The author suggests that more attention should be given to hypertension detection, adherence and control among the poor and ethnic minorities.
The following recommendations are made for future research:
1. A multicentre primary care RCT comparing nurse-led management with general practitioner-led management in hypertension, including economic evaluation.
2. Large-scale RCTs including economic appraisal of interventions that aim to improve patient adherence to treatment. Possible interventions that should be compared in factorial designs with usual care include educational/motivational approaches, follow-up, feedback, simplification of medication regimens.
3. RCTs to test the value of risk factor scores (or profiles) in giving general practitioners and nurses the information they need to reduce cardiovascular disease risk. Comparisons could include computer-aided prompts, and visual and interactive methods involving patients.
4. Controlled comparisons of the effects of organsiational and managerial initiatives on improving professional adherence to the best practice in the management of high blood-pressure compared with professional education and clinical guidelines.
The author makes the following suggestions for policy and practice: Detection: Standardisation of methods of blood-pressure measurement is essential. Use of Korotov V (disappearance of sounds) should be widely promoted in primary health care. facilities for the routine maintenance of sphygmomanometers should be available in all health districts.
The British Hypertension Society guidelines on thresholds for starting treatment require review.
Evidence to support detection and treatment of high blood-pressure in older people is very strong. This evidence should be widely disseminated, and professional barriers to treating older people recognised as unacceptable and not consistent with best practice.
Ambulatory monitoring methods increase the cost and complexity of blood-pressure detection without providing any tangible benefits, and should not be promoted in primary health care.
Adherence: improving professional adherence to best practice in the management of high blood-pressure through a range of mechanisms is required. More direct methods such as financial incentives and penalties require investigation as they may prove more effective than educational or clinical guideline approaches.
Standardisation of methods of measuring and reporting on patient adherence is required. Further research on patient adherence should be linked with the associated question of improving blood-pressure control.
Control: the British Hypertension Society's recommended target blood-pressures which should be achieved on drug treatment need to be reviewed. Criteria should take into account co-morbidity, age and level of hypertension.
A stepped-care approach to management is supported by American RCT evidence, but this is not directly applicable to British practice.