Review and special articleAn evidence-based review of patient-centered behavioral interventions for hypertension1
Introduction
Over 43 million individuals in the United States have hypertension, and less than one third reach adequate levels of blood pressure (BP) control.1, 2 Heightened awareness of inadequate levels of BP control for a majority of patients has helped bring to light the need to refocus strategies to improve hypertension control.3 While medications are arguably the most important therapy for hypertension, behavioral strategies have long been recommended as first-line initial and adjunctive therapy.1, 4, 5 Specifically, educational approaches designed to help patients incorporate commonly accepted lifestyle changes (e.g., nutrition, weight loss, exercise, and social behaviors, including altering tobacco and ethanol use) into their daily living have been advocated.6, 7, 8, 9, 10, 11, 12, 13 It has also been proposed that increasing patient participation in hypertension care through techniques such as self-BP monitoring may increase patients’ vigilance about their condition and potentially improve adherence to medications, ultimately leading to improvement in BP control.14
Improving BP through adjunctive, patient-centered, education-based behavioral interventions might have other potential salutary effects such as decreased costs of pharmaceuticals to patients and insurers, improved patient compliance with appointments, and decreased risk of complications from polypharmacy. However, some physicians may have difficulty employing such techniques because of increasing time pressures, limited resources and reimbursement for interventions such as counseling, and uncertainty regarding which approaches to patient education are most effective. At the same time, other physicians may employ these techniques without substantive evidence to support the time, energy, and resources required to appropriately carry out these interventions.
To address these issues, we performed a systematic review to assess the independent and incremental effects of three commonly performed patient education-based behavioral interventions on BP control: counseling techniques, structured training courses, and patient self-monitoring of BP.
Section snippets
Study design and eligibility criteria
We conducted a systematic review of the literature describing behavioral interventions for hypertension. We sought to address two hypotheses in this review: (1) that the structure of multidimensional patient education may be important in relaying commonly accepted lifestyle advice, and (2) that patient self-BP monitoring (alone or in combination with patient education), by more directly involving patients in their care, may offer independent and/or incremental advantages over education
Yield of relevant articles
The initial search identified 232 articles focusing on hypertension detection and management. Of these, 15 articles (studying a total of 4072 people) contained interventions focusing exclusively on counseling, self-monitoring of BP, and training courses.19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33
Characteristics of articles
Table 1 describes primary characteristics of the articles included in the analysis. The majority of articles were published between 1980 and 1999, with most focusing on counseling. Study
Discussion
While patient-centered, education-based behavioral interventions may be viewed as important strategies to educate patients and improve BP control, definition of the clinical benefits through careful and systematic review of these approaches in hypertension care is necessary to guide evidence-based practice. As such, this systematic review assessed in incremental and combined fashion the BP benefit provided by these three patient-centered behavioral interventions.
Pooled results favor counseling
Acknowledgements
We are grateful to Lynda Anderson, PhD, and Gail Janes, PhD, at the Centers for Disease Control and Prevention (Atlanta, GA) for their valuable support and contributions. This study was supported in part by a National Research Service Award #2T32PE10025, Health Resource and Services Administration (LEB); grant #K08MH0178701, National Institute of Mental Health (GLD); grant #5T32HL07024, National Heart, Lung and Blood Institute (GLD); and grant #K240502643, National Institute of Diabetes and
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The full text of this review article is available via AJPM Online at www.elsevier.com/locate/ajpmonline.