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Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

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Peer review
Christopher E Clark , clinical academic fellow ,
Lindsay F P Smith , senior clinical research fellow ,
Rod S Taylor , professor in health services research ,
John L Campbell , professor of general practice and primary care
1 Primary Care Research Group, Institute of Health Services Research, Peninsula College of Medicine and Dentistry, St Luke’s Campus, Exeter EX1 2LU
Correspondence to: C E Clark christopher.clark{at}pms.ac.uk
Accepted 11 June 2010

Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study.

Design Systematic review and meta-analysis.

Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database.

Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults.

Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken.

Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5).

Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

Introduction

Essential hypertension is a major cause of cardiovascular morbidity. 1 In 2003 the prevalence of hypertension in England was 32% in men and 30% in women. 2 Since the prevalence of hypertension increases with age it is a growing public health problem in the Western world faced with ageing populations. 3 The lowering of raised blood pressure in drug trials has been associated with a reduction in stroke of 35-40%, heart attack of 20-25%, and heart failure of over 50%. 4 To achieve these benefits, aggressive and organised treatment to attain blood pressure targets is required, yet often contacts with health professionals do not trigger changes in antihypertensive therapy 5 ; a phenomenon termed “clinical inertia.” 6

Most patients require a combination of antihypertensive drugs to reach target blood pressure. Guidelines advocate logical drug combinations, 7 and in England the National Institute for Health and Clinical Excellence has published a treatment algorithm for clinicians to follow. 8 Hypertension is a condition almost entirely managed in primary care, and in the United Kingdom is an important component of the Quality and Outcomes Framework, which rewards practices for achievement of blood pressure standards set by the National Institute for Health and Clinical Excellence. 9 Achievement between practices, however, varies considerably 10 and knowledge of guidelines among general practitioners does not necessarily translate into their implementation. 11

Doubt persists about how best to organise effective care and interventions to control hypertension by the primary care team. In 2005 a Cochrane review classified 56 trials of interventions into six categories: self monitoring, education of patients, education of health professionals, care led by health professionals (nurses or pharmacists), appointment reminder systems, and organisational interventions. The review concluded that an organised system of regular review allied to vigorous antihypertensive drug therapy significantly reduced blood pressure and that a stepped care approach for those with blood pressure above target was needed. 12 Nurse or pharmacist led care was suggested to be a promising way forward but required further evaluation. Another review found that appropriately trained nurses can produce high quality care and good health outcomes for patients, equivalent to that achieved by doctors, with higher levels of patient satisfaction. 13 Nurse led care is attractive as it has been associated with stricter adherence to protocols, improved prescribing in concordance with guidelines, more regular follow-up, and potentially lower healthcare costs. Without associated changes in models of prescribing, however, there seems to be little effect on blood pressure level. 14 At present the usual model of care is shared between general practitioners and practice nurses, with general practitioners prescribing. Our local survey of Devon and Somerset found that of 79 responding practices (n=182; response rate 43%) 53 were using this model, with only four using nurse led care, including nurse prescribing (unpublished observation). In the light of these uncertainties over models of care and whether blood pressure reduction with nurse led care can be achieved, we explored further the trial evidence for efficacy of nurse led interventions through a systematic review. To elucidate whether nurse prescribing is an important component of this complex intervention and to identify areas in need of further study, we reviewed the international evidence base for such an intervention and its applicability to primary care in the United Kingdom.

We searched the published literature for randomised controlled trials that included an intervention delivered by nurses, nurse prescribers, or nurse practitioners designed to improve blood pressure, compared with usual care. The population of interest was adults aged 18 or over with newly diagnosed or established hypertension above the study target, irrespective of whether or not they were taking antihypertensive drugs. Primary outcome measures were systolic and diastolic blood pressure at the end of the study, changes in systolic and diastolic blood pressure compared with baseline, percentage of patients reaching target blood pressure, and percentage taking antihypertensive drugs. The secondary outcome was cost or cost effectiveness of interventions.

Data sources and extraction

We searched Ovid Medline, the Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Using a strategy modified from the previous review of 2005 we searched for randomised controlled trials in original English language and published between January 2003 and November 2009. 12 We identified older citations from this review, hence the choice of cut-off date for the search (see web extra). We also corresponded with authors to identify missed citations.

Two authors (CEC, LFPS) independently selected potentially relevant studies by screening retrieved citations and abstracts. Trials assessed as definite or uncertain for inclusion were retrieved as full papers. Differences were resolved by discussion; arbitration from a third author (JLC) was planned but not required. Two authors (CEC, LFPS) independently extracted details of the studies and data using a standardised electronic form, with differences resolved by discussion. Risk of bias in the generation of the randomisation sequence, allocation concealment, and blinding (participants, carers, assessors) was assessed as adequate, uncertain, or inadequate using Cochrane criteria. 15 One author (LFPS) checked the reference lists of all included studies for further potentially relevant citations, and two authors (CEC, LFPS) reviewed this list and agreed on further potentially relevant papers to retrieve in full. Searches were undertaken in June 2009 and repeated in November 2009 before final writing up.

Statistical analysis

Data were pooled and analysed using RevMan v5.0. 16 We carried out separate analyses for each intervention and outcome measure compared with usual care. Intervention effects were calculated as relative risks with 95% confidence intervals for dichotomous data. For continuous data we used a conservative random effects meta-analysis model to calculate mean differences and weighted mean differences with 95% confidence intervals. When a study included more than one intervention group with a single comparator arm, we included both intervention groups and split the number of patients in the common comparator arm across the separate intervention arms. 15 Where required we calculated standard deviations from standard errors or confidence intervals presented within papers. Heterogeneity was quantified using the I 2 statistic and the χ 2 test of heterogeneity. Using sensitivity analysis we explored heterogeneity by excluding single outlying results or restricting analysis to studies of good quality. We reported pooled data only when heterogeneity was not significant (P>0.05). Two authors (CEC, RST) reviewed the data from cluster randomised controlled trials and either extracted the data as presented when the authors were deemed to have taken account of cluster effects or first adjusted using a design factor, 15 with intraclass correlation coefficients for systolic and diastolic blood pressure derived from cluster studies in primary care. 17

Searches identified 1465 potential citations. A further 66 potential studies were identified from citations in retrieved papers. After initial screening of the titles and abstracts 71 full studies were assessed for possible inclusion in the review and 33 met the inclusion criteria (fig 1 ⇓ ).

Fig 1 Flow of papers through study

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Included studies

Table 1 ⇓ summarises the characteristics of the included studies. Seven cluster randomised controlled trials were randomised at practice 18 19 20 21 22 23 or family level. 24 Five described adjustment for clustering effects but two did not seem to have done so, therefore these were adjusted for cluster size. 23 24 One study used a two level nested design of interventions at provider and patient level; combined patient level outcomes were extracted where possible, or as separate intervention and control groups for each provider intervention. 25 Four studies had three arms. Three compared telephone monitoring and face to face nurse monitoring with usual care 26 27 28 and outcomes were extracted as separate groups; one compared nurse and general practitioner interventions with usual care and only the nurse and control outcomes were extracted. 21 The remaining randomised controlled trials were two armed studies randomised at individual patient level.

Characteristics of included studies

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Interventions were categorised as nurse support delivered by either telephone (seven studies), 25 26 27 28 29 30 31 community monitoring (defined as home or other non-healthcare setting; eight studies), 24 26 32 33 34 35 36 37 or nurse led clinics. These were held in either primary care (13 studies) 20 21 22 23 27 28 35 38 39 40 41 42 43 or secondary care (six studies). 44 45 46 47 48 49 One study used alternate sessions with nurses at home and in general practice. 50 Fourteen studies included a stepped treatment algorithm 18 19 21 22 23 24 30 31 35 37 38 40 47 48 and nine included nurse prescribing in their protocol. 24 30 31 35 37 40 44 47 48

Although most of the studies recruited participants with hypertension, 11 also recruited participants with diabetes, 18 19 22 23 31 36 37 44 46 47 48 five with coronary heart disease, 20 21 33 39 50 and one the siblings of patients with coronary heart disease. 24 Most studies recruited predominantly white participants. Four studied hypertension care provided to African Americans, 24 26 29 40 three to Chinese, 33 34 46 two to South Asians, 19 23 one to American Indians, 37 and two to mixed non-white populations. 44 45 Thirty eight studies were excluded after review of the full paper (fig 1).

Risk of bias in included studies

Overall, study quality was moderate; random sequence generation was adequate in 70% (23/33) of studies, allocation concealment in 58% (19/33), and blinding of data collection in 43% (14/33); one study was described as an open (unblinded) randomised controlled trial. 41 Thirteen studies were assessed as adequate in two of the three domains and adequate or unclear for the third. 20 22 25 26 29 30 32 33 34 40 42 46 48 These studies were defined as of “good quality” and were used for sensitivity analysis by study quality. Only three of these reported UK trials; one of patients with ischaemic heart disease and hypertension 20 and two of people with diabetes and hypertension. 22 48 The method of blood pressure measurement was not described in 12 studies, 19 20 21 22 23 24 33 39 42 43 46 47 10 used automated monitors, 18 26 27 28 29 30 36 37 44 48 and seven referred to authoritative guidelines for measurement. 25 32 34 41 44 45 50

Effects of interventions

Pooling of data across different types of interventions was limited by noticeable statistical heterogeneity between studies, which was not explained by restriction to good quality studies. Consequently the results are presented as subgroup analyses by type of intervention (table 2 ⇓ ). (See web extra for forest plots for all comparisons; summary statistics were omitted if significant heterogeneity was present; see table 2). One study did not report any estimates of variance and did not contribute data to the meta-analyses. 42

Summary of meta-analyses of studies using nurse led interventions to manage hypertension. Values are for weighted mean differences unless stated otherwise

Use of a treatment algorithm

Fourteen studies included a stepped treatment algorithm in their intervention 18 19 21 22 23 24 30 31 35 37 38 40 47 48 and for nine it was the main focus of the intervention. 18 19 21 22 35 37 38 47 48 Two studies of good quality 30 40 showed greater magnitudes of reductions in blood pressure with the use of an algorithm compared with usual care: weighted mean difference, systolic −9.7 mm Hg (95% confidence interval −14.0. to −5.4 mm Hg) and diastolic −4.3 mm Hg (−7.4 to −1.2 mm Hg). Pooling of all four studies also showed a greater magnitude of reduction in systolic blood pressure (−8.2 mm Hg, −11.5 to −4.9; fig 2 ⇓ ) 23 30 37 40 with the use of an algorithm compared with usual care.

Fig 2 Change in systolic blood pressure with nurse led use of algorithm compared with usual care

Pooling of three good quality studies 22 40 48 showed no significant difference in achievement of study blood pressure targets in favour of an intervention including an algorithm (relative risk 1.09, 95% confidence interval 0.93 to 1.27). Although a total of 10 studies reported this outcome, 18 19 22 31 35 38 40 42 47 48 statistical and clinical heterogeneity between them was significant.

Nurse prescribing

Nine studies included nurse prescribing in their protocol; three in secondary care settings, 44 47 48 three using community interventions, 24 35 37 two using telephone monitoring, 30 31 and one based in primary care. 40

Two good quality studies 30 40 showed greater magnitudes of blood pressure reductions for nurse prescribing than for usual care: weighted mean difference, systolic −9.7 mm Hg (95% confidence interval −14.0 to −5.4) and diastolic −4.3 mm Hg (−7.4 to −1.2). Pooling of all studies showed similar reductions: systolic −8.9 mm Hg (−12.5 to −5.3) and diastolic −4.0 mm Hg (−5.3 to −2.7; fig 3 ⇓ ).

Fig 3 Changes in blood pressure with interventions including nurse prescribing compared with usual care

Only one good quality study reported absolute blood pressure as an outcome, but pooling of four studies showed a significantly lower absolute outcome systolic blood pressure in favour of nurse prescribing: weighted mean difference −7.2 mm Hg (95% confidence interval −10.9 to −3.5). 30 31 37 40

Two good quality studies showed no difference in achievement of study blood pressure target (relative risk 1.20, 95% confidence interval 0.96 to 1.50). 40 48 Significant statistical and clinical heterogeneity precluded further pooled analysis.

Telephone monitoring

Seven studies included telephone monitoring of blood pressure by nurses. 25 26 27 28 29 30 31 Meta-analysis of four groups from three good quality studies showed no significant difference in outcome systolic blood pressure (weighted mean difference −2.9 mm Hg, 95% confidence interval −7.5 to 1.6). 25 26 29 Pooling of all studies gave a similar result (−3.5 mm Hg, −7.4 to 0.4; fig 4 ⇓ ), and pooling of three studies also showed no difference for outcome diastolic blood pressure (−1.1 mm Hg, −5.8 to 3.6). 26 29 31

Fig 4 Absolute systolic blood pressure after nurse led telephone monitoring compared with usual care

Pooled data from three studies 25 27 31 (one of good quality 25 ) showed a higher achievement of study blood pressure targets with telephone monitoring than with usual care (relative risk 1.24, 95% confidence interval 1.08 to 1.43).

Community monitoring

Eight studies involved nurse interventions delivered outside of healthcare settings. Locations included the home, 32 33 37 50 community centres, 24 26 or a choice of both. 34 One study was set in the workplace 35 and one in a pharmacy. 36 Pooled data from four good quality studies 26 32 33 34 showed a lower outcome systolic blood pressure in favour of monitoring in the community (weighted mean difference −3.4 mm Hg, 95% confidence interval −6.1 to −0.7; fig 5 ⇓ ) and two good quality studies showed greater magnitudes of blood pressure reduction with community monitoring than with usual care: systolic −4.7 mm Hg (−8.3 to −1.2) and diastolic −3.1 mm Hg (−4.8 to −1.3). 32 34 Pooling of data from all four studies also showed a greater magnitude of reductions in favour of the intervention: systolic −4.8 mm Hg (−7.0 to −2.7) 32 34 36 37 and diastolic −3.5 mm Hg (−4.5 to −2.5). 32 34 35 37

Fig 5 Absolute systolic blood pressure after community nurse led interventions compared with usual care for good quality studies

Four studies, 32 35 36 50 including one of good quality, 32 reported significantly better achievement of blood pressure targets in favour of the intervention, but significant heterogeneity precluded pooled analysis.

Nurse led clinics

Fourteen studies were of nurse led clinics in primary care 20 21 22 23 27 28 35 38 39 40 41 42 43 50 and six in secondary care settings. 44 45 46 47 48 49 For primary care studies, two of good quality showed no difference in diastolic blood pressure (−2.9 mm Hg, −6.9 to 1.1). 20 40 Pooling of all studies showed a greater magnitude of reduction in blood pressure for nurse led clinics compared with usual care (systolic −3.5 mm Hg, −5.9 to −1.1 and diastolic −1.9 mm Hg, −3.4 to −0.5; fig 6 ⇓ ), 23 27 28 40 41 and two good quality studies showed no difference in achievement of blood pressure targets with nurse led clinics (relative risk 1.14, 95% confidence interval 0.83 to 1.57). 22 40

Fig 6 Changes in blood pressure with primary care nurse led clinics compared with usual care

For secondary care clinics, only two were of good quality and did not report comparable outcomes. 46 48 For all studies, pooling of data from three studies showed no difference in outcome diastolic blood pressure (weighted mean difference −1.4 mm Hg, −3.6 to 0.86) 44 46 49 and no greater achievement of study blood pressure targets (relative risk 1.47, 95% confidence interval 0.79 to 2.74) 44 47 48 in nurse led clinics compared with usual care.

Significantly lower systolic blood pressure was achieved for any nurse led intervention for four groups from three good quality studies recruiting African American participants (weighted mean difference −7.8 mm Hg, 95% confidence interval −14.6 to −0.9) 24 29 40 but neither systolic nor diastolic blood pressure was lower on pooling of three good quality studies of Chinese participants (systolic −2.6 mm Hg, −7.5 to 2.3 and diastolic −0.5 mm Hg, −2.3 to 1.3; fig 7 ⇓ ). 33 34 46 Pooling of two studies, neither of good quality, showed no significant increase in the use of antihypertensive drugs in South Asian participants (relative risk 1.22, 95% confidence interval 0.90 to 1.65), 19 23 but pooling of four studies across different ethnic groupings did show a small increase in favour of any nurse led intervention compared with usual care (1.22, 1.02 to 1.47). 19 23 24 44

Fig 7 Systolic blood pressure readings for participants from ethnic minority groups

Cost and cost effectiveness

Only four studies presented any data. From the United Kingdom one study reported a cost per patient of £434 (€525, $632) over two years to provide additional nurse clinics and support from specialist nurses, representing £28 933 per quality adjusted life year gained 19 and another study found that primary care costs were £9.50 per patient compared with £5.08 for usual care. 43 In the United States a study reported a 50% higher total cost of staff at $134.68 (£92.65, €111.90) per patient treated in a nurse led clinic compared with $93.70 for usual care, 47 but a Mexican study reported $4 (£2.75, €3.32) per patient or $1 per 1 mm Hg reduction of systolic blood pressure. 32

In comparison with usual patterns of care, nurse led interventions that included a stepped treatment algorithm showed significantly greater reductions of systolic and diastolic blood pressure, but this was not associated with higher achievement of blood pressure targets. Studies incorporating nurse led prescribing also showed bigger reductions of systolic and diastolic blood pressure. Telephone monitoring was associated with higher achievement of study targets for blood pressure. Community monitoring showed lower outcome systolic blood pressure, greater reductions in systolic and diastolic blood pressure, and, although pooling of data was not possible, greater achievement of study blood pressure targets. Nurse led clinics in primary care achieved greater reductions in systolic and diastolic blood pressure compared with usual care. No clear beneficial effects on our primary outcomes were observed from secondary care clinics.

Pooled interventions showed significantly lower systolic blood pressure in African American participants with nurse led interventions than with usual care, but little difference for other ethnic minority groups.

Strengths and limitations of this review

Since blood pressure was reported variously as final blood pressure or change from baseline for systolic or diastolic readings, less pooling of results was possible than may have been anticipated.

Thirteen of the 33 included randomised controlled trials met our quality criteria. Only three of these were from the United Kingdom 20 22 48 and none investigated an unselected primary care hypertensive population. Therefore the evidence base for nurse led care of hypertension in the United Kingdom relies on generalisation of findings from other, principally American, healthcare systems. In total, 12 trials were identified from the United Kingdom, of which six studied blood pressure control in people with diabetes 18 19 22 23 44 48 , four in patients with ischaemic heart disease, 20 21 39 50 and two in people with uncontrolled hypertension. 38 43

We restricted our search to articles in English, which may have excluded some potential international data; however, we consider it unlikely that significant evidence applicable to UK health care would have only been published in another language.

The usual reason for judging a trial’s quality as inadequate was weakness of blinding. As it was not possible for the participants to always be blinded to whether they were seeing a doctor, nurse, or other health professional, this limitation must be accepted for any face to face intervention. We aimed to assess blinding of the researchers collecting outcome data to the intervention; these were often the same nurses who delivered the intervention and therefore were open to bias. This lack of formal blinding in trials is recognised as a methodological challenge 51 but need not be seen as a limitation because implementation of these findings would also necessarily be unblinded, so a pragmatic approach to studying these interventions can be relevant. 52 Future trials will, however, need careful design to minimise bias.

One third of studies gave no description of the method used to measure blood pressure and only seven referred to published guidelines on blood pressure measurement, therefore the reliability of reported outcome measures cannot be judged easily.

Although interventions such as use of algorithms and nurse prescribing were associated with meaningful blood pressure reductions there was not a concomitant rise in achievement of target blood pressure. Although apparently inconsistent this could be a sample size effect, with some studies underpowered to show differences in dichotomous outcomes. It may also be explained by the noticeable variation in individual blood pressure targets in the studies, which were sometimes composite or multiple. 18 19 35 44 Therefore reporting of absolute blood pressure reductions may be the more robust outcome measure for comparison in future reviews.

Many studies combined the use of a treatment algorithm with the nurse intervention; therefore the results contributed to both analyses. It was not possible within this review to separate out thoroughly the components of each intervention that were or were not effective.

For most studies the duration of follow-up was relatively short; only five followed participants for more than 12 months. 19 21 25 40 41 Therefore it is not possible to extrapolate the findings as sustained benefits of the interventions.

We present evidence of benefit in some studies of ethnic minority groups because hypertension is recognised to carry higher levels of morbidity and mortality in some such populations. 8 These findings, however, pool different types of intervention so cannot identify specific nurse led interventions of benefit in these groups. Furthermore, the “usual care” arm of some studies, predominantly from America, 24 26 29 40 represented minimal care; therefore the benefits shown may be larger than could be expected if introduced to more inclusive healthcare systems, such as are found in the United Kingdom.

We included cost and cost effectiveness as a secondary outcome measure. It is, however, possible that other papers discussing this outcome (that is, non-randomised controlled trials) were not retrieved by our search strategy. Therefore a more thorough primary review of cost data may be needed.

Comparison with existing literature

The traditional view of the nurse’s role in hypertension care is to educate, advise, measure blood pressure, 51 and enhance self management. 53 Previous reviews have suggested that nurse led care may achieve better outcomes by increased adherence to protocols and guidelines, but we found insufficient evidence to confirm this. 14 The most recent review 12 identified an organised system of regular review and stepped care as essential components of successful interventions. This updated review supports this view, showing benefits in blood pressure reduction with the use of a treatment algorithm. No previous review has found sufficient evidence to support the assertion that nurse prescribing should be a key component of nurse interventions for hypertension 14 ; however, this review has shown better blood pressure outcomes in favour of nurse prescribing based on studies in American healthcare systems.

Interventions varied greatly in intensity and presumably therefore in cost. Lack of information on cost effectiveness has been identified previously, 54 and although this was only a secondary outcome measure for this review we noted that only four studies, including one of good quality, 32 reported on costs. 19 32 43 47 All four showed higher costs for the intervention, approaching 50% higher in two cases. 43 47 Only one study seemed to be cost effective, 32 but costs depend on the healthcare system within which the intervention is delivered, so we were unable to show any cost benefit that could be generalised across differing systems. Although nurses may save on salary costs, the evidence is conflicting, with potential savings being offset by an increased length of consultation. 55 Evidence of cost benefit in acute self limiting conditions 56 cannot be assumed to translate to the management of chronic disease, so future trials should incorporate a formal cost effectiveness analysis within their design.

Hypertension is identified with higher prevalence and morbidity levels in some ethnic minority groups such as African Americans and South Asians. 57 Studies recruiting from these populations found significant reductions in blood pressures with any nurse led intervention. For studies from non-UK healthcare systems, “usual care” represented minimal or absent care. 29 40 We therefore interpret this with caution.

Implications for clinical practice

The delivery of nurse led care in chronic conditions is a complex intervention. This review suggests that such care can improve on doctor led or usual care of hypertension. The key component of an intervention seems to be a structured treatment algorithm, and we have found evidence in favour of nurse prescribing. Although no clear benefits were seen for secondary care clinics improvements were found in both primary care and community based settings, suggesting that these findings can be applied to primary care clinics in the United Kingdom, or equivalent community settings in other healthcare systems. Although the absolute differences in blood pressure seem small—for example, a 4 mm Hg greater reduction in diastolic blood pressure with nurse prescribing than with usual care, a 2 mm Hg reduction in diastolic blood pressure is associated with a 15% reduction in risk of stroke or transient ischaemic attack in primary prevention. 58 Similarly a 20-30% reduction in frequency of stroke, coronary heart disease, major cardiovascular events, and cardiovascular death is seen with a 3 mm Hg reduction in systolic blood pressure, 59 and differences of this magnitude or greater are seen with nurse led clinics, nurse prescribing, and the use of an algorithm.

Implications for future research

In this review we found international evidence of benefit from nurse led interventions but no evidence of good quality was derived from an unselected UK population with hypertension in primary care. Evidence from other healthcare systems cannot necessarily be generalised, therefore further studies relevant to the United Kingdom are needed. Such studies should ideally include a structured algorithm, examine the role of nurse led prescribing, and include a robust economic assessment. They should report absolute measures of blood pressure as this would best permit comparison with the existing literature and take care to minimise bias by blinding outcome assessors to the intervention.

Conclusions

Nurse led interventions for hypertension in primary care should include an algorithm to structure care and can deliver greater blood pressure reductions than usual care. There is some evidence of improved outcomes with nurse prescribers, but there is no evidence of good quality from United Kingdom studies of essential hypertension in primary care. Therefore, although this review has found evidence of benefit for nurse led interventions in the management of blood pressure, evidence is insufficient to support the widespread use of nurses in hypertension management within the UK healthcare systems.

What is already known on this topic

Nurses are integral members of the primary healthcare team and are involved in the management of hypertension

Previous literature reviews have suggested that nurse led care may be beneficial in the care of hypertension but the data are conflicting

What this study adds

This review presents evidence to support structured algorithm driven nurse led care of hypertension, and nurse prescribers

There is little directly applicable evidence for benefits of nurse involvement in hypertension within the UK National Health Service

Cite this as: BMJ 2010;341:c3995

We thank Kate Quinlan (East Somerset Research Consortium) for carrying out the searches and retrieving articles, Joy Choules (Primary Care Research Group) for helping retrieve articles, and Liam Glynn (Cochrane Hypertension Group) for sharing citation lists.

Contributors: CEC and LFP reviewed the literature search results, identified papers for retrieval, reviewed full papers for inclusion, and extracted data for meta-analysis. CEC and RST undertook the meta-analysis. JLC acted as study supervisor. All authors contributed to the interpretation of the findings and drafting of the manuscript. CEC is guarantor for the study.

Funding: This research was supported by the Scientific Foundation Board of the Royal College of General Practitioners and by the South West GP Trust.

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

Ethical approval: Not required.

Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode .

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Guideline-Driven Management of Hypertension: An Evidence-Based Update

Affiliations.

1 Department of Medicine, University of Virginia Health System, Charlottesville (R.M.C).
2 Department of Medicine, Case-Western Reserve University School of Medicine, Cleveland, OH (J.T.W.).
3 Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN (S.J.T.).
4 Departments of Epidemiology and Medicine, Tulane University, New Orleans, LA (P.K.W.).
PMID: 33793326
PMCID: PMC8034801
DOI: 10.1161/CIRCRESAHA.121.318083

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Keywords: American Heart Association; antihypertensive agents; blood pressure; cardiovascular disease; hypertension; mortality.

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Nurse management for hypertension * : A systems approach

Supported by a grant to Stanford University from CorSolutions, Inc. (Buffalo Grove, IL).

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Supplementary Data

Peter Rudd, Nancy Houston Miller, Judy Kaufman, Helena C. Kraemer, Albert Bandura, George Greenwald, Robert F. Debusk, Nurse management for hypertension: A systems approach, American Journal of Hypertension , Volume 17, Issue 10, October 2004, Pages 921–927, https://doi.org/10.1016/j.amjhyper.2004.06.006

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Standard office-based approaches to controlling hypertension show limited success. Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent, regular blood pressure (BP) monitoring. We tested the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy, based on patients’ reports of home BP.

We randomized outpatients requiring drug therapy for hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria to receive usual medical care only (UC, n = 76) or usual care plus nurse care management intervention (INT, n = 74) over a 6-month period.

Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC: 14.2 ± 18.1 versus 5.7 ± 18.7 mm Hg systolic ( P < .01) and 6.5 ± 10.0 versus 3.4 ± 7.9 mm Hg diastolic, respectively ( P < .05). At 6 months, we observed one or more changes in drug therapy in 97% of INT patients versus 43% of UC patients, and 70% of INT patients received two or more drugs versus 46% of UC. Average daily adherence to medication, measured by electronic drug event monitors, was superior among INT subjects (mean ± SD, 80.5% ± 23.0%) than among UC subjects (69.2 ± 31.1%; t 113 = 2.199, P = .03). There were no significant adverse drug reactions in either group.

Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension.

The control of blood pressure (BP) remains a major challenge in clinical practice. Only half of those individuals with hypertension receive the diagnosis, and only half of these achieve BP goals established by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) and other scientific organizations. 1 , 2 Contributing factors for the failure to achieve goal BP cluster as patient related, provider related, and system related. Patient factors include medication side effects, drug regimen complexity, and unawareness of the need for long term therapy. 3 Physician-linked issues may involve timely access to relevant clinical data, ignorance of evidence-based management guidelines, and sense of nonaccountability for patient outcomes. The system-related factors reflect little if any attention or resources to design, implement, evaluate, and refine systems for guiding individual and groups of patients. Specialized hypertension clinics staffed by nurses have shown significant improvements in hypertension control compared with usual care. 4–6 The present study extends the model of nurse management to home-based treatment.

Study population

We conducted a randomized controlled trial in which patients received either usual care alone (UC) or usual care supplemented by nurse management for hypertension (INT). For initial screening purposes we defined hypertension as BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic, recorded in the medical record at least once in the previous 6 months, or a history of drug treatment for hypertension. In addition, patients had to be eligible for hypertensive drug therapy according to JNC VI criteria. 2 Clinical risk criteria assessed the presence of coronary risk factors (smoking, dyslipidemia, or diabetes mellitus), age >60 years, or a family history of premature cardiovascular disease or target organ damage. According to JNC VI criteria, 2 only patients with elevation of BP to levels greater than 140 to 159 mm Hg systolic and/or 90 to 99 mm Hg diastolic are considered eligible for BP lowering drug therapy. We adopted a more stringent BP threshold for hypertension: 150 mm Hg systolic, 95 mm Hg diastolic, or both.

Baseline BP measurement

During the baseline clinic visit, before randomization, the nurse care manager measured BP with a mercury sphygmomanometer using the arm with the higher reading as the “reference” arm for all subsequent BP recordings. The nurse used a second BP measurement, taken 5 min later, to establish the mean baseline BP. For study entry, subjects needed the mean of two BP values to be ≥150/95 mm Hg on two screening visits conducted on separate days at least 1 week apart.

We screened a total of 1580 patients, finding 743 (47%) who were ineligible because they lacked the risk factors specified by the JNC VI or had major medical comorbidity. An additional 603 (40%) either could not be contacted or refused participation after contact, and 84 (5%) had mean baseline BP values below the criterion of 150 mm Hg systolic or 95 mm Hg diastolic. We ended with 150 patients, representing 10% of the screened population, for randomization.

Recruitment and randomization

The same research staff implemented the same protocol for screening and enrollment of patients at each of two participating medical clinics, the Kaiser Permanente Mountain View Clinic and the Primary Care Clinics of the Stanford University Medical Center in California. We identified patients by physician referral or review of medical records. Patients received a postcard indicating their physician’s knowledge of the study and inviting study participation. Research staff telephoned patients to establish their medical eligibility and willingness to participate in the study.

After establishing eligibility, patients gave written informed consent and underwent randomization using computer-generated assignment. All patients provided baseline measurements of nonfasting blood urea nitrogen, creatinine, glucose, and potassium. These measurements guided drug therapy. At 3 and 6 months after randomization, a research assistant blinded to group assignment measured clinic BP and interviewed patients about medications taken since the previous visit.

Nurse management protocol

The nurse care manager conducted baseline counseling on intervention (INT) patients’ correct use of the automated BP device, regular return of the automatically printed BP reports, tips for enhancing drug adherence, and recognition of potential drug side effects. Printed materials extended this instruction, and patients confirmed their ability to operate the BP device. The nurse initiated follow up phone contacts at 1 week and at 1, 2, and 4 months. The calls averaged 10 min in duration, or 40 min in all. During phone contacts, the nurse asked INT patients about each medication dosage and any problems experienced since the previous contact. The nurse also encouraged patients to telephone anytime during regular hours with questions or concerns.

The nurse care manager contacted physicians to obtain permission to initiate any new BP drug but did not contact physicians regarding changes in medication dosage. Changes in drug therapy were categorized as either an increase (a drug added or dose of drug increased) or as a decrease (a drug withdrawn or dose of drug decreased). The nurse care manager implemented a management algorithm based on patients’ current medications, laboratory values, and BP measurements.

From prior studies, systolic pressures measured at home generally run about 10 mm Hg lower than those measured in the office, and diastolic pressures are approximately 5 mm Hg less. 7 Accordingly, we chose a treatment goal of 130/85 mm Hg, as measured with the home BP device over a 2-week period. 8 , 9 When 80% of the home BP readings achieved this treatment goal, the nurse made no further changes in drug therapy. When <80% of measurements met this criterion, the nurse increased drug dosage to the maximal level recommended for each drug or added one or more additional drugs in accordance with the protocol. The project cardiologist consulted by phone with the nurse care manager about problematic cases as needed.

Measurements of BP

We used the same semiautomated portable device to measure BP at home and during each clinic visits. This device (UA 751; A&D, Milpitas, CA), validated with a random zero mercury sphygmomanometer, 10 provided a digital display of BP values. At the end of each week, the device generated a printed report of up to 14 measurements. Patients recorded BP twice-daily at the same times each day. Every 2 weeks, patients mailed the values printed by the BP device to the nurse care manager, who used these BP data to guide drug therapy.

Physician review of protocol

Before the study, the investigators met with the medical staffs at the two sites to discuss the study protocol and management algorithm, based on the JNC VI report, 2 that were used by the nurse care manager for INT patients. After the 6-month clinic visit, all physicians received a final report of their patients’ medications and BP values. The Stanford University institutional review board reviewed and approved the project protocol.

Usual care patients in both groups continued to receive the routine care that they had received before the study. No attempt was made to alter the frequency of office visits or any other aspect of doctor-patient interactions. Only patients randomized to nurse management received portable BP monitors.

Patient monitoring

Patients in both groups returned to the clinic at 3 and 6 months for BP measurements, which were performed by study staff blinded to group assignment. Patients in both groups received instruction in the use of the electronic drug event monitor (eDEM; AARDEX-USA, Union City, CA). Each monitor contained a microchip in the pill bottle lid 11 , 12 to dispense the BP medication used most frequently. At 3- and 6-month clinic visits, project staff downloaded the data from the electronic drug event monitor but provided no feedback on drug adherence to patients, physicians, or nurse care managers.

Statistical analysis

The primary outcome measure was change in BP from baseline to 6-month visit, considering both systolic and diastolic BP and using a wall-mounted clinic sphygmomanometer. The primary statistical analysis was a two-sample t test comparing the change in BP measured between baseline and 6 months. We performed secondary analyses of BP medication, frequency of drug changes, and adherence to medication with the Student t test. The level of significance was a two-sided probability value of P < .05.

Population characteristics

The two patient samples, representative of hypertensive patients in the two participating clinics, exhibited similar sociodemographic and clinical characteristics, so data were pooled ( Table 1 ). Patients were typically of middle age, high educational status, and modest rates of cardiovascular comorbidities. The usual care only (UC) and usual care plus nurse care management intervention (INT) randomization successfully produced similar groups except for higher rates of married status and dyslipidemia among usual care patients. A total of 13 patients (9%), eight in the UC group and five in the intervention group, did not return for the 6-month visit and were classified as dropouts. Five of the eight dropouts in the UC group moved out of the area; the remainder declined to return for the 6-month follow-up visit. Two of the INT patients experienced difficulty in using the BP device and declined continued participation; three moved out of the area.

Study Population

.	Usual Care ( = 76) .	Intervention ( = 74) .
Sex
Female (% of total)	56	50
Age (y; mean ± SD)	60 ± 9	59 ± 10
Marital status (%)
Married	80	60
Divorced	8	15
Separated	2	5
Widowed	4	3
Single	6	17
Ethnicity (%)
White	72	76
African American	8	11
Asian American	4	4
Hispanic	8	1
Other	8	8
Educational status (%)
Some high school	5	5
High school graduate	19	17
Some college	23	24
College degree	31	27
Postdoctoral degree	22	27
Occupational status (%)
Full time	51	49
Part time	7	7
Disabled or unemployed	4	4
Retired	32	32
Other	6	8
Coronary risk factors (%)
Dyslipidemia	30	16
Current smoker	2	4
Diabetes	14	14
Family history of CAD	18	22
CAD	4	8
Cerebrovascular Disease	5	10

.	Usual Care ( = 76) .	Intervention ( = 74) .
Sex
Female (% of total)	56	50
Age (y; mean ± SD)	60 ± 9	59 ± 10
Marital status (%)
Married	80	60
Divorced	8	15
Separated	2	5
Widowed	4	3
Single	6	17
Ethnicity (%)
White	72	76
African American	8	11
Asian American	4	4
Hispanic	8	1
Other	8	8
Educational status (%)
Some high school	5	5
High school graduate	19	17
Some college	23	24
College degree	31	27
Postdoctoral degree	22	27
Occupational status (%)
Full time	51	49
Part time	7	7
Disabled or unemployed	4	4
Retired	32	32
Other	6	8
Coronary risk factors (%)
Dyslipidemia	30	16
Current smoker	2	4
Diabetes	14	14
Family history of CAD	18	22
CAD	4	8
Cerebrovascular Disease	5	10

CAD = coronary artery disease.

P < .05 by 2 analysis.

Patterns of BP

The UC and INT groups displayed similar patterns of baseline BP: 36% had elevation of both systolic and diastolic pressure, 55% had elevation of systolic pressure only, and 9% had elevation of diastolic pressure only. Between baseline and 6 months, systolic BP fell by 14.2 mm Hg in the INT group (95% CI −18.1 to −10.0) and by 5.7 mm Hg in the UC group (95% CI −10.2 to −1.3; P < .01). One-way ANOVA confirmed significant decreases in both systolic (F 212 = 17.30; P < .01) and diastolic BP (F 212 = 6.22; P < .01) among INT patients but nonsignificant changes among UC patients. Figure 1 depicts changes in office-based systolic BP.

Change in office-based systolic blood pressure (SBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Between baseline and 6 months, diastolic BP fell by 6.5 mm Hg in the intervention group (95% CI −8.8 to −4.1) and 3.4 mm Hg in the UC group (95% CI of −5.3 to −1.5, P < .05). Figure 2 depicts changes in office-based diastolic BP.

Change in office-based diastolic blood pressure (DBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Blood pressure measured with the mercury sphygmomanometer during clinic visits averaged 1 to 2 mm Hg higher than that measured with the semiautomated device. Blood pressure measured at home over a 2-week period using the semiautomated device was approximately 10 mm Hg lower than that measured with the same device during clinic visits. This pattern was consistent throughout the 6 months of the study.

Figure 3 summarizes differences between office versus home-based systolic BP. The INT subjects performed most scheduled home BP measurements (range 89% to 94%). Systolic and diastolic BP measured at home fell rapidly during the first 3 months of the study and remained relatively constant through month 6.

Office versus home-based systolic blood pressure: intervention patients only.

Antihypertensive medications

Patients in both INT and UC groups reported similar numbers of BP medications at baseline. At baseline, 22% of intervention patients and 30% of UC patients were taking no BP medications (NS). By 6 months, INT patients had significantly increased the number and variety of antihypertensive medications. The proportion of patients reporting two or more drugs at 6 months was 70% and 46%, respectively, among INT and UC patients. Similarly, the proportion of patients reporting no drug therapy at 6 months was 4% and 22%, respectively, among INT and UC subjects ( P < .01). The maximal dose of each individual medication was similar in the two groups.

Figure 4 summarizes the pattern of medication use in the study subjects. The distribution of medications remained similar in both groups at baseline and at 3 and 6 months. The proportion of patients taking angiotensin-converting enzyme inhibitors, diuretics, -blockers, and calcium blockers approximated respectively 40%, 25%, 20%, and 15% at the three assessment points. Among UC patients, 43% reported one or more changes in drug therapy during the 6-month study period, mostly initiated during office visits. In contrast, the rate of patients reporting changes in drug therapy was more than doubled (97%) among those receiving nurse management. Most therapy changes among INT patients arose from scheduled phone contacts. The number of medication changes (mean ± SD) reported by UC patients was 52 ± 1 (mean 0.69 changes/patient). The INT patients noted 223 ± 6 medication changes (mean 2.97 changes/patient; P < .01). Less than 5% of treatment decisions made by the nurse care manager required telephone discussion with a physician. Participating patients rarely telephoned the nurse care manager.

Pattern of medication use.

Medication adherence

Drug adherence, tracked by the electronic drug event monitor, assessed daily adherence (that is, the average number of days on which patients took the correct number of doses as prescribed). The INT patients’ rate of daily adherence during the 6-month study period was 80.5% ± 23.0% (mean ± SD, with 25th and 75th percentile values 77% to 95%), whereas the rate of UC patients was 69.2% ± 31.1% (25th and 75th percentile values 50% to 93%; t 113 = 2.199, P = .03).

