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] −2.5mmHg, 95%CI = −3.7 to −1.3 mmHg) and diastolic blood pressure (WMD −1.8mmHg, 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.     

Educational and organisational interventions used to improve the management of hypertension in primary care: a systematic review

BACKGROUND: The optimal way in which to organise and deliver care to patients with hypertension has not been clearly identified. AIM: To determine the effectiveness of educational and organisational strategies used to improve control of blood pressure. DESIGN OF STUDY: Systematic review of randomised controlled trials (RCTs). METHOD: Quantitative pooling of RCT data on patients with hypertension that evaluated the following interventions: (1) self monitoring, (2) educational interventions directed to the patient, (3) educational interventions directed to the health professional, (4) health professional (nurse or pharmacist) led care, (5) organizational interventions that aimed to improve the delivery of care, (6) appointment reminder systems. RESULTS: Fifty-six RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2mmHg, -11.7/-6.5mmHg, -10.6/-7.6mmHg for three strata of entry blood pressure) and all-cause mortality at 5 years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT (the Hypertension Detection and Follow-up study). Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure, weighted mean difference (WMD): -2.03 mmHg, 95% confidence interval (CI) = -2.7 to -1.4 mmHg. Educational interventions directed towards physicians were associated with small reductions in systolic blood pressure (WMD) -2.0mmHg, 95% CI = -3.5 to -0.6mmHg and diastolic blood pressure (WMD) -0.4mmHg, 95% CI -1.1 to 0.3mmHg. CONCLUSIONS: General practices and community-based clinics need to have an organised system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. These findings have important implications for recommendations concerning implementation of structured delivery of care in hypertension guidelines.     

A cluster randomized trial comparing two interventions to improve treatment of major depression in primary care

BACKGROUND: Many patients with major depression are non-adherent to antidepressant medication and do not receive care according to current guidelines. There is increasing evidence that treatment of depression in primary care can be improved. Comparison between effective interventions may help to establish the active ingredients of such interventions. METHOD: In a randomized trial two interventions to improve treatment of major depression in primary care were compared (1) a depression care programme, targeting general practitioners (GPs), patients, and systematic follow-up, and (2) a systematic follow-up programme. Thirty GPs were randomized and 211 primary-care patients with current major depression were included. All patients were prescribed a selective serotonin reuptake inhibitor. Outcome measures included adherence to antidepressant medication, and depression outcome. RESULTS: No significant differences in adherence rates and treatment outcome measures were demonstrated between interventions at week 10 or week 26. Adherence rates were high and treatment outcome was favourable. CONCLUSIONS: The depression care programme was not superior to the systematic follow-up programme. Systematic follow-up in depression treatment in primary care seems to be an intervention per se, having the potential to improve adherence and treatment outcome.     

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

Background

Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.

Aim

To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care.

Design and setting

Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework.

Method

Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians’ or nurses’ perceived influences on treatment goals for type 2 diabetes.

Results

A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.

Conclusion

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.     

Interventions to reduce primary care delay in cancer referral: a systematic review

Background

Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.

Aim

To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.

Design and setting

Systematic review in primary care.

Method

Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

Results

Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.

Conclusion

There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.     

Motivational interviewing to improve health screening uptake: A systematic review

ObjectiveHealth screenings, physical tests that diagnose disease, are underutilized. Motivational interviewing (MI) may increase health screening rates. This paper systematically reviewed the published articles that examined the efficacy of MI for improving health screening uptake.MethodsArticles published before April 28, 2015 were reviewed from PubMed, PsycINFO, and CINAHL. Study methodology, participant demographics, outcomes and quality were extracted from each article.ResultsOf the 1573 abstracts, 13 met inclusion criteria. Of the 13 studies, 6 found MI more efficacious than a control, 2 found MI more efficacious than a weak control yet equivalent to an active control, and 3 found MI was not significantly better than a control. Two single arm studies reported improvements in health screening rates following an MI intervention.ConclusionsMI shows promise for improving health screening uptake. However, given the mixed results, the variability amongst the studies and the limited number of randomized trials, it is difficult to discern the exact impact of MI on health screening uptake.Practice implicationsFuture research is needed to better understand the impact of MI in this context. Such research would determine whether MI should be integrated into standard clinical practice for improving health screening uptake.     

Bereavement care in primary care: a systematic literature review and narrative synthesis

Background

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

Aim

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them.

Design

Systematic literature review.

Method

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

Results

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to ‘medicalise’ normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

Conclusion

A small number of studies were identified, most of which were >10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.     

Treatment of eating disorders in primary care: a systematic review

This review evaluated psychological treatments for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder conducted in primary care. Five studies met inclusion criteria. Guided self-help cognitive-behavioral therapy via a self-help book may be a beneficial, first-line treatment for reducing binging and purging symptoms. Outcomes combining self-help with antidepressants remain unclear, although antidepressants alone may provide reduction of symptoms. High attrition and non-compliance rates among studies reviewed indicate the importance of a strong therapeutic alliance between provider and patient. Further research in primary care is needed to develop a standard of care for patients with eating disorders.     

Graduate mental health worker case management of depression in UK primary care: a pilot study.

BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.     

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.     

