Lindsay F P Smith

Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis.

Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. Design Systematic review and meta-analysis. Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5). Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis

Diabet. Med. 28, 250–261 (2011)

Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial

Objectives To compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial. Setting Early pregnancy clinics of acute hospitals in the south west region of England. Participants 1199 women who had had an early miscarriage (<13 weeks) confirmed by scan. Intervention Expectant, medical, or surgical management. Main outcome measures Self reported pregnancy rates and live birth rates. Results Of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth. Conclusion Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management. Trial registration National Research Register N0467011677/N0467073587.

Postnatal care: development of a psychometric multidimensional satisfaction questionnaire (the WOMBPNSQ) to assess women's views

BACKGROUND Postnatal care is the neglected area of pregnancy care, despite repeated calls to improve it. Changes would require assessment, which should include womens views. No suitable satisfaction questionnaire exists to enable this. AIM To develop a multidimensional psychometric postnatal satisfaction self-completion instrument. SETTING Ten maternity services in south west England from 2006-2009. METHOD Sources for questions were literature review, fieldwork, and related published instruments. Principal components analysis with varimax rotation was used to develop the final WOMens views of Birth Postnatal Satisfaction Questionnaire (WOMBPNSQ) version. Validity and internal reliability were assessed. Questionnaires were mailed 6-8 weeks postnatally (with one reminder). RESULTS The WOMBPNSQ comprises 36 seven-point Likert questions (13 dimensions including general satisfaction). Of 300 women, 166 (55.3%) replied; of these 155 (95.1 %) were white, 152 (93.8%) were married or cohabiting, 135 (81.3%) gave birth in a consultant unit, 129 (78.6%) had a vaginal delivery; and 100 (60.6%) were multiparous. The 12 specific dimensions were: support from professionals or partner, or social support; care from GP and health visitor; advice on contraception, feeding baby, the mothers health; continuity of care; duration of inpatient stay; home visiting; pain after birth. These have internal reliability (Cronbachs alpha varying from 0.624 to 0.902). Various demographic and clinical characteristics were significantly associated with specific dimensions. CONCLUSION WOMBPNSQ could be used to assess existing or planned changes to maternity services or as a screening instrument, which would then enable in-depth qualitative assessment of areas of dissatisfaction. Its convergent validity and test-retest reliability are still to be assessed but are an improvement upon existing postnatal satisfaction questionnaires.

Ear discharge in children presenting with acute otitis media: observational study from UK general practice

BACKGROUND National Institute for Health and Clinical Excellence (NICE) guidance to treat otitis media in older children immediately with antibiotics only if they have ear discharge is based on limited evidence. AIM To determine the clinical significance and outcome of ear discharge in children with acute otitis media, in routine clinical practice. DESIGN OF STUDY Observational cohort study of children with acute otitis media comparing those with and without ear discharge at presentation. SETTING Primary care in East Somerset. METHOD Two hundred and fifty-six children aged 6 months to 10 years were recruited from primary care. Clinical features and other characteristics were recorded at presentation. Follow-up was undertaken at 2 weeks and 3 months. RESULTS Children with otitis media who present with ear discharge are much more likely to be treated with antibiotics irrespective of age (adjusted odds ratio 15, 95% confidence interval [CI] = 3 to 66). Most with discharge have proven bacterial infection (58%, 95% CI = 42 to 72%). They have a more severe systemic illness, with higher axillary temperature (80% increase in odds of ear discharge for each additional degree centigrade, P = 0.02), pulse rate (9% increase in odds for each extra beat, P<0.001), and Yale score (mean 10.5 versus 9.0, P = 0.003). They may also have an increased likelihood of adverse outcome (adjusted odds ratio of pain at 1 week 2.9; further episodes of acute otitis media 3.3; hearing difficulty at 3 months 4.7; all P<0.10). CONCLUSION Ear discharge defines a group of children with otitis media who are sicker and may be at higher risk of adverse outcome. NICE guidance to treat them with antibiotics is supported.

