Making rational therapeutic decisions in hypertension: How useful are electronic monitors in improving blood pressure control?
- SourceAvailable from: Peter Sandercock[show abstract] [hide abstract]
ABSTRACT: Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition is increasing that other, non›pharmacological interventions should also be rigorously evaluated. 1-3 This paper examines the design and execution of research required to address the additional problems resulting from evalua› tion of complex interventions—that is, those "made up of various interconnecting parts." 4 The issues dealt with are discussed in a longer Medical Research Council paper (www.mrc.ac.uk/complex_packages.html). We focus on randomised trials but believe that this approach could be adapted to other designs when they are more appropriate.BMJ 10/2000; 321(7262):694-6. · 14.09 Impact Factor
Making Rational Therapeutic Decisions
in Hypertension: How Useful Are Electronic
Monitors in Improving Blood Pressure Control?
blood pressure (BP) control.1Clinicians faced with a pa-
tient whose BP does not improve despite adequate treat-
ment are often left with the difficult question as to whether
this is caused by suboptimal adherence or by nonresponse
to medication. Electronic monitors have been used to
inform treatment decisions, but previous studies were ei-
ther not randomized or lacked a control group, or both.2,3
In the study by Wetzels et al, participants were random-
ized to electronic monitoring or to usual care. Although
there was no difference in BP control between the groups,
the need to increase treatment or to add additional drugs
was reduced in the intervention group.
The strengths of this study are that it was a randomized
trial with a contemporaneous control group, and that it
used separate monitors for individual drugs. A weakness is
that it tells us little about how the intervention was devel-
oped and implemented. Electronic monitoring is a com-
plex intervention because there are different parts to it (for
example, administration, data interpretation and subse-
quent discussion) that may interlink and lead to separate or
combined effects. We need to know more about how
health care professionals interpret adherence data, how
they use this information to make clinical decisions, and
what the best way is to discuss results with patients.
Adherence levels in the study by Wetzels et al were high,
n this issue of the Journal, Wetzels et al1report
findings from a randomized controlled trial of elec-
tronic medication monitoring as a tool to improve
See related article on page 119.
which could explain why there was little effect on BP
control. This begs the question as to whether there may be
groups of patients who would particularly benefit from
electronic monitoring: for example, those with very high
BP readings or those who admit that they find it difficult to
take their medication. Finally, what are the cost implica-
tions of using electronic monitoring in clinical practice?
Electronic monitoring as an intervention should be rig-
orously developed in future studies.4If used appropriately,
it has the potential to play a key role in helping to manage
hypertension in day-to-day clinical practice and to become
part of a true therapeutic partnership between health care
professionals and patients.
1. Wetzels GEC, Nelemans PJ, Schouten JSAG, Dirksen CD, van der
Weijden T, Stoffers HEJH, Janknegt R, de Leeuw PW, Prins MH:
Electronic monitoring of adherence as a tool to improve blood
pressure control: a randomized controlled trial. Am J Hypertens
Burnier M, Schneider MP, Chiolero A, Stubi CL, Brunner HR:
Electronic compliance monitoring in resistant hypertension: the
basis for rational therapeutic decisions. J Hypertens 2001;19:335–
Waeber B, Vetter W, Darioli R, Keller U, Brunner HR: Improved
blood pressure control by monitoring compliance with antihyper-
tensive therapy. Int J Clin Pract 1999;53:37–38.
Campbell M, Fitzpatick R, Haines A, Kinmonth AL, Sandercock P,
Spiegelhalter D, Tyrer P: Framework for design and evaluation of
complex interventions to improve health. Br Med J 2000;321:694–
Received June 25, 2006. First decision July 4, 2006. Accepted July 5,
From the Academic Unit of Primary Health Care, University of
Bristol, Bristol, England.
Address correspondence and reprint requests to Dr. Knut Schroeder,
Academic Unit of Primary Health Care, University of Bristol, Cotham
House, Cotham Hill, Bristol BS6 6JL, England; e-mail: k.schroeder@
AJH 2007; 20:126
© 2007 by the American Journal of Hypertension, Ltd.
Published by Elsevier Inc.