Patient-held clinical guidelines for hypertension — a step too far?

Neil Adams; Peter Davidson; Matthew Smith

The aim of the study by McKinstry and colleagues1 was to determine if a clinical guideline posted to patients with hypertension improved their blood pressure control with the underlying assumption that any improvement would probably be due to patient empowerment.

As part of the routine patient–health professional relationship patients should be fully informed about what high blood pressure is, why it needs to be treated and how this could be achieved, including a discussion of possible lifestyle interventions. However, rather than empowering patients to take control of their health, the guideline was in effect asking patients to audit their own treatment. It should not have to be the patients' responsibility to ensure that they receive good basic health care.2

The study design used by the investigators was also unlikely to show any difference between the intervention and standard care, regardless of the underlying assumptions. The same health professionals were providing treatment to both groups of patients. Therefore, when they became aware of the guidelines, which presumably occurred during the set up of the trial, it would be difficult for them not to provide the same care to all patients. The power of the study was also reduced — according to the data at baseline, the accuracy of which is unknown, 50% of participants already had controlled blood pressure. Finally, the conclusion that it caused no harm needs to be reviewed. The HADS depression and anxiety scores were both increased at the end of the trial to higher levels in the intervention group, although not significantly.

An alternative use of the resources used in the study would have been to train the health professionals to provide good care, use the hypertension register to set up a system of routine appointments and develop clinical audit to ensure standards. If problems arose, such as patients not attending, an analysis of the reasons could then be undertaken, with perhaps a more suitable, targeted intervention being designed and piloted.

REFERENCES

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1. McKinstry B,
2. Hanley J,
3. Heaney D,
4. et al.
(2006) Impact on hypertension control of a patient-held guideline: a randomised controlled trial. Br J Gen Pract 56:842–847.
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1. National Institute of Health and Clinical Excellence
(2006) Hypertension. Management of hypertension in adults in primary care (National Institute of Health and Clinical Excellence, London) NICE clinical guideline 34.