Trends in the diagnosis and management of hypertension: repeated primary care survey in South West England

BACKGROUND Previous surveys identified a shift to nurse-led care in hypertension in 2010. In 2011 the National Institute for Health and Care Excellence (NICE) recommended ambulatory (ABPM) or home (HBPM) blood pressure (BP) monitoring for diagnosis of hypertension. AIM To survey the organisation of hypertension care in 2016 to identify changes, and to assess uptake of NICE diagnostic guidelines. DESIGN AND SETTING Questionnaires were distributed to all 305 general practices in South West England. METHOD Responses were compared with previous rounds (2007 and 2010). Data from the 2015 Quality and Outcomes Framework (QOF) were used to compare responders with non-responders, and to explore associations of care organisation with QOF achievement. RESULTS One-hundred-and-seventeen practices (38%) responded. Responders had larger list sizes and greater achievement of the QOF target BP ≤150/90 mmHg. Healthcare assistants (HCAs) now monitor BP in 70% of practices, compared with 37% in 2010 and 19% in 2007 (P<0.001). Nurse prescribers alter BP medication in 26% of practices (11% in 2010, none in 2007; P<0.001). Of the practices, 89% have access to ABPM, but only 71% report confidence in interpreting results. Also, 87% offer HBPM, with 93% of these confident in interpreting results. CONCLUSION In primary care BP monitoring has devolved from GPs and nurses to HCAs. One in 10 practices are not implementing NICE guidelines on ABPM and HBPM for diagnosis of hypertension. Most practices express confidence interpreting HBPM results but less so with ABPM. The need for education and quality assurance for allied health professionals is highlighted, and for training in ABPM interpretation for GPs.

What affects anticoagulation control in patients taking warfarin

BACKGROUND The ageing population is taking an increasing number of both prescribed and non-prescribed medication. Little is known of the potential for adverse drug reactions between these. Warfarin is a commonly prescribed medication, well known for its potential to cause serious adverse reactions in combination with many prescription medicines. It has been suggested that herbal medicines such as garlic, either as a dietary supplement or in cooking, may also interact with warfarin, resulting in poor international normalised ratio (INR) control. AIM To determine whether, for patients who take garlic as well as warfarin, the proportion of the INR tests in range is lower than in comparable patients who do not take garlic. DESIGN OF THE STUDY Retrospective study of patients taking prescribed warfarin. SETTING Primary care practices in Somerset and Devon. METHOD Three controls (not taking garlic) matched for age, sex, and general practice were compared with each patient self-reporting taking garlic as a supplement. INR results were assessed for the preceding 12 months. Potentially confounding factors were considered, for example diabetes mellitus; all prescribed medication; any bleeding episodes. RESULTS No evidence was found to suggest that garlic consumption either as a supplement or in cooking is associated with more frequent haemorrhagic complications or less control of INR. Poor INR control may, however, be associated with taking larger numbers of prescription medicines, particularly during prescription changes. CONCLUSION Further research would be warranted into whether increased INR monitoring is needed when drug changes are made. These data render clinically significant interactions between warfarin and garlic intake unlikely.

Nurse-led management of hypertension

We read the paper of Voogdt-Pruis et al 1 with interest, since we have recently reviewed the literature for nurse interventions in primary care management of hypertension. We would like to offer the following observations: Firstly, although no previous study …

Care in a midwife managed delivery unit. Analysis is invalid.

EDITOR,—V A Hundley and colleagues have missed the opportunity to contribute usefully to the debate about the safety of non-consultant intrapartum care because their analysis of their work is flawed.1 They state that their objective was “to examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward.” To achieve this they randomised low risk women at booking, provided all the women with the same standard antenatal care, and compared various maternal and fetal outcomes between the two groups …

Response to Carey and Courtenay. Nurse‐led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta‐analysis

these five studies comprised lifestyle advice, education, support and the monitoring and titration of medicines. Importantly, the monitoring and titration of medicines was achieved by the use of locally agreed protocols, treatment algorithms and guidelines. Although Clark et al. refer to these activities as prescribing, they are not. Furthermore, nurses in the UK have only been able to prescribe medicines independently for hypertension since 2006 [2]. Four of the 11 studies reviewed by Clark et al. were undertaken in the UK prior to 2006. Given the above, it is impossible to see how Clark et al. have reached the conclusion that there is evidence of improved outcomes with nurse prescribers. Nurses in the UK have the most extended prescribing rights in the world. Importantly, misunderstanding about the role and nature of nurse prescribing has been reported amongst some healthcare professionals [3–6]. Many countries, for example the Netherlands, are looking to follow our example and have used our experiences to inform the development of this role for nurses. It is therefore essential that the term prescribing is used appropriately and correctly. The following, provided by the Department of Health [2], is a useful definition of prescribing. Prescribing is an action undertaken: