ESH 2004 Paris 1 Blood Pressure Control by Home Monitoring

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  • Cochrane Database for Systematic Reviews Database of Abstracts of Clinical Effectiveness Health Technology Assessment Database NHS Economic Evaluation Database TRIP Database Website of the Centre for Reviews and Dissemination Website of the Agency for Healthcare Research & Quality Inclusion criteria: Patients: hypertension Intervention: home or self blood pressure monitoring Study design: randomised controlled trial 253 references found. 21 studies met inclusion criteria. 3 excluded for lack of BP as outcome measure
  • Cochrane Database for Systematic Reviews Database of Abstracts of Clinical Effectiveness Health Technology Assessment Database NHS Economic Evaluation Database TRIP Database Website of the Centre for Reviews and Dissemination Website of the Agency for Healthcare Research & Quality Inclusion criteria: Patients: hypertension Intervention: home or self blood pressure monitoring Study design: randomised controlled trial 253 references found. 21 studies met inclusion criteria. 3 excluded for lack of BP as outcome measure
  • Cochrane Database for Systematic Reviews Database of Abstracts of Clinical Effectiveness Health Technology Assessment Database NHS Economic Evaluation Database TRIP Database Website of the Centre for Reviews and Dissemination Website of the Agency for Healthcare Research & Quality Inclusion criteria: Patients: hypertension Intervention: home or self blood pressure monitoring Study design: randomised controlled trial 253 references found. 21 studies met inclusion criteria. 3 excluded for lack of BP as outcome measure
  • ESH 2004 Paris 1 Blood Pressure Control by Home Monitoring

    1. 1. Blood Pressure Control by Home Monitoring A Meta-Analysis of Randomised Trials FP Cappuccio, SM Kerry, L Forbes, A Donald Published in: Br Med J 2004; 329: 145-148
    2. 2. Background <ul><li>High blood pressure is the most preventable cause of death and disability due to CVD </li></ul>
    3. 3. Background <ul><li>High blood pressure is the most preventable cause of death and disability due to CVD </li></ul><ul><li>Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists) </li></ul>
    4. 4. Background <ul><li>High blood pressure is the most preventable cause of death and disability due to CVD </li></ul><ul><li>Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists) </li></ul><ul><li>With the introduction and validation of new electronic devices, self blood pressure monitoring at home is becoming increasingly popular </li></ul>
    5. 5. Background <ul><li>High blood pressure is the most preventable cause of death and disability due to CVD </li></ul><ul><li>Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists) </li></ul><ul><li>With the introduction and validation of new electronic devices, self blood pressure monitoring at home is becoming increasingly popular </li></ul><ul><li>However, there is little evidence as to whether using home monitoring is associated with a better control of high blood pressure </li></ul>
    6. 6. Objective <ul><li>To compare blood pressure levels and proportion on target in people with essential hypertension undergoing home blood pressure monitoring </li></ul>
    7. 7. Design and Methods <ul><li>Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system </li></ul>
    8. 8. Design and Methods <ul><li>Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system </li></ul><ul><li>Medline (1966 to Jan 2003), Embase (1980 to Jan 2003), Databases (Cochrane, Clinical Effectiveness, HTA, NHS Economic Evaluation, TRIP, CRD, AHRQ) identified 253 potential trials </li></ul>
    9. 9. Flow Diagram RCTs identified (n=253) RCTs retrieved (n=21) RCTs suitable (n=21) RCTs included (n=18) Not meeting inclusion criteria (n=232) Not using BP as outcome (n=3) Systolic (n=13) Diastolic (n=16) Mean (n=3) Targets (n=6)
    10. 10. Design and Methods <ul><li>Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system </li></ul><ul><li>Medline (1966 to Jan 2003), Embase (1980 to Jan 2003), Databases (Cochrane, Clinical Effectiveness, HTA, NHS Economic Evaluation, TRIP, CRD, AHRQ) identified 253 potential trials </li></ul>1359 patients allocated to home blood pressure monitoring and 1355 to ‘control’ groups
    11. 11. Statistical Analysis <ul><li>Random effects model </li></ul>
    12. 12. Statistical Analysis <ul><li>Random effects model </li></ul><ul><li>Difference in BP (95% CI) </li></ul><ul><li>Relative risk (95% CI) </li></ul>
    13. 13. Statistical Analysis <ul><li>Random effects model </li></ul><ul><li>Difference in BP (95% CI) </li></ul><ul><li>Relative risk (95% CI) </li></ul><ul><li>Publication bias by funnel plot and Egger’s test </li></ul><ul><li>‘ Trim and fill’ method </li></ul><ul><li>Heterogeneity by chi-square </li></ul>
    14. 14. RESULTS 1. Systolic blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings Heterogeneity p<0.001
    15. 15. RESULTS 2. Diastolic blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings Heterogeneity p=0.014
    16. 16. RESULTS 3. Mean blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings Heterogeneity p=0.319
    17. 17. RESULTS 4. Funnel plot for systolic blood pressure
    18. 18. RESULTS 5. Egger’s test for publication bias and revised estimates by ‘trim and fill’ test 0.6 to 3.2 1.9 0.095 DBP (mmHg) -0.9 to 5.3 2.2 0.038 SBP (mmHg) 95% C.I. ‘ Trim & Fill’ estimate Egger’s test (p)
    19. 19. RESULTS 6. Standardised relative risk of blood pressure above target in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings
    20. 20. Studies published in 2004 <ul><li>Staessen JA et al. JAMA 2004;291:955-64 </li></ul><ul><li>RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. </li></ul>
    21. 21. <ul><li>Staessen JA et al. JAMA 2004;291:955-64 </li></ul><ul><li>RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. </li></ul><ul><li>Bobrie G et al. JAMA 2004;291:1342-9 </li></ul><ul><li>Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP. </li></ul>Studies published in 2004
    22. 22. <ul><li>Staessen JA et al. JAMA 2004;291:955-64 </li></ul><ul><li>RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. </li></ul><ul><li>Bobrie G et al. JAMA 2004;291:1342-9 </li></ul><ul><li>Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP. </li></ul><ul><li>Cuspidi C et al. J Hum Hypert 2004; online 22 April </li></ul><ul><li>Cross-sectional study of 1350 hypertensives; 66% practising Home BP monitoring. Higher rate of Clinic BP control amongst them. </li></ul>Studies published in 2004
    23. 23. Summary and Conclusions <ul><li>Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system </li></ul>
    24. 24. Summary and Conclusions <ul><li>Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system </li></ul><ul><li>A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’ </li></ul>
    25. 25. Summary and Conclusions <ul><li>Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system </li></ul><ul><li>A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’ </li></ul><ul><li>The reasons for this are not clear. However, greater direct involvement of the patient in his/her own care might be beneficial through greater awareness, motivation, concordance etc </li></ul>
    26. 26. Summary and Conclusions <ul><li>Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system </li></ul><ul><li>A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’ </li></ul><ul><li>The reasons for this are not clear. However, greater direct involvement of the patient in his/her own care might be beneficial through greater awareness, motivation, concordance etc </li></ul><ul><li>Home blood pressure measurement can be used as an adjunctive practice to help patients manage their hypertension more effectively </li></ul>

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