Sheila Greenfield

Effect of Self-monitoring and Medication Self-titration on Systolic Blood Pressure in Hypertensive Patients at High Risk of Cardiovascular Disease The TASMIN-SR Randomized Clinical Trial

IMPORTANCE Self-monitoring of blood pressure with self-titration of antihypertensives (self-management) results in lower blood pressure in patients with hypertension, but there are no data about patients in high-risk groups. OBJECTIVE To determine the effect of self-monitoring with self-titration of antihypertensive medication compared with usual care on systolic blood pressure among patients with cardiovascular disease, diabetes, or chronic kidney disease. DESIGN, SETTING, AND PATIENTS A primary care, unblinded, randomized clinical trial involving 552 patients who were aged at least 35 years with a history of stroke, coronary heart disease, diabetes, or chronic kidney disease and with baseline blood pressure of at least 130/80 mm Hg being treated at 59 UK primary care practices was conducted between March 2011 and January 2013. INTERVENTIONS Self-monitoring of blood pressure combined with an individualized self-titration algorithm. During the study period, the office visit blood pressure measurement target was 130/80 mm Hg and the home measurement target was 120/75 mm Hg. Control patients received usual care consisting of seeing their health care clinician for routine blood pressure measurement and adjustment of medication if necessary. MAIN OUTCOMES AND MEASURES The primary outcome was the difference in systolic blood pressure between intervention and control groups at the 12-month office visit. RESULTS Primary outcome data were available from 450 patients (81%). The mean baseline blood pressure was 143.1/80.5 mm Hg in the intervention group and 143.6/79.5 mm Hg in the control group. After 12 months, the mean blood pressure had decreased to 128.2/73.8 mm Hg in the intervention group and to 137.8/76.3 mm Hg in the control group, a difference of 9.2 mm Hg (95% CI, 5.7-12.7) in systolic and 3.4 mm Hg (95% CI, 1.8-5.0) in diastolic blood pressure following correction for baseline blood pressure. Multiple imputation for missing values gave similar results: the mean baseline was 143.5/80.2 mm Hg in the intervention group vs 144.2/79.9 mm Hg in the control group, and at 12 months, the mean was 128.6/73.6 mm Hg in the intervention group vs 138.2/76.4 mm Hg in the control group, with a difference of 8.8 mm Hg (95% CI, 4.9-12.7) for systolic and 3.1 mm Hg (95% CI, 0.7-5.5) for diastolic blood pressure between groups. These results were comparable in all subgroups, without excessive adverse events. CONCLUSIONS AND RELEVANCE Among patients with hypertension at high risk of cardiovascular disease, self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN87171227.

The Birmingham rehabilitation uptake maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation

Objective: To compare the outcomes of home-based (using the Heart Manual) and centre-based cardiac rehabilitation programmes. Design: Randomised controlled trial and parallel economic evaluation. Setting: Predominantly inner-city, multi-ethnic population in the West Midlands, England. Patients: 525 patients referred to four hospitals for cardiac rehabilitation following myocardial infarction or coronary revascularisation. Interventions: A home-based cardiac rehabilitation programme compared with centre-based programmes. Main outcome measures: Smoking cessation, blood pressure (systolic blood pressure (SBP), diastolic blood pressure (DBP)), total cholesterol (TC) and high-density lipoprotein (HDL)-cholesterol, psychological status (HADS anxiety and depression) and exercise capacity (incremental shuttle walking test, ISWT) measured at 12 months. Health service resource use, quality of life utility and costs were quantified. Results: There were no significant differences in the main outcomes when the home-based was compared with the centre-based programme at 12 months. Adjusted mean difference (95% CI) for SBP was 1.94 mm Hg (−1.1 to 5.0); DBP 0.42 mm Hg (−1.25 to 2.1); TC 0.1 mmol/l (−0.05 to 0.24); HADS anxiety −0.02 (−0.69 to 0.65); HADS depression −0.35 (−0.95 to 0.25); distance on ISWT −21.5 m (−48.3 to 5.2). The relative risk of being a smoker in the home arm was 0.90. The cost per patient to the NHS was significantly higher in the home arm at £198, (95% CI 189 to 208) compared to £157 (95% CI 139 to 175) in the centre-based arm. However when the patients’ cost of travel was included, these differences were no longer significant. Conclusions A home-based cardiac rehabilitation programme does not produce inferior outcomes when compared to traditional centre-based programmes as provided in the United Kingdom.

