Fluent Essays

Important aspects of your essay.Frame the IssueWhat is your question/hypothesis?What type of information would readers need to understand to understand your question and this paper? Give the information.Evidence GatheringSummarize the feature and the articleIdentify the evidence in both the feature and articleAre their any similarities or differences in the presented evidence?Using the feature and the article:How did the feature/article set up their experimental design?What empirical evidence does the feature/article state?Do the feature/article come to the same or different conclusions?Are there any problems with the evidence given in the feature or the article?What conclusions can you make about the topic or question now that you have learned about it in class and read the feature and the article?AnalysisWhat is the answer to your question or the analysis of your hypothesis given the evidence from both sources.ConclusionsRestate your hypothesis!What are your conclusions based on your analysis of the evidence and what you have learned in class? (is your hypothesis supported or not supported?)Are there any implications or limitations of your conclusions?How do the conclusions apply to your everyday life?Essay Format:Provide a copy of your chosen article.Staple the article to the back of your essay.2-3 pages.No more than 3 pages.(this does not include the Bibliography page)Times New Roman12 FontDouble SpacedWhile writing remember to:make sure that your essay is well organizedsupport your statements by evidencecite when appropriateadhere to rules of grammar and spellingCreate a Bibliography Page. You should have at least two citations in APA format.One from the textbook and the other from your article you found.Ive posted two photos from the text book of the feature mentioned in the instructions and an article that could be used as a reference. I can upload photos of the whole chapter if necessary. fullsizeoutput_1393.jpeg fullsizeoutput_1395.jpeg .full.pdf Unformatted Attachment Preview Cite this article as: BMJ, doi:10.1136/bmj.38121.684410.AE (published 11 June 2004) Blood pressure control by home monitoring: meta-analysis of randomised trials Francesco P Cappuccio, Sally M Kerry, Lindsay Forbes, Anna Donald Abstract Objective To determine the effect of home blood pressure monitoring on blood pressure levels and proportion of people with essential hypertension achieving targets. Design Meta-analysis of 18 randomised controlled trials. Participants 1359 people with essential hypertension allocated to home blood pressure monitoring and 1355 allocated to the “control” group seen in the healthcare system for 2-36 months. Main outcome measures Differences in systolic (13 studies), diastolic (16 studies), or mean (3 studies) blood pressures, and proportion of patients achieving targets (6 studies), between intervention and control groups. Results Systolic blood pressure was lower in people with hypertension who had home blood pressure monitoring than in those who had standard blood pressure monitoring in the healthcare system (standardised mean difference 4.2 (95\% confidence interval 1.5 to 6.9) mm Hg), diastolic blood pressure was lower by 2.4 (1.2 to 3.5) mm Hg, and mean blood pressure was lower by 4.4 (2.0 to 6.8) mm Hg. The relative risk of blood pressure above predetermined targets was lower in people with home blood pressure monitoring (risk ratio 0.90, 0.80 to 1.00). When publication bias was allowed for, the differences were attenuated: 2.2 ( − 0.9 to 5.3) mm Hg for systolic blood pressure and 1.9 (0.6 to 3.2) mm Hg for diastolic blood pressure. Conclusions Blood pressure control in people with hypertension (assessed in the clinic) and the proportion achieving targets are increased when home blood pressure monitoring is used rather than standard blood pressure monitoring in the healthcare system. The reasons for this are not clear. The difference in blood pressure control between the two methods is small but likely to contribute to an important reduction in vascular complications in the hypertensive population. Introduction High blood pressure is one of the most readily preventable causes of stroke and other cardiovascular complications.1–4 It can be easily detected, and most cases have no underlying detectable cause; the