In both groups, once-daily regimens yielded higher daily adherence rates than for more frequent dosing. The respective adherence rates were 82% ± 28% and 75% ± 27% for once-daily dosing and 69% ± 34% and 49% ± 41% for twice-daily or more than twice-daily dosing in the INT and UC groups. None of these differences reached statistical significance.

In this randomized controlled trial, we found that home-based, physician-directed, nurse-guided drug therapy proved superior in BP control to standard office-based management among eligible hypertensive patients by JNC VI criteria. The size of achieved reductions in systolic and diastolic BP approximate those reported for intensive interventions in other trials. 13 Pill-taking adherence by the electronic drug event monitor remained high in both groups but reached statistically higher levels among INT subjects. The greater variety of BP drugs, the greater proportion of patients on antihypertensive therapy, and the progressive medication adjustment contributed to the superior INT outcomes.

Most hypertension management studies reflect ambulatory settings. 14–16 Inauspicious characteristics include large numbers of patients, diverse comorbidities, no consistent standards for antihypertensive management, and providers’ nonaccountability for clinical outcomes. Berlowitz et al 14 reported that physicians defer changing drug therapy, even when BP remain elevated: “clinical inertia” from infrequent assessments, ignorance of established clinical guidelines, and distraction by unrelated medical priorities. 17

The nurse management system in this study addressed some of the relevant obstacles. The system used external clinical guidelines (JNC VI 2 ) to define entry criteria, treatment goals, preferred medications, and management of side effects. It closely linked ongoing surveillance of BP values and responsive changes in drug therapy. By periodic phone contacts, the nurse managers made timely medication changes, adjusting treatment intensity as needed. Over the 6-month trial, INT patients underwent more than four times the number of drug changes than UC patients and usually achieved control in less than 3 months. These results approximate those of Mehos et al applying pharmacists’ regulation of BP medications in a home-based intervention. 18

Most prior studies of home BP measurement reported BP sampling over only a few days. 7 In the present study, sampling twice daily over several months, commonly >300 measurements in all, offered more confidence about central tendency with day-to-day BP fluctuations. Home BP determinations closely approximated clinic BP with both portable device and mercury sphygmomanometer.

This study supports using home BP measurement as a reliable alternative to office BP measurement 19 and suggests that it provides a more representative indicator of BP status, when the number of home determinations is large. 20 , 21 The accuracy of clinic measurements may suffer from nonstandardized measurement and brief sampling. Training patients can standardize BP measurement 19 and minimize so-called white coat effects. 22

The theoretical underpinning for the current study comes from social cognitive theory. 23 The behavioral model reflects self-regulation, enabling patients to differentially select health promoting behaviors. The core features of effective self-regulation of health habits include knowledge, self-monitoring, goal setting, and corrective self-regulation when most needed rather than at fixed intervals. Ongoing interactivity permits adjustment of interventions contingent on the progress being made.

This study assessed the efficacy of the home-based management system as a whole rather than the relative contribution of the various components: baseline instruction, patients’ measurement and reporting of home BP, modulation of drug therapy by standardized protocol, and systematic phone contacts. Despite its relative complexity, the management system was readily understood and accepted by physicians in both managed care settings (Kaiser) and fee-for-service academic settings (Stanford).

The study inescapably includes some limitations. The participating patients, given the larger recruitment pool, may be atypical in their willingness or ability to monitor home BP. By sociodemographic characteristics, the participants represent an affluent and well educated cohort. The two clinical facilities are typical of similar settings, even if not representative of all primary care practices.

Several implications emerge for optimizing future antihypertensive management. Clinical inertia will likely continue in the absence of efforts toward standardization and accountability for outcomes. Individual clinicians— however devoted, knowledgeable, and skilled—may still fail to implement consistent and optimally effective guidelines of diagnosis, monitoring, and treatment adjustment. The present study provides a successful example of moving from general guidelines, as in JNC VI, to an operational protocol for nurses working with a consultant cardiologist.

Medical measurement devices for home use will soon permit guidance via the Internet similar to nurse-mediated case management. These technological innovations do not diminish the need for physicians’ active involvement in the creation, critical appraisal, and periodic refinement of management protocols. Physicians will remain vital to evaluating comorbid risk factors and to prescribing appropriate antihypertensive therapies.

The present care management system facilitates and expands the reach and scope of traditional health care by three interdependent means. First, it reduces the need for physicians to mediate the routine tasks of managing antihypertensive therapy. Second, the management system encourages physicians to focus their energies on problem cases, such as those individuals who fail to achieve satisfactory control. Third, the management system reinforces the value of collaboration among teams of health professionals. Formal study of such hypertension case management will likely confirm its cost-effectiveness. 24

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Author notes

hypertension
pharmacotherapy
patient care management
medication adherence

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Mini Review
Mini review series: Current topic in Hypertension 2024
Published: 16 August 2024

Sleep and hypertension – up to date 2024

Naoko Tomitani 1 ,
Satoshi Hoshide 1 &
Kazuomi Kario 1

Hypertension Research ( 2024 ) Cite this article

Metrics details

People spend one-third of their lives sleeping, and adequate, restful sleep is an essential component of a healthy life. Conversely, disruption of sleep has been found to cause various physical and mental health problems. Emerging research has shown that blood pressure (BP) during sleep is a stronger predictor of cardiovascular events than conventional office BP or daytime BP. Thus, management of both sleep health and nighttime BP during sleep is important for preventing cardiovascular events. However, recent studies demonstrated that nighttime BP is poorly controlled compared with office BP and daytime BP. This finding is understandable, given the challenges in monitoring BP during sleep and the multiplicity of factors related to nocturnal hypertension and BP variability. This review summarizes recent evidence and considers future perspectives for the management of sleep and hypertension.

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Tomitani, N., Hoshide, S. & Kario, K. Sleep and hypertension – up to date 2024. Hypertens Res (2024). https://doi.org/10.1038/s41440-024-01845-x

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v.25(Suppl 1); 2023 Jun
PMC10207473

Effectiveness of nurse-led interventions to manage hypertension and lifestyle behaviour effectively: a systematic review and meta-analysis

Doctor l bulto.

Flinders University, Adelaide, Australia

Doctor J Roseleur

Ms s noonan, doctor a pinero de plaza, doctor s champion, doctor h a dafny, mr v pearson, ms k nesbitt, doctor l gebremichael, doctor a beleigoli, doctor t schultz, doctor s hines, professor r clark, professor j hendriks, funding acknowledgements.

Type of funding sources: None.

Hypertension is a leading risk factor in the development and worsening of cardiac arrhythmias, in particular atrial fibrillation. Practice guidelines recommend an integrated management approach which includes multidisciplinary teams.

to investigate the role of nurses in the management process, and to evaluate the effectiveness of nurse-led interventions on hypertension management, lifestyle behaviour and associated patient knowledge.

A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), Emcare (Ovid), CINAHL (EBSCO), Cochrane library and ProQuest (Ovid) were searched from inception to February 2022. Randomised controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, and full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI (Joanna Briggs Institute) tools. A statistical meta-analysis was conducted using RevMan version 5.4.1.

A total of 37 RCTs and 9,731 participants were included. The overall pooled data demonstrated nurse-led interventions significantly improved systolic blood pressure (MD -5.39; 95% CI -7.59, -3.34; I2 = 81.33; 23 RCTs; moderate certainty evidence) and diastolic blood pressure (MD –1.94 95% CI -3.27, -0.60; I2 = 79.66; 22 RCTs; moderate certainty evidence) compared to usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent.

This review revealed beneficial effects of nurse-led interventions in hypertension management compared to usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension and conditions it may be associated with.

Open access
Published: 15 August 2024

Evaluation of a specialist nurse-led structured self-management training for peer supporters with type 2 diabetes mellitus with or without comorbid hypertension in Slovenia

Tina Virtič Potočnik 1 , 2 ,
Matic Mihevc 1 , 3 ,
Črt Zavrnik 1 , 3 ,
Majda Mori Lukančič 1 ,
Nina Ružić Gorenjec 1 , 4 ,
Antonija Poplas Susič 1 , 3 &
Zalika Klemenc-Ketiš 1 , 2 , 3

BMC Nursing volume 23 , Article number: 567 ( 2024 ) Cite this article

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The training of peer supporters is critical because the success of the entire peer support intervention depends on the knowledge and experience that peer supporters can share with other patients. The objective of this study was to evaluate the pilot implementation of a specialist nurse-led self-management training programme for peer supporters with type 2 diabetes mellitus (T2DM) with or without comorbid hypertension (HTN) at the primary healthcare level in Slovenia, in terms of feasibility, acceptability, and effectiveness.

A prospective pre-post interventional pilot study was conducted in two Community Health Centres (CHC) in Slovenia from May 2021 to August 2022. Purposive sampling was employed to recruit approximately 40 eligible volunteers to become trained peer supporters. A specialist nurse-led structured training lasting 15 h over a 2-month period was delivered, comprising four group and two individual sessions. The comprehensive curriculum was based on interactive verbal and visual learning experience, utilising the Diabetes Conversation Maps™. Data were collected from medical records, by clinical measurements, and using questionnaires on sociodemographic and clinical data, the Theoretical Framework of Acceptability, knowledge of T2DM and HTN, and the Appraisal of Diabetes Scale, and evaluation forms.

Of the 36 participants, 31 became trained peer supporters (retention rate of 86.1%). Among them, 21 (67.7%) were women, with a mean age of 63.9 years (SD 8.9). The training was evaluated as satisfactory and highly acceptable. There was a significant improvement in knowledge of T2DM ( p < 0.001) and HTN ( p = 0.024) among peer supporters compared to baseline. Six months post-training, there was no significant improvement in the quality of life ( p = 0.066), but there was a significant decrease in body mass index (BMI) ( p = 0.020) from 30.4 (SD 6.2) at baseline to 29.8 (SD 6.2).

The pilot implementation of a specialist nurse-led self-management training for peer supporters was found to be feasible, acceptable, and effective (in the study group). It led to improvements in knowledge, maintained disease control, and promoted positive self-management behaviours among peer supporters, as evidenced by a decrease in their BMI over six months. The study emphasises the need for effective recruitment, training, and retention strategies.

Trial registration

The research is part of the international research project SCUBY: Scale up diabetes and hypertension care for vulnerable people in Cambodia, Slovenia and Belgium, which is registered in ISRCTN registry ( https://www.isrctn.com/ISRCTN41932064 ).

Peer Review reports

New models for comprehensive, patient-centred, integrated care have been introduced in Slovenian primary care to improve the quality of care for people with type 2 diabetes mellitus (T2DM) and hypertension (HTN) [ 1 , 2 , 3 , 4 ]. One example of an evidence-based model of such care is the Integrated Care Package [ 5 ], which encompasses elements of early detection and diagnosis, treatment in primary care, health education, self-management support by patients and caregivers, and collaboration among caregivers [ 5 , 6 ]. The integrated care provided for patients with T2DM and HTN in Slovenia is generally of high quality. However, the implementation of self-management support is only weakly developed [ 7 ]. The provision of self-management support for T2DM and HTN requires the ongoing engagement and motivation of patients, which cannot be adequately addressed by the healthcare system alone [ 8 , 9 ]. Consequently, the focus of patient-centered care should shift from healthcare institutions to the patient’s local and home environment [ 10 ]. One potential solution is the introduction of peer support by appropriately trained lay people, which would empower patients, family members and other informal caregivers in the local community [ 7 ]. This form of collaboration between peer supporters, patients, healthcare providers, and the local community is not yet established in Slovenia. Therefore, there is a necessity to investigate and implement this approach to scale-up integrated care for individuals with T2DM and HTN.

Patients are well-suited for the role of volunteer peer supporters because they can share first-hand knowledge, similar experiences and lifestyle issues with others who have the same chronic disease. As they operate within the local community, there are no demographic, language or cultural barriers between them. Peer supporters do not possess medical qualifications; rather, their role is to complement health services by providing practical assistance to individuals living with the same chronic disease. This assistance encompasses a range of activities, including offering guidance on coping with daily life, creating a supportive emotional and social environment, and providing ongoing support to assist with the lifelong needs of disease self-management [ 11 , 12 , 13 ]. Several systematic reviews have demonstrated that peer support interventions significantly improve glycaemic outcomes in adults with T2DM who receive such support [ 14 , 15 , 16 ]. A systematic review and meta-analysis on the effects of peer support interventions on other cardiovascular disease risk factors in adults with T2DM found a positive effect only on recipients’ systolic blood pressure (SBP) but not on diastolic blood pressure (DBP), cholesterol, body mass index (BMI), diet, or physical activity [ 17 ].

Training and coordinating peer supporters is crucial for the success of the peer support intervention, as it is essential that peer supporters have the knowledge and experience to effectively assist others [ 11 , 12 ]. The main problem is the lack of studies describing training models that provide comprehensive knowledge and enhance the ability of peer supporters to support self-management. The literature predominantly focuses on the peer support intervention itself and only a handful on peer supporter’s training, changes in knowledge, skills acquired [ 19 , 20 , 21 ] or impact on health outcomes [ 22 ]. There is a lack of guidelines in the methodology of training programme, including recruitment strategies, materials used, individuals delivering the training and duration of the training [ 11 , 12 , 18 , 21 , 23 , 24 ].

The primary objective of this study was to assess the feasibility and acceptability of a specialist nurse-led structured self-management training programme for peer supporters with T2DM, with or without comorbid HTN, at the primary healthcare level in Slovenia. Additionally, the study aimed to determine the improvement in peer supporters in terms of changes in their acquired knowledge about T2DM and HTN, quality of life and clinical outcomes.

Study design and settings

This was a prospective pre-post interventional pilot study conducted in two Community Health Centres (CHCs) in Slovenia. The initial criteria for the selection of the CHCs was based on the objective of ensuring both urban and rural settings. The CHC Ljubljana is situated in the largest municipality and capital city of Slovenia. It serves approximately 300,000 residents and is representative of an urban setting, contributing 38.4% of Slovenia's total GDP in 2022. In contrast, CHC Slovenj Gradec, located in the smallest municipality in Slovenia, serves an estimated population of 17,000 residents, representing a rural region. This CHC contributed 6.4% of Slovenia's total GDP in 2022 [ 25 ]. This approach considered the different cultural and social environments in urban and rural areas, and acknowledged that distinct forms of peer support are acceptable in each setting [ 26 ].

The study was nested within a larger parent study, which spanned from May 2021 to December 2023. Its objective was to develop an evidence-based model of peer support for people with T2DM, with or without comorbid HTN, at the primary healthcare level in Slovenia. The peer support intervention was a prospective, mixed-methods pilot study that commenced with the recruitment of eligible individuals with T2DM and HTN through purposive sampling, with the objective of training them as peer supporters via specialist nurse-led structured self-management training. Each trained peer supporter voluntarily shared their knowledge and experience at monthly group meetings with up to 10 people with T2DM and HTN over a three-month period in the local community. Data was collected through series of interviews, focus groups, and questionnaires to evaluate the role of peer support. This involved introducing trained peer supporters, determining the relationships between peer support and patient-reported quality of life and level of empowerment, and assessing the acceptability and feasibility of the peer support intervention [ 27 ].

The study was approved by the National Medical Ethics Committee (reference number 0120–219/2019/4, approved on 24 May 2019).

Participants and recruitment

Purposive sampling was employed to recruit eligible patients with T2DM, with or without comorbid HTN, from two CHCs by registered nurses and family medicine physicians. These patients were interested in serving as volunteer peer supporters. The purposive sampling method ensured that the recruited participants were suitable for the peer supporter role based on their responsibility, confidence, communication skills and willingness to collaborate with an educator from the CHC. It is important to note that peer supporters should be aware that they are not medical professionals and should not attempt to provide medical treatment or diagnosis. In the event that a situation arises that is beyond the scope of their knowledge and experience, it is recommended that they refer the recipient of peer support to a healthcare professional for appropriate care [ 27 ].

Inclusion criteria were as follows: i) a confirmed diagnosis of T2DM with fasting blood glucose (BG) value ≥ 7.0 mmol/l or venous plasma glucose ≥ 11.1 mmol/l two hours after glucose tolerance test or at any random opportunity, or glycated haemoglobin (HbA1c) ≥ 6.5% [ 28 ], ii) with or without comorbid HTN with a 7-day mean home BP values ≥ 135/85 mmHg or with 24-h blood pressure monitoring mean ≥ 130/80 mmHg [ 29 ], iii) for a duration of at least one year. This was deemed necessary in order to ensure that participants have had sufficient time to adapt to their diagnosis, understand their treatment regimen, and develop a baseline level of disease management.

Exclusion criteria included: type 1 diabetes or gestational diabetes, < 18 years of age and a documented diagnosis of cognitive decline obtained from the participant’s medical records. This diagnosis was based on comprehensive assessments of the individual’s clinical presentation, medical history, and relevant test results conducted by family physicians and other healthcare professionals.

Participation in the study was voluntary. All participants received an explanation of the study objectives and a participant information sheet that provided additional information. To participate in the study, it was obligatory to sign the informed consent form.

Structured self-management educational training

The self-management training was designed to empower peer supporters and equip them with comprehensive knowledge of T2DM and HTN and communication skills to provide effective peer support to other patients with T2DM, with or without comorbid HTN. The training was led by an educator with the expertise of a registered nurse with specialised knowledge in the field of health education of people with T2DM—a specialist nurse. There was ongoing consultation with the mentor-educator throughout the training, who remained their mentor while providing peer support, either in person, by telephone or by email. In addition, a specialist nurse actively promoted the awareness and value of peer support, thereby reducing the spread of misinformation and concerns about recommending it [ 11 , 17 ].

The training lasted a total of 15 h over a period of 2 months and consisted of four group sessions and two individual sessions. The training was organised in small groups of 6–10 candidates and conducted in accordance with the T2DM education [ 30 ] and treatment [ 28 ] guidelines. To ensure a consistent programme, each educator led the training based on the comprehensive curriculum (Table 1 ). To provide a comprehensive and interactive verbal and visual learning experience and to facilitate T2DM self-management through a patient-centred approach, the educators used Diabetes Conversation Maps™. Several well-established models of health behavior, such as the Biopsychosocial Model of health and illness, were considered in the development of this effective health education tool [ 31 ].

After the group sessions, participants had two individual sessions with the educator, a specialist nurse. The focus was on analysing the themes from the group session (Table 1 ), reviewing the self-monitoring diary of BG and BP, assessing the knowledge gained and discussing the aims of voluntary peer support, the role of a trained peer supporter and opportunities of organising peer group meetings, and ways of further collaboration with healthcare professionals, patients, and the local community. Throughout the training, the educator taught participants how to communicate assertively and used motivational and coaching techniques to approach volunteering and working with people. At the end of the 15-h training, each participant was given four different Conversation Maps™ and a honorary certificate of the acquired title of “trained peer supporter” and CHC ambassador at the award ceremony to ackowledge the completion of the training, and to acknowledge the participants’ efforts [ 27 ]. The study flow chart is presented in Fig. 1 .

Study flow chart (n, number; T2DM, type 2 diabetes mellitus; HTN, hypertension; CHC, Community Health Centre)

Theoretical intervention model

The theory of change underlying the intervention was based on the hypothesis that training peer supporters would influence their knowledge, perceptions, and intentions, which in turn would lead to changes in self-management behavior and ultimately improved health outcomes. This would also enable effective delivery of peer support, resulting in behavior change and health benefits among people with T2DM, with or without comorbid HTN, receiving peer support. The theory of planned behavior [ 32 ] was used to predict and explain behavior change. Our pilot study protocol is schematically presented in Fig. 2 , outlining its objectives in terms of feasibility, acceptability, and effectiveness (in the study group). The ongoing collaboration between trained peer supporters, people with T2DM, with or without comorbid HTN, caregivers in the local community, and healthcare professionals aims to make them partners in health and care.

Schematic presentation of the pilot study and the theory of change framework (HTN –hypertension; T2DM – type 2 diabetes mellitus)

Instruments and data collection

The study lasted from May 2021 to August 2022. Data were collected from medical records, clinical measurements were conducted by a registered nurse at both the pre- and post-intervention stages, and structured questionnaires were completed by the peer supporters at entry into the study (baseline) and after completing the training. At the conclusion of the training, peer supporters were invited to complete an evaluation form as the sole method to provide qualitative feedback with quotations on their overall satisfaction with the training. Variables were observed across several categories (Table 2 ).

Participants underwent anthropometric and biochemical measurements at baseline and 6 months after completing the training. Measurements were performed by a registered nurse at CHC using a validated scale and blood pressure monitor. SBP and DBP were measured as recommended in the guidelines [ 29 ]. HbA1c level and fasting BG value were determined using peripheral venous blood sampling. To assess the acceptability of the healthcare intervention Sekhon et al. developed the TFA tool (Table 3 ) [ 33 ]. Specifically, we used a 19-items TFA questionnaire (Appendix 1) developed by Timm et al. [ 34 ], which covers all 7 domains of acceptability based on the TFA tool: affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness and self-efficacy [ 33 ]. Each item is rated on a 5-point Likert scale, the score for each of the 7 domains and the total score range between 1 and 5. To assess knowledge about HTN and T2DM, we used validated Slovenian versions of the Hypertension Knowledge Test (HKT) [ 35 ] with 11 true/false questions and the first 14-item questionnaire of the Diabetes Knowledge Test (DKT) [ 36 ], the result of both is between 0 and 100%. The Appraisal of Diabetes Scale (ADS) [ 37 ] was used to assess the individual’s appraisal of T2D, which is diabetes-specific indicator of quality of life [ 38 ], consists of 28 items on a 5-point Likert scale yielding the final score between 7 and 35 where lower score is better.

Sample size elaboration

We employed purposive sampling method to recruit approximately 40 eligible individuals (30 from CHC Ljubljana and 10 from CHC Slovenj Gradec) with T2DM, with or without comorbid HTN, to become volunteer peer supporters. Each peer supporter was expected to share their knowledge and experience with around 10 patients with the same chronic condition in their local community, potentially providing support to up to 400 patients. Considering an estimated dropout rate of 20%, we anticipated that 32 peer supporters would remain, each supporting a group of 8 patients, resulting in 256 patients receiving peer support. The power analysis was done for the sample size of patients receiving peer support for the two outcomes in that larger parent study. Specifically, for the ADS score, a planned sample size of 256 patients achieves 80% power to detect a mean difference (between pre- and post-intervention) of 1.6 using two-tailed paired samples t-test, assuming the SD of differences of 9.3 (this represents the largest possible SD if the differences in ADS scores are normally distributed, given their range is at most [-28,28]) [ 27 ].

Statistical analysis

We summarised categorical variables with frequencies and percentages, and numerical variables with means and standard deviations (SD) or medians and interquartile ranges (IQR) in the case of asymmetric distributions (determined by Shapiro–Wilk normality test and visual inspection of graphs). To compare numerical variables between pre- and post-intervention, we used paired-samples t -test (together with 95% confidence interval (CI) for the mean difference) or Wilcoxon signed-rank test in the case of asymmetric distributions. A p -value of < 0.05 was considered statistically significant.

Of 36 patients (10 from CHC Slovenj Gradec and 26 from CHC Ljubljana) with T2DM, with or without comorbid HTN, recruited for the study, 31 (86.1%) attended all meetings, successfully completed the specialist nurse-led training, and became trained peer supporters. All the results are for the sample of 31 trained peer supporters.

Sociodemographic data and clinical history

The basic socio-demographic characteristics of the 31 trained peer supporters are shown in Table 4 . Among them, 21 (67.7%) were women, with a mean age of 63.9 (SD 8.9) years. They had all been treated for T2DM for a median duration of 15.0 years (IQR 5.0 – 20.5). As a comorbidity, 24 (77.4%) peer supporters had HTN. The median duration of treatment was 8.5 years (IQR 2.8 – 18.2). Of the 31 trained peer supporters, 7 (22.6%) were treated non-pharmacologically with diet and exercise, 13 (41.9%) with hypoglycaemic agents, 5 (16.1%) with a combination of hypoglycaemics and insulin, and 6 (19.3%) with insulin alone.

Acceptability of the self-management educational training

Participants rated the training as highly acceptable in all 7 domains, with median scores ranging from 4.0 to 5.0 and the lowest first quartile being 4.0 (Table 5 ). The median total score was 4.5 with IQR (4.1 – 4.7).

Peer supporters’ satisfaction with educational training

Some of the quotations from the evaluation forms highlight the satisfaction with the training: “It is fascinating how much I have learned about both diseases, even though I have been living with T2DM and HTN for years;” “I can always contact my educator by mail or phone if I have a problem;” “The training encouraged me to continue with a healthy lifestyle and to take greater control of my health;” “This programme gave me additional motivation to maintain my health and to share my experiences with others;” “I believe that the Conversation Maps are great; when I showed them at home, the words about T2DM just rolled out of my tongue.”

Knowledge about T2DM and HTN

After completing the training, knowledge of T2DM and HTN increased significantly ( p < 0.001 and p = 0.024, respectively). The mean knowledge of T2DM at baseline was 72.9% (SD 15.6%, median 79.0%, IQR (64.0% – 86.0%)), the mean difference in knowledge of T2DM was 9.4% (SD 12.9%, median 8.0%, IQR (0.0% – 14.5%)) with 95% CI for the mean difference (4.7%, 14.1%). The median knowledge of HTN at baseline was 91.0% with IQR (77.5% – 91.0%), the median difference in knowledge of HTN was 0.0% but with IQR (0.0% – 9.0%).

Quality of life

Quality of life with T2DM was not significantly better after the completed training ( p = 0.066). Participants' perceived burden of T2DM decreased from a mean score of 16.1 (SD 3.5) to 14.8 (SD 4.2) after the training (lower ADS score is better), the 95% CI for the mean difference was (-0.1, 2.7).

Clinical outcomes

The mean anthropometric and biochemical measurements at baseline and 6 months after completion of the training are shown in Table 6 . Peer supporters' weight decreased significantly ( p = 0.022) from 85.8 (SD 19.5) kg at baseline to 84.2 (SD 20.0) kg 6 months after training, and BMI decreased from 30.4 (SD 6.2) to 29.8 (SD 6.2) ( p = 0.020). Changes in fasting BG, HbA1c, SBP and DBP were not significant.

Our pilot study indicates that specialist nurse-led self-management training for peer supporters is feasible, acceptable, effective (in the study group), and highly valued by participants. The training enabled peer supporters to acquire knowledge about T2DM and HTN and equipped them with self-management skills to effectively support other people with the same chronic condition by sharing first-hand knowledge, similar experiences and lifestyle issues. Our study was unique in measuring changes in clinical measures of peer supporters in primary care settings. Peer supporters were successful in maintaining disease control and making positive changes in their self-management behaviours, as reflected in the reduction in their BMI over the six-months following the training.