Self-care and adherence to medication: a survey in the hypertension outpatient clinic

BackgroundSelf-care practices for patients with hypertension include adherence to medication, use of blood pressure self-monitoring and use of complementary and alternative therapies (CAM) The prevalence of CAM use and blood pressure self-monitoring have not been described in a UK secondary care population of patients with hypertension and their impact on adherence to medication has not been described. Adherence to medication is important for blood pressure control, but poor adherence is common. The study aimed to determine the prevalence of self-care behaviours in patients attending a secondary care hypertension clinic.MethodsCross-sectional questionnaire survey. 196 patients attending a secondary care hypertension clinic in a teaching hospital serving a multiethnic population, Birmingham, UK. Main outcome measures: Prevalence of use of CAM, home monitors, adherence to anti-hypertensive medication.ResultsCAM use in previous 12 months was reported by 66 (43.1%) respondents. CAM users did not differ statistically from non-CAM users by age, gender, marital status or education. Vitamins, prayer a dietary supplements were the most commonly used CAM. Nine (12.7%) women reported using herbal CAM compared to one man (1.2%), (p = 0.006). Ten (6.7%) respondents reported ever being asked by a doctor about CAM use. Perfect adherence to anti-hypertensive medication was reported by 26 (44.8%) CAM-users and 46 (60.5%) non-CAM users (p = 0.07). Being female and a CAM user was significantly associated with imperfect adherence to anti-hypertensive medication. Older and white British respondents were significantly more likely to report perfect adherence. Blood pressure monitors were used by 67 (43.8%) respondents, which was not associated with gender, CAM use or adherence to medication.ConclusionHypertensive patients use a variety of self-care methods, including CAM, home blood pressure monitors, and adherence to prescribed medication. This study found the prevalence of CAM use in hypertensive patients was higher than in the UK population. It is important to acknowledge the self-care behaviour of hypertensive patients, in order to assess potential harm, and encourage effective methods of self-care.

Systematic review: the effectiveness of hypnotherapy in the management of irritable bowel syndrome

To systematically review the literature evaluating hypnotherapy in the management of irritable bowel syndrome (IBS).

A randomized trial of the addition of home‐based exercise to specialist heart failure nurse care: the Birmingham Rehabilitation Uptake Maximisation study for patients with Congestive Heart Failure (BRUM‐CHF) study

Supervised exercise can benefit selected patients with heart failure, however the effectiveness of home‐based exercise remains uncertain. We aimed to assess the effectiveness of a home‐based exercise programme in addition to specialist heart failure nurse care.

Health beliefs about bottled water: a qualitative study

BackgroundThere has been a consistent rise in bottled water consumption over the last decade. Little is known about the health beliefs held by the general public about bottled water as this issue is not addressed by the existing quantitative literature. The purpose of this study was to improve understanding of the publics health beliefs concerning bottled mineral water, and the extent to which these beliefs and other views they hold, influence drinking habits.MethodsA qualitative study using semi-structured interviews, with 23 users of the Munrow Sports Centre on the University of Birmingham campus.ResultsHealth beliefs about bottled water could be classified as general or specific beliefs. Most participants believed that bottled water conferred general health benefits but were unsure as to the nature of these. In terms of specific health beliefs, the idea that the minerals in bottled water conferred a health benefit was the most commonly cited. There were concerns over links between the plastic bottle itself and cancer. Participants believed that bottled water has a detrimental effect on the environment. Convenience, cost and taste were influential factors when making decisions as to whether to buy bottled water; health beliefs were unimportant motivating factors.ConclusionThe majority of participants believed that bottled water has some health benefits. However, these beliefs played a minor role in determining bottled water consumption and are unlikely to be helpful in explaining recent trends in bottled water consumption if generalised to the UK population. The health beliefs elicited were supported by scientific evidence to varying extents. Most participants did not feel that bottled water conferred significant, if any, health benefits over tap water.

Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]

BackgroundCardiac rehabilitation following myocardial infarction reduces subsequent mortality, but uptake and adherence to rehabilitation programmes remains poor, particularly among women, the elderly and ethnic minority groups. Evidence of the effectiveness of home-based cardiac rehabilitation remains limited. This trial evaluates the effectiveness and cost-effectiveness of home-based compared to hospital-based cardiac rehabilitation.Methods/designA pragmatic randomised controlled trial of home-based compared with hospital-based cardiac rehabilitation in four hospitals serving a multi-ethnic inner city population in the United Kingdom was designed. The home programme is nurse-facilitated, manual-based using the Heart Manual. The hospital programmes offer comprehensive cardiac rehabilitation in an out-patient setting.PatientsWe will randomise 650 adult, English or Punjabi-speaking patients of low-medium risk following myocardial infarction, coronary angioplasty or coronary artery bypass graft who have been referred for cardiac rehabilitation.Main outcome measuresSerum cholesterol, smoking cessation, blood pressure, Hospital Anxiety and Depression Score, distance walked on Shuttle walk-test measured at 6, 12 and 24 months. Adherence to the programmes will be estimated using patient self-reports of activity.In-depth interviews with non-attendees and non-adherers will ascertain patient views and the acceptability of the programmes and provide insights about non-attendance and aims to generate a theory of attendance at cardiac rehabilitation. The economic analysis will measure National Health Service costs using resource inputs. Patient costs will be established from the qualitative research, in particular how they affect adherence.DiscussionMore data are needed on the role of home-based versus hospital-based cardiac rehabilitation for patients following myocardial infarction and revascularisation, which would be provided by the Birmingham Rehabilitation Uptake Maximisation Study (BRUM) study and has implications for the clinical management of these patients. A novel feature of this study is the inclusion of non-English Punjabi speakers.

The effect of complementary and alternative medicine on the quality of life of cancer survivors: a systematic review and meta-analyses.

PURPOSE To assess whether quality of life (QOL) improved in cancer survivors who had undertaken a complementary and alternative medicine (CAM) intervention, compared to cancer survivors who had not. METHODS A systematic review of randomised controlled trials (RCTs) was undertaken. Electronic databases including MEDLINE, Cochrane CENTRAL, CINAHL, PSYCHINFO, EMBASE, and ClinicalTrials.gov were searched from 1990 to 2012. Search terms incorporating the concepts of cancer survivors, QOL and various types of CAM were used. RESULTS From 1767 records retrieved and screened 13 full text articles were included in the review. Nine studies were deemed to have a high risk, one a low risk, and three an unclear risk of bias. CAM interventions used incorporated yoga, meditation or mindfulness, energy healing, medical qigong, homoeopathy, or mistletoe therapy. Ten of the studies used breast cancer survivors, whilst the remaining three included other cancer types. The studies had mixed results either showing a significantly greater improvement in QOL in the intervention group compared to the control group, or no significant difference between groups. However, twelve studies were of low to moderate quality, limiting the robustness of findings. CONCLUSIONS This review has identified significant gaps in the evidence base for the effectiveness of CAM on QOL in cancer survivors. Further work in this field needs to adopt more rigorous methodology to help support cancer survivors to actively embrace self-management and effective CAMs, without recommending inappropriate interventions which are of no proven benefit.

What impact will an increased number of teaching general practices have on patients, doctors and medical students?

Background  Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community – primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching.

The use of herbal medicines by people with cancer: a cross-sectional survey

Background:A large proportion of cancer patients are estimated to use herbal medicines, but data to substantiate this are lacking. This study aimed to investigate the prevalence of herbal medicine use among cancer patients in the West Midlands, and determine the characteristics predicting herbal medicine use.Methods:A cross-sectional survey of oncology patients (n=1498) being followed up at a hospital in Coventry was undertaken. Recipients were asked about herbal medicine use since their cancer diagnosis, and the association between sociodemographic and cancer-related characteristics and herbal medicine use was evaluated.Results:A total of 1134 responses were received (75.7%). The prevalence of herbal medicine use was 19.7% (95% CI: 17.4–22.1; n=223). Users were more likely to be affluent, female, and aged under 50 years. Usage increased with time since cancer diagnosis (X2 for trend=4.63; P=0.031). A validation data set, derived from a survey of oncology patients in Birmingham (n=541) with differing socioeconomic characteristics showed no significant difference in estimated prevalence (16.6%; 95% CI: 11.9–22.2).Conclusion:A substantial number of people with cancer are likely to be taking herbal medicines. Understanding the self-medication behaviours of these individuals is essential if health-care professionals are to support treatment adherence and avoid unwanted pharmacological interactions.