most effective way to reduce the associated risk is to reduce the blood pressure. Unlike many other common, chronic conditions, we have very effective ways of treating high blood pressure and we have clear evidence of the benefits of such interventions.1 However, despite a great deal of time and effort, hypertension is still underdiagnosed and undertreated.5 Furthermore, losses to follow up are high and are responsible for avoidable vascular deaths.6 BMJ Online First bmj.com Blood pressure is usually measured and monitored in the healthcare system by doctors or nurses in hospital outpatient departments and, increasingly, in primary care settings. New electronic devices have been introduced and validated in the clinical setting to replace the mercury sphygmomanometer and to overcome the large variations in measurement due to variability between observers. Ambulatory blood pressure monitoring is also being used more often to assess individuals’ blood pressures outside the clinical setting. Measuring blood pressure at home is becoming increasingly popular with both doctors and patients.7 8 Some national and international guidelines also recommend home monitoring in certain circumstances.9 A recent qualitative review of the role of home blood pressure measurement in managing hypertension concluded that no evidence exists as to whether home monitoring leads to better control of high blood pressure.10 We reviewed the literature on home blood pressure monitoring and did a meta-analysis of the effect of home monitoring on blood pressure levels and the control of hypertension in randomised trials that compared home or “self ” blood pressure monitoring and usual blood pressure monitoring in the healthcare system. Methods Identification and selection of trials To identify published trials that met the inclusion criteria we searched Medline (1966 to January 2003) and Embase (1980 to January 2003) for randomised controlled trials of home or self blood pressure monitoring in people with high blood pressure (see appendix A on bmj.com for strategy). We also searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Clinical Effectiveness, the Health Technology Assessment Database, the NHS Economic Evaluation Database, the TRIP database, and the websites of the Centre for Reviews and Dissemination and the Agency for Healthcare Research and Quality for reviews of blood pressure monitoring studies. Finally, we examined reference lists of the relevant reviews and all identified studies and reviewed the cited literature. We extended the search to all languages. We included studies in which the intervention under test was at least one measurement of blood pressure at home by study participants or their family members, whether the result was recorded by the participant or transmitted to a healthcare provider.11–31 We excluded studies that were not randomised conAppendices A-D are on bmj.com page 1 of 6 BMJ: first published as 10.1136/bmj.38121.684410.AE on 11 June 2004. Downloaded from http://www.bmj.com/ on 23 May 2020 by guest. Protected by copyright. Primary care Primary care RCTs excluded: did not meet inclusion criteria (n=232) RCTs retrieved for more detailed evaluation (n=21) RCTs excluded: did not use blood pressure as an outcome (n=3) Potentially appropriate RCTs to be included in meta-analysis (n=18) RCTs excluded from meta-analysis (n=0) RCTs included in meta-analysis (n=18) RCTs withdrawn because did not report: Systolic blood pressure (n=5) Diastolic blood pressure (n=2) Mean blood pressure (n=15) Targets (n=12) RCTs with usable information on: Systolic blood pressure (n=13) Diastolic blood pressure (n=16) Mean blood pressure (n=3) Targets (n=6) Fig 1 QUORUM statement flow diagram. RTC=randomised controlled trial trolled trials and those that used “ambulatory” blood pressure monitoring rather than “home” or “self” blood pressure monitoring. When several publications reported aspects of the same study, we chose only one paper to represent the trial data on blood pressure control or on achievement of hypertension targets. Where endpoints were presented at different time points—for example, Earp et al and Stahl et al with endpoints at one and two years of follow up17 19—we repeated analyses with the alternative time point. We extracted data from