Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7156 (Published 20 November 2012)
Cite this as: BMJ 2012;345:e7156

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I've just spotted that the trial registration details didn't make it into the final version of this paper. They should have been included in the last line of the abstract.

The study was prospectively registered here:

ClinicalTrials.gov (NCT00902304)
http://clinicaltrials.gov/ct2/show/NCT00902304

Competing interests: None declared

Trish Groves, deputy editor

BMJ, BMJ Editorial, BMA House, Tavistock Square, London WC1H 9JR

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The authors are to be congratulated on their undertaking of a ‘real life’ clinical trial in a setting where most hypertension is, or at least should, be controlled. This study compares ‘usual’ primary care physician-led blood pressure (BP) management with that dictated by a computer-assisted structured algorithm. However, another significant difference between the control and intervention groups is the intensity of the follow up to achieve BP control. The control group is followed up as is usual for the individual primary care practice – and there may be some significant variability in this. The VIPER-BP cohort of patients was obliged to attend the clinic at 6, 10, 14, 18 and 26 weeks. Thus, the contribution of more intensive follow up to the results achieved is unclear and should be commented upon by the authors. Supportive of this, it is interesting that almost one in five patients achieved early BP control during the study run-in phase, suggesting that a structured approach to BP control (in the absence of a computer-generated algorithm) is worthwhile. It would have perhaps been useful to have a third group of patients which received ‘usual’ primary physician care but who were also reviewed in the clinic at the same time points as the VIPER-BP group.

At the discretion of the primary care physician 14% of participants were randomised to a BP target other that indicated by the automated clinical profiling. It would be of interest to know which of the two groups (usual vs. intervention) these patients were in and whether using the pre-specified computer-generate BP targets would have impacted upon the results.

According to Table 1, 40% and 41% of participants in the usual and intervention groups, respectively, had either microalbuminuria or proteinuria, reflecting a group of patients at high cardiovascular risk. Are there data on whether there were different reductions between groups in these and other relevant cardiovascular risk factors?

Finally, as suggested both by the authors and in the accompanying Editorial, the financial implications of this study may be significant. If BP control may be better managed using a computer-generated algorithm than by a primary care physician could hypertension control in primary care become nurse-led with referral to a physician as needed, or even computer-assisted at home by patients themselves? Clearly, this would require supportive safety protocols to be in place but the authors should consider this as a potential area of future research.

Competing interests: None declared

Neeraj Dhaun, Nephrologist

James P Blackmur, Gary Cooney

University of Edinburgh, Queen's Medical Research Institute, Edinburgh.

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Stewart et al.[1] present a robust study into use of structured algorithms for treatment of hypertension in general practice.

The impact of initial blood pressure may be a further confounding factor not considered for response to anti-hypertensive therapy.[2] Intervention groups had slightly higher mean systolic blood pressure, possibly generating a greater response to therapy. Though this effect has been disputed, an artificially greater reduction in blood pressure may still be present.[3] The significance of this variable for response to treatment deserves further exploration.

1. Stewart S, Carrington MJ, Swemmer CH, Anderson C, Kurstjens NP, Amerena J, et al. Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial. BMJ 2012; 345: e7156

2. Sumner DJ, Meredith PA, Howie CA, Elliott HL. Initial blood pressure as a predictor of the response to antihypertensive therapy. Br J Clin Pharmacol 1988; 26: 712-720

3. Gill JS, Beevers DG, Zezulka AV, Davies P. Relation between initial blood pressure and its fall with treatment. Lancet 1985; 1: 567-569

Competing interests: None declared

Simon Pybus, Medical Student

University of Liverpool, Ashton Street, Liverpool, L69 3GE

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