The literature has not used rigorous approaches to recruit appropriate peer supporters [ 19 , 21 ]. Recruitment has mainly been done through referrals from healthcare professionals based on candidate interest in volunteering and diagnosis of T2DM as inclusion criteria [ 21 , 39 ]. In contrast to our study, some listed inclusion criteria of acceptable glycemic control (HbA1c ≤ 8.5%) [ 21 , 23 , 39 , 40 ], which could increase the retention rate and improve the chances of success [ 21 ]. We used the purposeful sampling method to ensure that recruited participants were suitable for the peer supporter role. Recruitment of peer supporters should emphasize the importance of their personal experience with the same chronic condition as people they will be supporting. This unique perspective allows them to better understand and empathize with the challenges that their support recipients are facing [ 12 ]. We believe it is important to promote this uniqueness when recruiting peer supporters, as it can help to build trust and confidence in the support programme.

There is limited data on the socio-demographic characteristics of peer supporters; most were female and had at least a high school education [ 21 , 39 , 41 , 42 ], which is consistent with the findings of our study. Most of our trained peer supporters were retired, had a longer duration of T2DM and were older than in other studies [ 21 , 39 , 43 ]. In one study, 90% of peer supporters were unemployed [ 43 ]. The Slovenian peer supporters were mainly older, disease-experienced individuals who were no longer involved in the daily stress of work. They rated the training as very acceptable. Participating in the training was effortless for them, it fitted well with their life beliefs and values, and they understood the process of the whole intervention. They felt empowered and confident in their ability to transfer the knowledge and skills they had acquired to other patients.

There are no clear recommendations on who should lead the training of peer supporters (nurse educator, multidisciplinary team, research expert, etc.) and how long the training should last (from a few hours to several months) [ 12 , 18 , 19 , 20 , 24 , 39 , 42 ]. Training programmes were mostly based on a structured curriculum [ 12 , 18 , 20 , 21 , 23 , 40 ]. Teaching methods included role-playing [ 12 , 20 , 21 , 43 ], brainstorming, group facilitation simulations [ 20 ], PowerPoint presentations [ 12 ], training booklets [ 19 , 21 ], and Conversation Maps™ [ 19 ]. We used four different Diabetes Conversation Maps™ as teaching tools, and trained peer supporters were given the same collection of four Maps™ to bring to peer support meetings after completing the training. These maps are designed to be interactive and engaging, encouraging participants to talk about the challenges of living with T2DM and HTN, to share their stories, knowledge and experiences, and to emphasise the importance of medication adherence, healthy lifestyles and regular check-ups with healthcare professionals. The maps help to create a structured and supportive environment where participants can learn from each other and feel empowered to take control of their disease management [ 31 , 44 ]. Our detailed self-management training programme (Table 1 ) makes the lesson preparation transparent and allows for replication when designing future interventions.

Consistent with the findings of our pilot study, other studies have also shown that the development of self-management educational training leads to improved knowledge of T2DM among peer supporters [ 19 , 43 ]. Six months after the training, peer supporters' weight and BMI decreased significantly compared with baseline measurements. There were no significant differences in the measurements of fasting BG, HbA1c, SBP and DBP after six months, nor were the changes that occurred clinically significant. We did not expect clinically significant changes in such a short period of time, as we believe that a longer study period is needed to detect significant changes. In addition, the peer supporters already had well-controlled clinical parameters at baseline. The results are still relevant as they show that patients were able to maintain their disease control and even improve some clinical parameters over the six-month period. Peer supporters who can model healthy behaviours and share their own experiences of disease management may be more effective in helping others to make positive changes in their own lives. To our knowledge, only Yin et al. have investigated the effects of peer support on the health of peer supporters. However, their study was conducted in hospital-based diabetes clinics and involved a multidisciplinary team to train the peer supporters, unlike our primary care setting. They found improvements in peer supporters self-care behaviours and maintenance of their glycaemic control over 4 years [ 22 ].

The actual implementation of our research depends on the willingness and motivation of individuals to provide peer support voluntarily, so a gradual decline in motivation and in some cases withdrawal can be expected [ 11 ]. We recognised the importance of acceptability in the evaluation of the healthcare interventions [ 33 ]. Participants assessed our training as highly acceptable and satisfactory. Consequently, we found that participation in the training was high and consistent, with 86.1% of patients successfully completing the training and becoming trained peer supporters. The reasons for dropping out were all external, such as changes in personal or family health status, rather than dissatisfaction with the programme or its content. The demographic and clinical characteristics of the non-completers were diverse, supporting the assertion of external reasons for dropping out (they were aged 57–77 years, with a gender split of 3 women and 2 men, 4 were retired and 1 was still working, 4 had completed secondary school and 1 university, had been managing T2DM for a range of 5–30 years, with only 2 having HTN as a comorbidity). In the study by Chan et al. 74.7% completed the training and 41.8% agreed to continue providing peer support [ 39 ]. In a study by Afshar et al., the retention rate among peer leaders ranged from 56 to 88% [ 21 ]. To overcome this problem, it is important to focus on engagement and recognition strategies, such as good communication, collaboration among stakeholders and a clear presentation of the benefits of peer support [ 11 ]. The future connection and collaboration between trained peer supporters, patients, family members, caregivers in the local community and health professionals could make them partners in health and care. Together they could achieve the ultimate goal of a comprehensive, patient-centred approach: empowering individuals to take an active role in managing their illness and achieving their health goals [ 45 ].

Strengths and limitations

Peer supporters are becoming an integral part of diabetes management. This study addresses an important gap in person-centred diabetes care by providing new insights into the feasibility and acceptability of a training programme for peer supporters. To ensure that the intervention is well organised, effective and sustained, emphasis needs to be placed on recruiting, training and retaining peer supporters for ongoing effective self-management and support of others with the same chronic condition. This can be achieved through several key strategies, including purposive sampling to select suitable candidates for the peer supporter role, the involvement of a mentor-educator to provide ongoing support and supervision, regular evaluation and monitoring of the training to identify challenges and areas for improvement, and the acknowledgement of peer supporters with honorary titles and certificates. The study provided valuable insights that could contribute to the successful implementation of peer support training interventions in diabetes care.

Our study has several limitations. Firstly, the lack of a control group of potential peer supporters who did not attend the training makes it impossible to estimate the real effectiveness of the training programme, and further research with a control group is needed. We decided not to use a control group due to our limited sources and our goal to train as many peer supporters as possible in a short period of time. Secondly, the use of the same DKT and HKT questionnaires at the beginning and the end of the two-month training means that participants already knew the questions, which could influence their actual knowledge. However, previous studies showing improved knowledge of T2DM after training [ 19 , 43 ], also repeated the same test, suggesting that question familiarity is not predictive of the second test results. Thirdly, it is not possible to measure the long-term effects as the questionnaires were only measured after the training was compiled, and clinical outcomes were only measured 6 months after the training. Fourthly, we cannot say that 15 h of training is sufficient. Therefore, a follow-up evaluation is needed to examine retention and acquisition of skills and knowledge for ongoing peer support intervention. Fifthly, in anticipation of a small sample size and difficulty in recruiting a large enough sample of participants with both T2DM and HTN who were willing to become peer supporters, we included in the pilot study all individuals with a confirmed diagnosis of T2DM, regardless of whether they had comorbid HTN. In addition, the use of purposive sampling introduces potential bias and limits the generalisability of the findings. Finally, we did not formally evaluate the teaching effectiveness or information transfer skills of the peer supporters. However, to the best of our knowledge, no studies [ 11 , 12 , 18 , 21 , 23 , 24 ] have included teaching skills in peer support training programmes, as the focus has been on practical and experiential skills that are crucial for managing their condition.

Conclusions

The structured self-management training for peer supporters, led by a specialist nurse, was found to be highly acceptable, effective (in the study group), and feasible, indicating significant potential for scaling-up integrated care for people with T2DM, with or without comorbid HTN, at the primary healthcare level in Slovenia. Trained peer supporters improved their knowledge and gained self-management skills, leading to positive changes in their behaviour, as evidenced by a decrease in their BMI over six months. The training programme enabled them to effectively support others with the same chronic condition by sharing first-hand knowledge, similar experiences, and lifestyle advice. However, further research is needed to confirm the true effectiveness of the training programme with a control group and to improve the quality of the peer support provided.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available because the data is part of an unpublished dissertation but are available from the corresponding author upon reasonable request.

Abbreviations

Type 2 diabetes mellitus

Hypertension

Community Health Centres

Body mass index

Systolic blood pressure

Diastolic blood pressure

Blood glucose

Glycated haemoglobin

Appraisal of Diabetes Scale

Theoretical Framework of Acceptability

Diabetes Knowledge Test

Hypertension Knowledge Test

Standard deviation

Interquartile range

Confidence interval

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Acknowledgements

We want to thank all peer supporters who participated in this study.

The research is part of the international research project SCUBY, funded from the European Union’s Horizon 2020 programme under grant agreement number 825432. The funding is not involved in study design, data collection, analysis and interpretation of data, writing of the paper or decision to submit the article for publication.

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Tina Virtič Potočnik, Matic Mihevc, Črt Zavrnik, Majda Mori Lukančič, Nina Ružić Gorenjec, Antonija Poplas Susič & Zalika Klemenc-Ketiš

Faculty of Medicine, Department of Family Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia

Tina Virtič Potočnik & Zalika Klemenc-Ketiš

Faculty of Medicine, Department of Family Medicine, University of Ljubljana, Poljanski Nasip 58, 1000, Ljubljana, Slovenia

Matic Mihevc, Črt Zavrnik, Antonija Poplas Susič & Zalika Klemenc-Ketiš

Faculty of Medicine, Institute for Biostatistics and Medical Informatics, University of Ljubljana, Vrazov Trg 2, 1000, Ljubljana, Slovenia

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TVP, MML, TPS, ZKK, MM and ČZ were responsible for study conception and design. MML and TVP performed the data collection. TVP and NRG contributed to the data analysis and interpretation. TV drafted the manuscript under the supervision of ZKK. To ensure the quality of the study MM, ČZ, NRG, TPS, MML and ZZK made critical revisions to the paper. All authors read and approved the final manuscript.

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Correspondence to Tina Virtič Potočnik .

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The research was approved on 24 May 2019 by the Slovenian National Medical Ethics Committee (reference number 0120–219/2019/4), which is exclusively responsible for making determinations on ethical issues that are relevant to the unification of ethical practices in the Republic of Slovenia. The study followed the Declaration of Helsinki on ethical standards. Written informed consent was obtained from all the participants.

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Virtič Potočnik, T., Mihevc, M., Zavrnik, Č. et al. Evaluation of a specialist nurse-led structured self-management training for peer supporters with type 2 diabetes mellitus with or without comorbid hypertension in Slovenia. BMC Nurs 23 , 567 (2024). https://doi.org/10.1186/s12912-024-02239-7

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Hypertension

Hypertension, or high blood pressure, is a risk factor for cardiovascular disease and stroke—the two leading causes of death in the United States ( 1–3 ).

Featured Chart

Explore data, definitions, key findings, hypertension in adults age 20 and older.

This line graph shows the percentage of adults age 20 and older with hypertension from 2001 through 2004 to 2017 through March 2020.

The age-adjusted percentage of adults age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March 2020. See Featured Chart for additional analysis.

SOURCE: National Center for Health Statistics, National Health and Nutrition Examination Survey. See Sources and Definitions, National Health and Nutrition Examination Survey (NHANES) and Health, United States , 2022 Table Htn .

Estimates are based on the U.S. civilian noninstitutionalized population. See Sources and Definitions, Population .
Age-adjusted estimates are presented to eliminate differences that result from changes in the distribution of age in the population over time. See Sources and Definitions, Age adjustment .
For information on the methods used to assess trends, see Sources and Definitions, Statistical testing .
The NHANES program suspended field operations in March 2020 due to the COVID-19 pandemic. As a result, data collection for the 2019–2020 cycle was not completed. Consequently, data collected during 2019–March 2020 were combined with data from the 2017–2018 cycle to create a 2017–March 2020 prepandemic file. This file covers 3.2 years of data collection. For more information, see: “ National Health and Nutrition Examination Survey, 2017–March 2020 Prepandemic File: Sample Design, Estimation, and Analytic Guidelines .”

Hypertension in men age 20 and older

This line graph shows the percentage of men age 20 and older with hypertension from 2001 through 2004 to 2017 through March 2020.

The age-adjusted percentage of men age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March. See Featured Chart for additional analysis.

Hypertension in women age 20 and older

This line graph shows the percentage of women age 20 and older with hypertension from 2001 through 2004 to 2017 through March 2020.

The age-adjusted percentage of women age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March 2020 (42.1% in 2017–March 2020). See Featured Chart for additional analysis.

From 2001–2004 to 2017–March 2020, hypertension was stable across all ages and was higher among older adults for both men and women.

Figure 1 is a two-panel chart with line graphs showing the percentage of men (left graph) and women (right graph) age 20 and older with hypertension from 2001 through 2004 to 2017 through March 2020. Age groups shown are 75 and older, 65 through 74, 55 through 64, 45 through 54, 35 through 44, and 20 through 34.

NOTE: “Stable” refers to no statistically significant trend during the period.

From 2001–2004 to 2017–March 2020, the percentage of men and women age 20 and older with hypertension did not change significantly for any age group.
Throughout the period, the percentage of men and women with hypertension generally increased with increasing age.
For men in 2017–March 2020, the percentage of those with hypertension ranged from 28.0% for men ages 20–34 to 83.2% for men age 75 and older.
For women in 2017–March 2020, the percentage of those with hypertension ranged from 13.6% for women ages 20–34 to 84.1% for women age 75 and older.
In 2017–March 2020, men were more likely to have hypertension than women for those younger than age 55. For those age 55 and older, the prevalence of hypertension was similar for men and women.