text, tables, and graphs. Two reviewers (SMK and LF) independently examined the data. Differences about inclusion of studies and interpretation of data were resolved by arbitration (FPC), and consensus was reached after discussion. We found 253 references. Twenty one studies met the inclusion criteria.11–31 We excluded three of these studies because they did not use blood pressure as an outcome measure11–13 (fig 1). Outcome measures We assessed change in blood pressure (systolic, diastolic, and mean) between intervention and control arms as mean (SD) and change in the proportion of people with blood pressure above target (see appendix B on bmj.com for methods of assessment of outcome). We used target blood pressure as defined in each paper (see appendix C on bmj.com for targets used in each study); older studies used diastolic blood pressure only (90 or 95 mm Hg), and others used systolic pressure of 140 mm Hg and diastolic pressure of 90 mm Hg (see appendices D1-D3 on bmj.com for detailed blood pressure values and effects in each study). Statistical analysis We used a random effects model (StataCorp, College Station, TX, USA) for the meta-analysis of the difference in change in systolic blood pressure, diastolic blood pressure, or mean arterial pressure. Where standard deviation of the change was not reported or could not be calculated from the 95\% confidence interval, we estimated it. As the standard deviation of the change was approximately the same as the standard deviations of the initial and follow up blood pressures in studies in which these page 2 of 6 were reported, we estimated the standard deviation of the change as the average of the standard deviations of the initial and follow up pressures where only the standard deviation of the change was missing. If no standard deviations were reported then we used the average standard deviation for all the remaining studies. We used relative risk to estimate the effect of intervention on the percentage of patients with blood pressure above target at follow up. We assessed potential publication bias by using a funnel plot and Egger’s test.32 Publication bias is due to small negative studies failing to be accepted for publication, which then causes the funnel plot to display asymmetry. We recalculated the combined estimate after estimating from the asymmetry of the funnel plot the number of “missing” studies and their effect sizes and standard errors, a method known as “trim and fill.”33 34 We assessed heterogeneity between trials by using the
2 test. Results We identified 18 randomised controlled trials that compared blood pressure control or the proportion of people with blood pressure above target. The table shows the characteristics of the analysed trials. Six were based in hospital outpatient clinics,14 19 21 22 25 31 eight in communities and general practices,16 18 23 24 26–29 and four in mixed settings.15 17 20 30 Treatment in the “control” group was mainly “usual” or “standard” care,15–19 21 22 24–29 31 but some trials had nurse clinics,14 30 educational interventions,20 or flagged medical records.23 Trials used different methods of home or self blood pressure monitoring. In total, 1359 people were randomised to home or self blood pressure monitoring and 1355 to a control group of blood pressure monitoring by health professionals in clinical settings. Two trials used a factorial design,16 18 four had more than two randomised groups,17 19 20 29 and one was randomised in clusters.23 Only in eight trials was outcome assessment stated to have been blind,14–16 24 25 29 31 and only in nine was randomisation concealed.15–18 20 21 24 29 31 The duration of the intervention varied between two months31 and 36 months.19 Systolic blood pressure Thirteen studies reported systolic blood pressure at follow up and baseline or the change from baseline (see appendix D1 on bmj.com), but only five of these studies reported full data on means and the standard deviation of the difference. For the remaining seven studies we estimated standard deviations. The overall effect of intervention was 4.2 (95\% confidence interval 1.5 to 6.9) mm Hg, with highly significant heterogeneity between studies (P < 0.001) (fig 2, top panel). The funnel plot showed some asymmetry, and Egger’s test for publication bias was