Institute for Clinical Excellence.
8 Ramsay LE, Williams B, Johnston GD, et al. Guidelines for the management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens (1999) 13:569–592.[CrossRef][Web of Science][Medline]
9 Winocour PH. Effective diabetes care: a need for realistic targets. BMJ (2002) 324:1577–1580.
10 Hippisley-Cox J, O'Hanlon S, Coupland C. Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53 000 patients in primary care. BMJ (2004) 329:1267–1269.
11 Schaars CF, Denig P, Kasje WN, Stewart RE, Wolfenbuttel BHR, Haaijer-Ruskamp FM. Physician, organisational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care. Diabetes Care (2004) 27:123–128.
12 Pellegrini F, Belfiglio M, De Berardis G, et al. Role of organizational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group-quality of care and outcomes in type 2 diabetes. Arch Intern Med (2003) 163:473–480.
13 Bebb C, Kendrick D, Coupland C, et al. A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes. Br J Gen Pract (2007) 57:136–143.[Web of Science][Medline]
14 World Health Organisation. Definition, Diagnosis and Classification of Diabetes Mellitus and Its Complications (1999) Geneva: World Health Organisation.
15 Harvey JN, Craney L, Kelly D. Estimation of the prevalence of diagnosed diabetes from primary care and secondary care source data: comparison of record linkage with capture-recapture analysis. J Epidemiol Community Health (2002) 56:18–23.
16 Gray J, Orr D, Majeed A. Use of read codes in diabetes management in a south London primary care group: implications for establishing disease registers. BMJ (2003) 326:1130.
17 Stewart J, Dyas J, Brown K, Kendrick D. Achieving blood pressure targets: lessons from a study with practice nurses. J Diabetes Nurs (2006) 10:186–193.
18 Lusignan S, Sismanidis C, Carey IM, DeWilde S, Richards N, Cook DG. Trends in the prevalence and management of diagnosed type 2 diabetes 1994–2001 in England and Wales. BMC Fam Pract (2005) 6:13.[CrossRef][Medline]
19 Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care (2003) 26:355–359.
20 Shah S, Cook DG. Inequalities in the treatment and control of hypertension: age, social isolation and lifestyle are more important than economic circumstances. J Hypertens (2001) 19:1333–1340.[CrossRef][Web of Science][Medline]
21 Pears E, Hannaford PC, Taylor MW. Gender, age and deprivation differences in the primary care management of hypertension in Scotland: a cross-sectional database study. Fam Pract (2003) 20:22–31.
22 Cranney M, Warren E, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Pract (2001) 18:359–363.
23 Dickerson JE, Brown MJ. Influence of age on general practitioners' definition and treatment of hypertension. BMJ (1995) 310:574.
24 Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension (1995) 25:305–313.
25 Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA (2003) 289:2363–2369.
26 Benetos A, Waeber B, Izzo J, et al. Influence of age, risk factors, and cardiovascular and renal disease on arterial stiffness: clinical applications. Am J Hypertens (2002) 15:1101–1108.[CrossRef][Web of Science][Medline]
27 O'Rourke MF, Hashimoto J. Mechanical factors in arterial aging: a clinical perspective. J Am Coll Cardiol (2007) 50:1–13.
28 Butler C, Peters J, Stott N. Glycated haemoglobin and metabolic control of diabetes mellitus: external versus locally established clinical targets for primary care. BMJ (1995) 310:784–788.
29 Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen PA. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ (2001) 323:970–975.
30 Malm U, Ivarsson B, Allebeck P, Falloon IR. Integrated care in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs. Acta Psychiatr Scand (2003) 107:415–423.[CrossRef][Web of Science][Medline]
31 Woollard J, Burke V, Beilin LJ. Effects of general practice-based nurse-counselling on ambulatory blood pressure and antihypertensive drug prescription in patients at increased risk of cardiovascular disease. J Hum Hypertens (2003) 17:689–695.[CrossRef][Web of Science][Medline]
32 Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ (1998) 317:1202–1208.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||