From 2001–2004 to 2017–March 2020, the age-adjusted percentage of adults age 20 and older with hypertension did not change significantly for Black, Mexican, and White adults. The percentage for Asian adults increased from 2013–2016 to 2017–March 2020 .

Figure 2 is a line graph showing the percentage of adults age 20 and older with hypertension by race and Hispanic origin from 2001 through 2004 to 2017 through March 2020. Categories shown are Black non-Hispanic, White non-Hispanic, Mexican, and Asian non-Hispanic.

1 Data for the Asian population are available only starting in 2013.

From 2001–2004 to 2017–March 2020, the age-adjusted percentage of adults age 20 and older with hypertension did not change significantly for Black, Mexican, and White adults.
For Asian adults, the age-adjusted percentage of hypertension increased from 41.2% in 2013–2016 to 46.2% in 2017–March 2020.
Throughout the period, hypertension was higher in Black adults compared with Mexican, White, and Asian adults.
In 2017–March 2020, the age-adjusted percentage of adults with hypertension was 58.9% for Black adults, 46.2% for Asian adults, 44.5% for White adults, and 42.6% for Mexican adults.
Estimates are Age-adjusted estimates are presented to eliminate differences that result from changes in the distribution of age in the population over time. See Sources and Definitions, Age adjustment .
Race groups (Asian, Black, and White) are non-Hispanic.
Data on race and Hispanic origin are presented in the greatest detail possible considering the quality of the data, the amount of missing data, and the number of observations. Although data for Hispanic people are available starting in 2007–2008, to provide estimates for the entire period starting with 2001–2004, estimates for people of Mexican origin are presented in the figure rather than Hispanic. Data for Asian people are available starting in 2011–2012.

Hypertension in adults age 20 and older, by selected characteristics: United States, selected years 1988–1994 to 2017–March 2020

SOURCE: National Center for Health Statistics, National Health and Nutrition Examination Survey.

NCHS Data Query System
Data.CDC.gov

Cholesterol in adults age 20 and older, by selected characteristics: United States, selected years 1988–1994 to 2017–March 2020

Hypertension: Defined as having measured high blood pressure (systolic pressure of at least 130 mm Hg or diastolic pressure of at least 80 mm Hg), taking high blood pressure medication, or both. Those who report taking high blood pressure medication may not have measured high blood pressure but are still classified as having hypertension. See Sources and Definitions, Hypertension .
Mexican: People of Mexican or Hispanic origin may be of any race. For 1999–2006, the NHANES sample was designed to provide estimates specifically for people of Mexican origin and not for all Hispanic-origin people. Starting with 2007–2008 data, estimates for all Hispanic people are available. To provide the full trend, estimates for people of Mexican origin only are presented in the figure. For data on the Hispanic population, see Health, United States, 2022 Table Htn . Also see Sources and Definitions, Hispanic origin .
Race: Estimates are presented according to the 1997 Office of Management and Budget’s “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity” and are for people who reported only one racial group. Starting in 2011, NHANES oversampled the Asian non-Hispanic population. In Health, United States , estimates are presented for Asian non-Hispanic, Black non-Hispanic, and White non-Hispanic people, as well as for people of Hispanic and Mexican origin. Insufficient numbers of observations are available during this period to meet statistical reliability or confidentiality requirements for reporting estimates for additional race categories. See Sources and Definitions, Race .
Centers for Disease Control and Prevention. High blood pressure . 2023.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 71(6):e13-e115. 2018.
Kochanek KD, Murphy SL, Xu J, Arias E. Deaths: Final data for 2020. NCHS National Vital Statistics Reports; vol 72 no 10. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:131355 .

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Making Sense of Hypertension Guidelines

DeWald, Tracy PharmD, MHS, BS; Granger, Bradi PhD, MSN, RN; Bowers, Margaret DNP, RN, FNP-BC

Tracy DeWald, PharmD, MHS, BS Clinical Pharmacist, Duke University Hospital, Durham, North Carolina.

Bradi Granger, PhD, MSN, RN Professor, Duke University School of Nursing, Durham, North Carolina.

Margaret Bowers, DNP, RN, FNP-BC Associate Professor, Duke University School of Nursing, Durham, North Carolina.

The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.jcnjournal.com ).

Correspondence Tracy A. DeWald, PharmD, MHS, BS, Duke Heart Center and Heart Failure Program, Division of Clinical Pharmacology, Department of Medicine, Duke University Medical Center, 3943 Durham, NC 27710 ( [email protected] ).

Hypertension is a leading risk factor for heart disease, stroke, kidney failure, and diabetes and is a predisposing risk factor for most cardiovascular chronic illnesses. The risk for major cardiovascular events drops significantly when guideline-based blood pressure targets are achieved. Several different societies and organizations have released guidelines during the past 6 years, and significant clinical trial data have been recently released. Here, we summarize existing guidelines and recent pertinent clinical trial data to assist practitioners in identifying optimal treatment strategies for the successful management of hypertension.

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AHA Says Renal Denervation Is an Effective Hypertension Treatment

Blood pressure, discoveries & impact (august 2024).

Hypertension, or the pathologic condition of having elevated blood pressure, is the leading risk factor for cardiovascular disease in both the United States and globally. Even with many pharmacological and lifestyle therapeutic options, only 23% of individuals with high blood pressure achieve adequate control.

In 2023, the U.S. Food and Drug Administration (FDA) approved renal denervation, a catheter-based procedure that silences the renal nervous system, which is an important contributor to hypertension. Renal denervation was approved as an adjunctive treatment for patients in which traditional antihypertensive management remains inadequate.

The American Heart Association (AHA) recently published a scientific statement reviewing the current clinical data surrounding renal denervation as a therapeutic option for hypertension. The statement was co-authored by Carlos Mena-Hurtado, MD , associate professor of medicine (cardiovascular medicine).

Randomized controlled trial data, beginning in 2010, showed efficacy for two main groups of patients: those with true resistant hypertension (who have failed multiple medications) and those with mild to severe hypertension (for whom medications were withdrawn for various reasons).

The statement concludes that renal denervation is an effective treatment for many patients with a favorable immediate safety profile. More research is required to better understand which patients may benefit most.

To learn more, read the article, “ Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association .”

Cluett JL, Blazek O, Brown AL, East C, Ferdinand KC, Fisher NDL, Ford CD, Griffin KA, Mena-Hurtado CI, Sarathy H, Vongpatanasin W, Townsend RR ; American Heart Association Council on Hypertension; Council on Cardiovascular and Stroke Nursing; Council on the Kidney in Cardiovascular Disease; and Council on Peripheral Vascular Disease. Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association . Hypertension. 2024 Aug 5. doi: 10.1161/HYP.0000000000000240. Epub ahead of print. PMID: 39101202.

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Carlos Mena-Hurtado, MD, FACC, FSCAI, FAHA Associate Professor of Medicine (Cardiology); Director CME, Section of Cardiology, Internal Medicine; Co-Director Limb Preservation Program, Yale New Haven Health System; Honorary Clinical Reader in Centre, Clinical Pharmacology in the William Harvey Research Institute; Co-Director Vascular Outcomes Program, Internal Medicine; Primary Member, Yale Institutional Review Board; Consultant, Center For Devices and Radiological Health; Member, Yale School of Medicine Progress Committee; Medical Director Vascular Medicine - YNHH, Internal Medicine; Interventional Cardiology Item-Writing Task Force, Task Force

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Revisiting the covid-19 pandemic: mortality and predictors of death in adult patients in the intensive care unit.

1. Introduction

2.1. type of study and data collection, 2.2. data recoding, 2.3. statistical analysis, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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	% Yes (95% Confidence Interval) [n]		p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Trait	Survivor (n = 263)	Non-Survivor (n = 325)	p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Admitted from another service	67.30 (61.63–72.97) [177]	63.38 (58.15–68.62) [206]	0.321	0.84 (0.60–1.19)
Female sex	45.25 (39.23–51.26) [119]	33.85 (28.70–38.99) [110]	0.005	0.62 (0.44–0.87)
Obesity presence	35.74 (29.95–41.53) [94]	32.62 (27.52–37.71) [106]	0.427	0.87 (0.62–1.23)
Systemic arterial hypertension presence	48.29 (42.25–54.33) [127]	53.23 (47.81–58.66) [173]	0.233	1.22 (0.88–1.69)
Diabetes mellitus presence	19.01 (14.27–23.75) [50]	32.92 (27.81–38.03) [107]	<0.001	2.09 (1.42–3.07)
Cardiovascular disease presence	10.65 (6.92–14.37) [28]	12.92 (9.28–16.57) [42]	0.395	1.25 (0.75–2.07)
Asthma presence	1.90 (0.25–3.55) [5]	1.54 (0.20–2.88) [5]	0.736	0.81 (0.23–2.82)
Chronic obstructive pulmonary disease presence	7.60 (4.40–10.81) [20]	11.38 (7.93–14.84) [37]	0.120	1.56 (0.88–2.76)
Chronic kidney disease presence	7.22 (4.10–10.35) [19]	10.15 (6.87–13.44) [33]	0.210	1.45 (0.81–2.62)
Etilism habit presence	4.94 (2.32–7.56) [13]	8.00 (5.05–10.95) [26]	0.134	1.67 (0.84–3.32)
Smoking habit presence	18.63 (13.93–23.34) [49]	23.08 (18.5–27.66) [75]	0.187	1.31 (0.88–1.96)
COVID-19 vaccine previous hospital admission	17.11 (12.56–21.66) [45]	20.31 (15.93–24.68) [66]	0.323	1.23 (0.81–1.88)
Invasive mechanical ventilation use	39.54 (33.63–45.45) [104]	98.46 (97.12–99.80) [320]	<0.001	97.85 (39.1–244.86)
	Median (Quartile 1–Quartile 2) [n]		p-value	Odds-Ratio (95% Confidence interval)
Trait	Survivor (n = 263)	Non-survivor (n = 325)	p-value	Odds-Ratio (95% Confidence interval)
Age in years	53 (40.5–65.5) [263]	65 (52–73) [325]	<0.001	1.03 (1.02–1.04)
Total number of comorbidities	1 (0–2) [263]	1 (1–2) [325]	0.007	1.19 (1.03–1.36)
Time in days from symptom to ICU admission	11 (8–14) [245]	11 (7–14) [285]	0.229	0.99 (0.96–1.02)
Simplified Acute Physiology Score 3 score	49 (38–58) [263]	61 (49–71) [325]	<0.001	1.05 (1.04–1.06)
Simplified Acute Physiology Score in %	15.9 (6–31.5) [263]	39.8 (19–58.5) [325]	<0.001	1.04 (1.03–1.05)
Length of stay at the ICU in days	8 (4–17) [263]	11 (6–22) [325]	<0.001	1.02 (1.00–1.03)
Length of stay at the Hospital in days	19 (11–31) [263]	15 (7–27) [325]	<0.001

	% Yes (95% Confidence Interval) [n]		p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Trait	Survivor	Non-Survivor	p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Admitted from another service	74.04 (65.61–82.46) [77]	62.81 (57.52–68.11) [201]	0.033	0.59 (0.36–0.97)
Female sex	57.69 (48.2–67.19) [60]	32.81 (27.67–37.96) [105]	<0.001	0.36 (0.23–0.56)
Obesity presence	38.46 (29.11–47.81) [40]	33.13 (27.97–38.28) [106]	0.322	0.79 (0.5–1.25)
Systemic arterial hypertension presence	45.19 (35.63–54.76) [47]	53.13 (47.66–58.59) [170]	0.160	1.37 (0.88–2.14)
Diabetes mellitus presence	20.19 (12.48–27.91) [21]	33.13 (27.97–38.28) [106]	0.010	1.96 (1.15–3.33)
Cardiovascular disease presence	7.69 (2.57–12.81) [8]	12.81 (9.15–16.47) [41]	0.140	1.76 (0.8–3.89)
Asthma presence	0 (0–0) [0]	1.56 (0.2–2.92) [5]	0.092
Chronic obstructive pulmonary disease presence	4.81 (0.70–8.92) [5]	11.56 (8.06–15.07) [37]	0.032	2.59 (0.99–6.77)
Chronic kidney disease presence	2.88 (0–6.1) [3]	10.31 (6.98–13.64) [33]	0.009	3.87 (1.16–12.9)
Etilism habit presence	5.77 (1.29–10.25) [6]	8.13 (5.13–11.12) [26]	0.417	1.44 (0.58–3.61)
Smoking habit presence	11.54 (5.40–17.68) [12]	23.44 (18.8–28.08) [75]	0.006	2.35 (1.22–4.52)
COVID-19 vaccine previous admission	13.46 (6.90–20.02) [14]	20.31 (15.9–24.72) [65]	0.109	1.64 (0.88–3.06)
Blood transfusion	26.92 (18.40–35.45) [28]	31.56 (26.47–36.65) [101]	0.368	1.25 (0.76–2.05)
Use of noradrenaline	90.38 (84.72–96.05) [94]	99.38 (98.51–100.00) [318]	<0.001	16.92 (3.64–78.55)
Use of vasopressin	17.31 (10.04–24.58) [18]	70.94 (65.96–75.91) [227]	<0.001	11.66 (6.65–20.47)
Use of hydrocortisone	29.81 (21.02–38.6) [31]	71.56 (66.62–76.51) [229]	<0.001	5.93 (3.65–9.63)
Use of neuroblocker	71.15 (62.45–79.86) [74]	68.13 (63.02–73.23) [218]	0.560	0.87 (0.53–1.41)
Use of midazolam	94.23 (89.75–98.71) [98]	91.25 (88.15–94.35) [292]	0.315	0.64 (0.26–1.59)
Use of fentanyl	98.08 (95.44–100.72) [102]	93.44 (90.72–96.15) [299]	0.045	0.28 (0.06–1.21)
Use of propofol	59.62 (50.19–69.05) [62]	51.25 (45.77–56.73) [164]	0.136	0.71 (0.46–1.12)
Use of ketamine	37.5 (28.20–46.8) [39]	44.06 (38.62–49.5) [141]	0.238	1.31 (0.83–2.07)
Use of non-invasive ventilation	62.5 (53.20–71.8) [65]	61.56 (56.23–66.89) [197]	0.864	0.96 (0.61–1.52)
Use of indwelling bladder catheter	100 (100–100) [104]	97.19 (95.38–99.00) [311]	0.024
Use of tracheostomy	40.38 (30.95–49.81) [42]	13.75 (9.98–17.52) [44]	<0.001	0.24 (0.14–0.39)
Use of central venous catheter	100 (100–100) [104]	98.75 (97.53–99.97) [316]	0.132
Renal replacement therapy	18.27 (10.84–25.7) [19]	58.44 (53.04–63.84) [187]	<0.001	6.29 (3.65–10.85)
Haematocrit abnormal	33.65 (24.57–42.74) [35]	48.28 (42.79–53.76) [154]	0.009	1.84 (1.16–2.82)
Red cell distribution width >15	13.46 (6.9–20.02] [14]	27.59 (22.68–32.49] [88]	0.002	2.45 (1.32–4.53)
Neutrophil to platelet ratio abnormal	17.48 (10.14–24.81] [18]	33.54 (28.34–38.75] [106]	0.001	2.38 (1.36–4.17)
Prototombin activation time abnormal	6.12 (1.38–10.87] [6]	19.02 (14.61–23.42] [58]	0.001	3.60 (1.50–8.63)
International Normalized Ratio abnormal	5.1 (0.75–9.46] [5]	15.84 (11.73–19.95] [48]	0.003	3.50 (1.35–9.06)