significant (P = 0.038) (fig 3, top panel). The trim and fill method estimated three missing studies and gave a revised estimate of 2.2 ( − 0.9 to 5.3) mm Hg. Diastolic blood pressure Sixteen studies reported diastolic blood pressure at follow up and baseline or the change from baseline (see appendix D2 on bmj.com), but only eight of these studies reported full data on means and the standard deviation of the difference. For the remaining eight studies we estimated standard deviations. One study had multiple endpoints.19 We included results from the one year endpoint. Use of the two year endpoint did not make an important difference to the results (2.2 (1.0 to 3.3) mm Hg). The overall effect of intervention was 2.4 (1.2 to 3.5) mm Hg, with significant heterogeneity between studies (P = 0.014) (fig 2, middle panel). The funnel plot showed some asymmetry (fig 3, bottom BMJ Online First bmj.com BMJ: first published as 10.1136/bmj.38121.684410.AE on 11 June 2004. Downloaded from http://www.bmj.com/ on 23 May 2020 by guest. Protected by copyright. Potentially relevant RCTs identified and screened for retrieval (n=253) Primary care Author and country Setting Age group (years) Definition of hypertension Length of intervention (months) Intervention group Control group Carnahan 1975, USA14 Hospital outpatient Not stated DBP >90 mm Hg 6 Home BP self recorded twice daily Nurse clinic Haynes 1976, Canada15 Workplace Not stated DBP ≥90 mm Hg 6 Daily BP self recorded on chart “Usual care” Johnson 1978, Canada16 Community 35-65 On BP treatment at baseline and DBP ≥95 mm Hg 6 Daily BP self recorded on chart Home visits or “usual care” Earp 198217 Hospital outpatient and general practice Not stated Not stated 18 Daily or twice weekly BP by family member Home visits Pierce 1984, Australia18 General practice <70 SBP >160 mm Hg or DBP >95 mm Hg 6 Daily BP self recorded on chart “Usual care” or health education programme Stahl 1984, USA19 Hospital outpatient 16-70 3xDBP ≥95 mm Hg if >30 years; DBP >90 mm Hg if 16-30 years; 2xDBP >100 mm Hg; DBP >120 mm Hg 36 Daily BP self recorded at home “Standard care” Binstock 1988, USA20 Not clear Not stated “Documented” hypertension on treatment 9 Home BP monitoring Educational intervention Midanik 1991, USA21 Hospital outpatient Not stated SBP <180 mm Hg and DBP 90-99 mm Hg 12 Twice weekly BP self recorded Standard care (not measuring at home BP at home) Soghikian 1992, USA22 Hospital outpatient Not stated Not stated 12 Twice weekly BP self recorded “Usual care” at home Muhlhauser 1993, Germany23 General practice 30-60 2xBP >160 or >95 mm Hg 18 Twice daily BP self recorded at home “Usual care” with flagged notes Friedman 1996, USA24 Community ≥60 On BP treatment at baseline and SBP ≥160 or DBP ≥90 mm Hg 6 Weekly BP self recorded at home Regular medical care Zarnke 1997, Canada25 Hospital outpatient 18-80 Not stated 2 Twice daily BP self recorded at home Standard office based care Bailey 1999, Australia26 General practice Not stated Not stated 2 Twice daily BP self recorded at home “Usual care” Mehos 2000, USA27 General practice ≥35 SBP 140-179 mm Hg or DBP 90-109 mm Hg 6 Daily BP self recorded at home No home monitoring Vetter 2000, Switzerland28 General practice 18-85 SBP 160-200 and DBP 95-115 mm Hg and losartan 2 Twice daily BP self recorded at home before and 12 hours after treatment Doctor’s office Artinian 2001, USA29 Community Not stated SBP ≥140 or DBP ≥90mm Hg; if diabetes or myocardial infarction, SBP ≥130 or DBP ≥85 mm Hg 3 BP self recorded at home three times a week “Usual care” Broege 2001, USA30 Community and hospital outpatient ≥65 SBP >150 and DBP <90 (on treatment) or >90 mm Hg (not on treatment) 3 BP self recorded at home every other day (also monthly clinic visits) Fortnightly nurse clinic Rogers 2001, USA31 Hospital outpatient ≥18 Between ≥130 or ≥85 mm Hg and ≥180 or ≥110 mm Hg, depending on complications BP self recorded at home three times a week Usual outpatient care 2-7 BP=blood pressure; DBP=diastolic blood pressure; SBP=systolic blood pressure. panel) (Egger’s test for publication bias, P = 0.095). The trim and fill method estimated two missing studies and gave a revised estimate of 1.9 (0.6 to 3.2) mm Hg. Mean arterial pressure Three studies reported mean arterial pressure, one of which did not