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Title: Effects of nurse-led hypertension management model in mainland China : a randomised controlled trial
Authors: Zhu, Xuejiao
Degree: Ph.D.
Issue Date: 2016
Abstract: Background: Hypertension is a major risk factor for stroke, ischemic heart disease, and other diseases. Its high prevalence rates coupled with low control rates not only threaten patients' health but also increase the financial burden on both the individual and the entire healthcare system. Finding a cost-effective way to manage hypertension has been an international concern. In a conventional treatment-oriented practice model, doctors play the primary role in hypertension management. However, doctors are more likely to focus on pharmacological treatments and put relatively little emphasis on non-pharmaceutical and sustained strategies for blood pressure (BP) control. Their strategies rarely involve patient self-care behaviours and the provision of structured follow-ups to monitor the effects of treatment or intervention. Compared with this medical-oriented usual care, nurse-led care is relatively low-cost and more likely to use non-pharmacological strategies that promote healthy behaviour. There is a paucity of literature, however, reporting the effects of community-based nurse-led care for hypertensive patients, especially in countries with poor resources, such as mainland China. This study fills this research gap. Aim: To develop a nurse-led hypertension management model and evaluate its effects in the community health setting in mainland China. Methods: A randomised controlled trial (RCT) was conducted in a community health centre in Guangzhou, China. A total of 134 eligible participants was recruited and randomly assigned to two groups (67 in the study group and 67 in the control group). The inclusion criteria for study participation were: (a) with a diagnosis of hypertension, (b) ≥ 18 years old, (c) with uncontrolled BP (BP reading ≥ 140 / 90 mmHg), and (d) living within the health service network of the community health centre. The exclusion criteria were: (a) with secondary hypertension, (b) taking medicine that could increase BP, (c) unable to communicate, (d) unable to be contacted by phone, (e) with diagnosis of terminal illness, (f) with co-morbidity in contradiction with the intervention programme, (g) pregnancy, breastfeeding or planning pregnancy. The control group received usual care that included a clinic physical examination with the establishment of a health record, health education pamphlets and arrangements for routine clinic follow-ups. The study group received usual care and a 12-week intervention programme guided by the nurse-led hypertension management model. In the programme, trained community nurses led a team to deliver the following hypertension management services: a home visit followed by six follow-up telephone calls at two-weekly intervals, and referrals, if appropriate. Outcome measures were: BP reductions (primary outcome), BP control rate, self-care behaviour, self-efficacy, quality of life, utilisation of healthcare services and patient satisfaction. Data were collected at three time points: recruitment (T0), immediately after the intervention programme (T1), four weeks after the end of the intervention (T2). Research assistants blinded to the allocation of participants handled data collection. Ultimately, a total of 119 (89%) participants completed data collection. Missing data was replaced by carrying forward the last data with intention-to-treat.
Results: Baseline demographic and clinical characteristics were equivalent between the control and study groups. A significant interaction between group and time was detected in systolic blood pressure (SBP) (p < .05) and diastolic blood pressure (DBP) (p < .05). Both groups had a significant reduction over time in SBP (p < .01) and DBP (p < .01). When the reductions of BP from T0 to T1 were compared between groups, a statistically significant difference between groups was observed both in SBP (Control -5.10 mmHg versus Study -14.37 mmHg, p < .01) and DBP (Control -2.69 mmHg versus Study -7.43 mmHg, p < .01). However, there was no statistically significant difference between groups from T0 to T2 in SBP (Control -9.22 mmHg versus Study -14.72 mmHg, , p > .05) or DBP (Control -5.14 mmHg versus Study -7.43 mmHg, p > .05), even though the study group maintained a lower trend of BP reduction. In terms of self-care behaviours, the study group had a statistically significant improvement over time both in pharmacological self-care behaviour (p < .01) and non-pharmacological self-care behaviour, which included home BP monitoring (p < .01), salt restriction (p < .01) and regular physical activity (p < .01). The control group had a statistically significant improvement over time in two non-pharmacological self-care behaviours: salt restriction (p < .01) and regular physical activity (p < .01). A statistically significant difference between groups was observed in home BP monitoring at T1 (p < .01) and T2 (p < .01). As for salt restriction and regular physical activity, a statistically significant difference between groups at T1 was detected. For self-efficacy, there was no significant interaction between group and time, and the difference between groups and within group was also not significant. For quality of life, the study group significantly improved over time in the domains of Role-physical (p < .01), Bodily Pain (p < .01), General Health (p < .05), Social Functioning (p < .01), Role-emotional (p < .05) and Mental Health (p < .01). The control group, like the study group, had significant improvement over time in the domains of Role-physical (p < .01), Role-emotional (p < .05) and Mental Health (p < .05). No between-group and interaction effect was found. For the utilisation of healthcare services at the community health centre, no statistically significant difference was found between the two groups. The study group was more satisfied with hypertensive care than the control group at T1 (Study 28.0 versus Control 7.0, p < .01). Discussion: This was a pioneering effort to develop a nurse-led model for managing hypertensive patients at the community level by adopting the Chronic Care Model and incorporating the Four-C model of comprehensiveness, collaboration, coordination, and continuity. This nurse-led hypertension management model involved re-organisation of the existing hypertension care delivery system, patients' self-management support, team members' decision support and establishment of a more comprehensive documentation system for patients' clinical records. The nurses in the team were equipped with the competencies required to manage hypertensive patients. The results of this RCT confirmed that a structured and standardised 12-week nurse-led home-based care programme produced better effects on BP reduction than usual clinic-based care. The results of the study showed that, when compared with usual care, nurse-led care did not only reduce BP but also enhanced patient self-care behaviours and improved patient satisfaction. These trained healthcare providers, supported by an evidence-based designed programme, contributed to the positive outcomes. The competency training followed a structured curriculum designed to prepare the team of nurses and a physician for hypertension management. The curriculum can be helpful in standardising the preparation of care providers. Conclusion: This study presents a nurse-led model that translated evidence into practical protocols for hypertension management. By using this model and testing its effects, this study confirmed the significant contributions of nurses to improving patient outcomes and demonstrated that nurse-led hypertension management has great potential in the community healthcare setting.
Subjects: Hypertension -- Treatment.
Hypertension -- Nursing.
Hong Kong Polytechnic University -- Dissertations
Pages: xxi, 273 pages
Appears in Collections:Thesis

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