	Median (Quartile 1–Quartile 2) [n]		p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Trait	Survivor	Non-Survivor	p-Value	Unadjusted Odds-Ratio (95% Confidence Interval)
Age in years	49.50 (38–61) [104]	64.00 (51–72) [320]	<0.001	1.05 (1.03–1.06)
Total number of comorbidities	1 (0–2) [104]	1 (1–2) [320]	0.003	1.31 (1.08–1.6)
Time in days from symptom to ICU admission	11 (8–13.75) [98]	11 (7–14) [282]	0.676	0.99 (0.95–1.03)
Length of stay at the ICU in days	21.5 (13–33.5) [104]	12 (6–22) [320]	<0.001	0.97 (0.96–0.98)
Simplified Acute Physiology Score 3 score	51 (37.75–62) [104]	61 (49–71) [320]	<0.001	1.04 (1.02–1.05)
Simplified Acute Physiology Score in %	20.25 (6–39.8) [104]	39.8 (19–58.5) [320]	<0.001	1.03 (1.02–1.04)
Days of mechanical ventilation use	15.5 (9–27.25) [104]	11.5 (5–19) [312]	<0.001	0.98 (0.97–1.00)
Hemoglobin in g/dL	12.6 (11.18–14.13) [104]	12.4 (10.8–14.05) [319]	0.641	0.97 (0.88; 1.06)
Leukocytes in 1000/mm	11.3 (7.58–13.7) [104]	11.9 (8.4–17.05) [319]	0.056	1.05 (1.01–1.09)
Haematocrit in %	37.65 (34.18–41.58) [104]	37.3 (32.7–41.55) [319]	0.631	0.99 (0.96–1.02)
Mean Corpuscular Volume in fL	88.9 (85.35–91.2) [104]	88.9 (85.1–93.2) [319]	0.275	1.02 (0.99–1.05)
Mean Corpuscular Hemoglobin in pg	29.65 (28.8–30.6) [104]	29.9 (28.6–31.1) [319]	0.219	1.06 (0.97–1.16)
Mean Corpuscular Hemoglobin Concentration in g/dL	33.5 (32.2–34.63) [104]	33.6 (32.45–34.6) [319]	0.873	0.98 (0.86–1.13)
Red cell distribution width in %	13.9 (13.2–14.6) [104]	14.1 (13.2–15.2) [319]	0.097	1.16 (1.00–1.34)
Mean platelet volume in fL	10.5 (10–11.1) [103]	10.7 (10–11.4) [314]	0.405	1.05 (0.84–1.32)
Myelocytes in units by mm	0 (0–0) [104]	0 (0–0) [319]	0.590	1.00 (1.00–1.00)
Rods in units by mm	601 (298–1349) [104]	755 (377.5–1444.5) [319]	0.177	1.00 (1.00–1.00)
Segmented in units by mm	8406 (5901.5–11,436.25) [104]	9480 (6335.5–13,751) [319]	0.044	1.00005 (1.00001–1.0001)
Lymphocytes in units by mm	810.5 (483.5–1120.5) [104]	687 (385–1150) [319]	0.256	1.00 (1.00–1.00)
Monocytes in units by mm	380 (271–633) [102]	426 (282–750) [317]	0.215	1.00 (1.00–1.00)
Neutrophils in units by mm	9400 (6499–12,578.25) [104]	10250 (7138–15,178) [319]	0.057	1.00 (1.00–1.00)
Platelet in units/1000 by mm	234 (190.5–299) [103]	215 (167.25–292) [316]	0.040	0.998 (0.996–1.00)
Neutrophils Lymphocytes Ratio	11.63 (7.86–17.65) [104]	14.67 (8.96–23.5) [319]	0.017	0.999 (0.996–1.002)
Platelet Lymphocytes Ratio	299.43 (209.61–477.12) [104]	308.97 (191.26–483.73) [318]	0.798	1.00 (1.00–1.00)
Creatinine in mg/dL	0.81 (0.61–1.09) [104]	1.22 (0.85–2.24) [318]	<0.001	1.52 (1.21–1.91)
Albumin in mg/dl	3.23 (2.85–3.56) [84]	3.13 (2.65–3.44) [265]	0.060	1.01 (0.97–1.05)
Glutamic-oxaloacetic transaminase in U/L	50.1 (37.98–73.18) [100]	52.9 (33.8–85.6) [283]	0.845	1.00 (1.00–1.01)
Glutamic-pyruvic transaminase in U/L	45.05 (28.45–74.7) [100]	37.15 (22.4–59.68) [282]	0.061	1.00 (1.00–1.00)
Lactic dehydrogenase in U/L	562 (432.5–670) [87]	615 (453–856) [233]	0.016	1.00 (1.00–1.01)
C-reactive protein in mg/dL	12.64 (7.41–19.1) [102]	13.4 (6.95–21.69) [300]	0.499	1.01 (0.99–1.04)
D-dimer in ng/mL	1135 (628.5–4063) [91]	2381 (826.2–6545) [263]	0.009	1.0003 (0.999–1.0001)
Interleukin 6 in pg/mL	48.7 (26.57–142.68) [76]	89.37 (40.86–178.4) [219]	0.024	0.9999 (0.9995–1.0003)
Prototombin activation time in %	100.00 (96.5–100) [98]	96.00 (75–100) [305]	<0.001	0.97 (0.96–0.99)
International Normalized Ratio	1.00 (1.00–1.02) [98]	1.01 (1.00–1.12) [303]	<0.001	5.32 (1.07–26.51)
Neutrophils Lymphocytes derivate Ratio	7.33 (5.25–10.11) [104]	7.33 (5.25–11.5) [319]	0.180	1.04 (1.00–1.08)
Monocytes Lymphocytes Ratio	0.60 (0.33–0.8) [102]	0.67 (0.33–1.18) [317]	0.049	1.48 (1.07–2.06)
Neutrophils Platelet Ratio	38.80 (28.52–51.39) [103]	47.35 (33.09–67.27) [316]	0.001	1.02 (1.01–1.03)
Systemic immune-inflammation index	2.86 (1.63–4.54) [104]	3.31 (1.70–5.39) [319]	0.187	0.99 (0.98–1.01)
Length of stay at the Hospital in days	31.5 (22.75–48.50) [104]	15.50 (7.00–27) [320]	<0.001

Model Applied to All Patients
	Full Multiple Model		Reduced Multiple Model
Traits Included	p-Value	Adjusted Odds Ratio (95% Confidence Interval)	p-Value	Adjusted Odds Ratio (95% Confidence Interval)
Invasive mechanical ventilation use	<0.001	351.70 (95.94–1289.22)	<0.001	306.74 (87.47–1075.71)
Age in years	<0.001	1.05 (1.03–1.07)	<0.001	1.04 (1.03–1.06)
Simplified Acute Physiology Score 3 score	0.001	1.03 (1.01–1.05)	0.001	1.03 (1.01–1.04)
Length of stay at the ICU in days	<0.001	0.96 (0.95–0.98)	<0.001	0.96 (0.95–0.98)
Asthma presence	0.299	6.13 (0.20–187.18)
Chronic kidney disease presence	0.331	1.80 (0.55–5.93)
Diabetes mellitus presence	0.288	1.44 (0.74–2.80)
COVID-19 vaccine previous hospital admission	0.491	1.29 (0.62–2.68)
Obesity presence	0.415	1.26 (0.72–2.22)
Smoking habit presence	0.728	1.16 (0.51–2.61)
Time in days from symptom to ICU admission	0.701	1.01 (0.96–1.06)
Etilism habit presence	0.995	1.00 (0.27–3.61)
Cardiovascular disease presence	0.791	0.87 (0.32–2.36)
Chronic obstructive pulmonary disease presence	0.616	0.75 (0.24–2.33)
Admitted from another service	0.118	0.64 (0.36–1.12)
Systemic arterial hypertension presence	0.095	0.59 (0.32–1.10)
Model applied to patients in invasive mechanical ventilation
	Full Multiple model		Reduced multiple model
Traits included	p-value	Adjusted Odds Ratio (95% Confidence Interval)	p-value	Ajusted Odds Ratio (95% Confidence Interval)
Use of vasopressin	<0.001	7.49 (3.29–17.05)	<0.001	7.87 (3.54–17.46)
Renal replacement therapy	<0.001	5.19 (2.23–12.09)	<0.001	5.42 (2.55–11.51)
Red cell distribution width >15	0.011	3.52 (1.34–9.26)	0.003	3.84 (1.60–9.21)
Use of hydrocortisone	0.030	2.57 (1.10–6.03)	0.038	2.33 (1.05–5.16)
Age in years	0.041	1.03 (1.00–1.05)	0.006	1.03 (1.01–1.05)
Days of invasive mechanical ventilation use	<0.001	0.94 (0.92–0.96)	<0.001	0.95 (0.93–0.97)
Admitted from another service	0.026	0.43 (0.21–0.90)	0.020	0.43 (0.21–0.87)
Female sex	0.035	0.47 (0.23–0.95)	0.010	0.42 (0.22–0.82)
Use of noradrenaline	0.060	15.67 (0.90–274.17)
Neutrophil to platelet ratio abnormal	0.088	2.18 (0.89–5.32)
Diabetes mellitus presence	0.492	1.54 (0.45–5.22)
Haematocrit abnormal	0.478	1.30 (0.63–2.67)
Smoking habit presence	0.733	1.19 (0.44–3.18)
Time from symptom to ICU admission	0.510	1.02 (0.96–1.09)
Simplified Acute Physiology Score 3 score	0.527	1.01 (0.98–1.03)
Total number of comorbidities	0.712	0.91 (0.55–1.50)
Chronic kidney disease presence	0.862	0.84 (0.13–5.68)
Chronic obstructive pulmonary disease presence	0.675	0.72 (0.16–3.29)
Use of Fentanyl	0.050	0.13 (0.02–1.00)

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Sousa Neto, A.L.d.; Mendes-Rodrigues, C.; Pedroso, R.d.S.; Röder, D.V.D.d.B. Revisiting the COVID-19 Pandemic: Mortality and Predictors of Death in Adult Patients in the Intensive Care Unit. Life 2024 , 14 , 1027. https://doi.org/10.3390/life14081027

Sousa Neto ALd, Mendes-Rodrigues C, Pedroso RdS, Röder DVDdB. Revisiting the COVID-19 Pandemic: Mortality and Predictors of Death in Adult Patients in the Intensive Care Unit. Life . 2024; 14(8):1027. https://doi.org/10.3390/life14081027

Sousa Neto, Adriana Lemos de, Clesnan Mendes-Rodrigues, Reginaldo dos Santos Pedroso, and Denise Von Dolinger de Brito Röder. 2024. "Revisiting the COVID-19 Pandemic: Mortality and Predictors of Death in Adult Patients in the Intensive Care Unit" Life 14, no. 8: 1027. https://doi.org/10.3390/life14081027

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Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

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Nurse management for hypertension * : A systems approach

Study population

Baseline BP measurement

Recruitment and randomization

Nurse management protocol

Measurements of BP

Physician review of protocol

Patient monitoring

Statistical analysis

Population characteristics

Patterns of BP

Change in office-based systolic blood pressure (SBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Change in office-based diastolic blood pressure (DBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Office versus home-based systolic blood pressure: intervention patients only.

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Effectiveness of nurse-led interventions to manage hypertension and lifestyle behaviour effectively: a systematic review and meta-analysis

Doctor J Roseleur

Evaluation of a specialist nurse-led structured self-management training for peer supporters with type 2 diabetes mellitus with or without comorbid hypertension in Slovenia

Trial registration

Study design and settings

Participants and recruitment

Structured self-management educational training

Theoretical intervention model

Instruments and data collection

Sample size elaboration

Statistical analysis

Sociodemographic data and clinical history

Acceptability of the self-management educational training

Peer supporters’ satisfaction with educational training

Knowledge about T2DM and HTN