report either systolic or diastolic blood pressure.25 All studies reported change from baseline (see appendix D3 on bmj.com) with standard deviation of the difference. The overall effect was 4.4 (2.0 to 6.8) mm Hg, with no significant heterogeneity (P = 0.319) (fig 2, bottom panel). Blood pressure above target Six studies reported the number of patients whose blood pressure was controlled at follow up. Different definitions of blood pressure control were used (see appendix C on bmj.com). Two studies reported the outcome at more than one time point. The analysis reported here is for the one year outcome in both studies. The overall relative risk was 0.90 (0.80 to 1.00), with no significant heterogeneity between studies (P = 0.34) (fig 4). Inclusion of the two year outcomes for Earp17 and Stahl19 slightly reduced the effect—relative risk 0.92 (0.83 to 1.04). BMJ Online First bmj.com Discussion Main findings The meta-analysis of 18 randomised controlled clinical trials found that “self ” blood pressure monitoring at home results in better blood pressure control and greater achievement of blood pressure targets than “usual” blood pressure monitoring in the healthcare system. The size of the difference is rather small from the clinical viewpoint: 2.2/1.9 mm Hg (when allowing for publication bias), with 10\% greater proportion on target. However, this may represent an adjunctive useful improvement in management of hypertension likely to contribute to a better outlook for cardiovascular events. The main inclusion criterion in the study was that participants had undertaken blood pressure monitoring at home either by themselves or with the aid of a family member. As this is the likely scenario for implementation in a population setting, the results of our meta-analysis could be applicable to the general population of people with mild to moderate essential hypertension. page 3 of 6 BMJ: first published as 10.1136/bmj.38121.684410.AE on 11 June 2004. Downloaded from http://www.bmj.com/ on 23 May 2020 by guest. Protected by copyright. Characteristics of trials included in meta-analysis of home or self blood pressure monitoring Primary care Weighted mean difference (95\% CI) in fall in systolic blood pressure (mm Hg) Weighted mean difference (95\% CI) Carnahan 197514 7.50 (0.93 to 14.07) Pierce 198418 -1.20 (-9.04 to 6.64) Binstock 198820 18.00 (9.16 to 26.84) Midanik 199121 2.40 (-2.26 to 7.06) Soghikian 199222 3.20 (-0.22 to 6.62) Muhlhauser 199323 5.00 (-0.45 to 10.45) Friedman 199624 0.40 (-3.56 to 4.36) Bailey 199926 -5.00 (-14.80 to 4.80) Mehos 200027 10.10 (-0.60 to 20.80) Vetter 200028 0.50 (-1.81 to 2.81) Artinian 200129 25.60 (11.43 to 39.77) Broege 200130 4.00 (-7.55 to 15.55) Rogers 200131 4.80 (0.15 to 9.45) 4.25 (1.55 to 6.95) Overall (95\% CI) -20 Favours control 0 20 40 Favours intervention Weighted mean difference (95\% CI) in fall in diastolic blood pressure (mm Hg) Study Weighted mean difference (95\% CI) Carnahan 197514 0.00 (-3.70 to 3.70) Haynes 197615 3.50 (-1.54 to 8.54) Johnson 197816 0.40 (-2.91 to 3.71) Pierce 198418 1.30 (-2.37 to 4.97) Stahl 198419 3.10 (0.89 to 5.31) Binstock 198820 10.00 (5.02 to 14.98) Midanik 199121 -0.10 (-3.03 to 2.83) Soghikian 199222 1.60 (-0.32 to 3.52) Muhlhauser 199323 4.00 (0.74 to 7.26) Friedman 199624 2.10 (-0.13 to 4.33) Bailey 199926 -2.00 (-7.54 to 3.54) Mehos 200027 6.70 (1.28 to 12.12) Vetter 200028 1.30 (0.19 to 2.41) Artinian 200129 12.50 (3.17 to 21.83) Broege 200130 2.00 (-5.25 to 9.25) Rogers 200131 4.10 (0.99 to 7.21) 2.37 (1.25 to 3.49) Overall (95\% CI) -10 Favours control Study 0 10 20 Favours intervention Weighted mean difference (95\% CI) in fall in mean arterial pressure (mm Hg) Weighted mean difference (95\% CI) Zarnke 199725 2.85 (-0.87 to 6.57) Mehos 200027 7.80 (2.52 to 13.08) Rogers 200131 4.10 (0.85 to 7.35) Overall (95\% CI) 4.36 (1.96 to 6.76) -10 Favours control 0 10 20 Favours intervention Fig 2 Standardised mean differences (95\% confidence interval) in systolic (top), diastolic (middle), and mean (bottom) blood pressures achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings Limitations of the study The studies included in the quantitative review were done in a variety of settings, with different method ... 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