Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes

Abstract

OBJECTIVE -To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) Ն140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA 1c , UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores.RESULTS -The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9 -19.3) (P ϭ 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP Ͻ140 mmHg compared with conventional care (P ϭ 0.003). A significant fall in 10-year CHD (P ϭ 0.004) and stroke risk (P ϭ 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months.CONCLUSIONS -Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP Ͻ140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores. Diabetes Care 26:2256 -2260, 2003H ypertension is a major and modifiable risk factor for cardiovascular disease that frequently coexists with diabetes (1). A progressive rise in blood pressure (BP) is also a promoter of renal dysfunction and the development of end-stage renal failure (2). The presence of proteinuria and hypertension also increases the risk of premature death from cardiovascular disease eightfold compared with unaffected patients (3,4). A large evidence base of randomized controlled trials have demonstrated that treating hypertension reduces morbidity and mortality from hypertension-related diseases (5,6). More recently, the use of antihypertensive agents that interrupt the renin-angiotensin system has been shown to be an effective strategy to retard the progression of nephropathy and reduce cardiovascular events in people with diabetes (7-9). Throughout the western world, expert committees on hypertension recommend that treatment to lower BP is warranted in patients with diabetes who have a systolic BP Ն140 mmHg (10,11). Currently, hypertension is poorly managed. The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the maj...

An exploration of the continuing professional development needs of nurse independent prescribers and nurse supplementary prescribers who prescribe medicines for patients with diabetes

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