Screening for increased cardiometabolic risk in primary care: a systematic review

Background

Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear.

Aim

To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy.

Design and setting

Systematic review of studies performed in primary care in Western countries.

Method

MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities.

Results

The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995–2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967–2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods.

Conclusion

The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.     

Multimorbidity in primary care: a systematic review of prospective cohort studies

Background

Primary care increasingly deals with patients with multimorbidity, but relevant evidence-based interventions are scarce. Knowledge about multimorbidity over time is required to inform the development of effective interventions.

Aim

This review identifies prospective cohort studies of multimorbidity in primary care to determine: their nature, scope and key findings; the methodologies used; and gaps in knowledge.

Design

Systematic review.

Method

Studies were identified by searching electronic databases, reviewing citations, and writing to authors. Searches were limited to adult populations with no restrictions on publication date or language. In total, 996 articles were identified and screened.

Results

Of the 996 articles, six detailing five completed prospective cohort studies were selected as appropriate. Three of the studies were undertaken in the US and two in The Netherlands; none was nationally representative. The main focus of the studies was: healthcare utilisation and/or costs (n = 3); patients'' physical functioning (n = 1); and risk factors for developing multimorbidity (n = 1). The conditions that were included varied widely. The findings of these studies showed that multimorbidity increased healthcare costs (n = 2), inpatient admission (n = 1), death rates (n = 1), and service use (n = 3), and reduced physical functioning (n = 1). One study identified psychosocial risk factors for multimorbidity. No study used random sampling, sample sizes were relatively small (414–3745 patients at baseline), and study duration was relatively short (1–4 years). No study focused on prevalence, treatment use, patient safety, service models, cultural or socioeconomic factors, and patient experience, and no study collected qualitative data.

Conclusion

Few longitudinal studies based in primary care have investigated multimorbidity. Further large, long-term prospective studies are required to inform healthcare commissioning, planning, and delivery.     

Referral interventions from primary to specialist care: a systematic review of international evidence

Background

Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure.

Aim

To review the international evidence on interventions to manage referral from primary to specialist care.

Design and setting

Systematic review.

Method

Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions.

Results

The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no ‘magic bullet’ to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts.

Conclusions

To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.     

Management of major depression in the primary care setting

BACKGROUND: Patients treated in community clinics, particularly those of minority status, may rely more heavily on primary care physicians (PCPs) for the diagnosis and management of depression. We wished to determine how PCPs in a community clinic setting initially manage patients newly diagnosed with major depression. METHODS: 698 patients were screened for major depression by the Structural Clinical Interview for DSM-III-R in a community-based primary care health center. Forty outpatients (29 Hispanic) were found to suffer from major depression. A letter explaining positive findings was sent to the patients' PCPs. Medical record charts were reviewed 3 months later to determine the PCP's management following the diagnosis. RESULTS: Of the 38 patients who remained in the study at 3 months, 20 (53%) received no intervention from the PCP by the end of 3 months after diagnosis, and of these, 14 were Hispanic. Five (13%) were prescribed an antidepressant by the PCP. Nine (24%) were referred to mental health services for medication, psychotherapy or combination treatment. Four (11%) were prescribed an antidepressant and then referred to mental health services. Differences between management of Hispanic and non-Hispanic patients were not statistically significant. CONCLUSIONS: Independent screening by psychiatrists in primary care settings may not be adequate enough to ensure appropriate management of depression by PCPs. Possible explanations may include time constraints during primary care visits, patient and/or physician reticence, and insufficient education of PCPs about depression.     

Follow-up of cancer in primary care versus secondary care: systematic review

Background

Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care.

Aim

To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care.

Design of study

Systematic review.

Setting

Primary and secondary care settings.

Method

A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care.

Results

There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals.

Conclusion

Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached.     

Prognostic factors for musculoskeletal pain in primary care: a systematic review.

BACKGROUND: Estimating the future course of musculoskeletal pain is an important consideration in the primary care consultation for patients and healthcare professionals. Studies of prognostic indicators tend to have been viewed in relation to each site separately, however, an alternative view is that some prognostic indicators may be common across different sites of musculoskeletal pain. AIM: To identify generic prognostic indicators for patients with musculoskeletal pain in primary care. DESIGN OF STUDY: Systematic review. SETTING: Observational cohort studies in primary care. METHOD: MEDLINE, EMBASE, PsychINFO and CINAHL electronic databases were searched from inception to April 2006. Inclusion criteria were that the study was a primary care-based cohort, published in English and contained information on prognostic indicators for musculoskeletal conditions. RESULTS: Forty-five studies were included. Eleven factors, assessed at baseline, were found to be associated with poor outcome at follow up for at least two different regional pain complaints: higher pain severity at baseline, longer pain duration, multiple-site pain, previous pain episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction. CONCLUSION: Despite substantial heterogeneity in the design and analysis of original studies, this review has identified potential generic prognostic indicators that may be useful when assessing any regional musculoskeletal pain complaint. However, Its unclear whether these indicators, used alone, or in combination, can correctly estimate the likely course of individual patients' problems. Further research is needed, particularly in peripheral joint pain and using assessment methods feasible for routine practice.