Hypertension management research priorities from patients, caregivers, and healthcare providers: A report from the Hypertension Canada Priority Setting Partnership Group

The effects of a digital lifestyle intervention in patients with hypertension: Results of a pilot randomized controlled trial

In this pilot study, the authors investigated the preliminary effectiveness of the digital lifestyle intervention, actensio (mementor DE GmbH), in treating arterial hypertension. Adults with arterial hypertension were randomly assigned to an intervention group (actensio + standard care) or a control group (waiting list + standard care) in a 1:1 ratio. Primary and secondary endpoints were assessed at baseline (t0) and 3 months post-randomization (t1). The primary endpoint was average systolic blood pressure, measured at home for 1 week. Secondary endpoints included patient engagement (measured using the "patient activation measure"; PAM-13), average diastolic blood pressure, and heart rate. All endpoints were analyzed using ANCOVA models, following an intention-to-treat approach, while adjusting for baseline values. Missing data were estimated using multiple imputation models. A total of N = 102 participants (f = 59, age = 52.94 ± 9.01) were randomized to either the intervention (IG; N = 52) or the control group (CG; N = 50), of which N = 80 completed the blood pressure diary, and N = 81 the PAM-13 at t1. Between-group comparisons showed an average group difference in systolic blood pressure of -5.06 mm Hg (95% CI = -8.71 to -1.41, p = .013) between the intervention group (M = 137.37 ± 10.13) and the control group (M = 142.35 ± 11.23). Average group difference for patient engagement was 3.35 points with a trend towards statistical significance (95% CI = -018 to 6.89, p = .064), favoring the intervention group (MIG = 79.38 ± 9.44 vs. MCG = 75.45 ± 10.62). There were no group differences in diastolic blood pressure (-1.78 mm Hg; 95% CI = -4.50 to 0.95, p = .402) and heart rate (-0.684; 95% CI = -3.73 to 2.36, p = 0.683). The results of the present pilot study confirm the preliminary effectiveness of the digital lifestyle intervention, actensio, in reducing high blood pressure in patients with hypertension.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Setting Patient-Centered Priorities for Cardiovascular Disease in Central Appalachia: Engaging Stakeholder Experts to Develop a Research Agenda

The disproportionate burden of cardiovascular diseases (CVD) and associated risk factors continues to exist in the Central Appalachian Region (CAR) of the United States. Previous studies to gather data about patient-centered care for CVD in the region were conducted through focus group discussions. There have not been any studies that used a collaborative framework where patients, providers, and community stakeholders were engaged as panelists. The objective of this study was to identify patient-centered research priorities for CVD in the CAR. We used a modified Delphi approach to administer questionnaires to forty-two stakeholder experts in six states representing the CAR between the fall of 2018 and the summer of 2019. Their responses were analyzed for rankings and derived priorities by research gaps. Six of the fifteen research priorities identified were patient-centered. These patient-centered priorities included shorter wait times for appointments; educating patients at their level; empowering patients to take responsibility for their health; access to quality providers; heart disease specialists for rural areas; and lifestyle changes. The participants' commitments to identify patient-centered research priorities indicate the potential to engage in community-based collaboration to address the burden of CVD in the CAR.

International research priority setting exercises in stroke: A systematic review

BACKGROUND

Agreeing on priority topics for stroke research can help make best use of limited funding, people, and time. Formal priority-setting exercises collate stakeholders' opinions to reach consensus on the most important research questions. Several stroke research priority setting exercises have been published. Exploring commonalities and differences between these exercises could bring a better understanding of priority research topics.

AIM

We collated and compared published stroke research priority setting exercises across international healthcare systems.

SUMMARY OF REVIEW

Multidisciplinary, electronic literature databases were searched from 2000 to 2021, using a validated search syntax. Inclusion criteria were: full article; stroke focus (any subtype); prioritization method described; and lists priorities for research. Priorities were extracted, coded, and assigned to categories using thematic analysis. The Nine Common Themes of Good Practice and the Reporting guideline for priority setting of health research checklists were used to assess methodological and reporting quality respectively. From 623 titles assessed, 14 studies were eligible for inclusion, including 2410 participants and describing 165 priorities. The majority of priority setting exercises were conducted in high-income countries (86%, n = 12 articles), published between 2011 and 2021 (64%, n = 9), and included views of healthcare professionals (57%, n = 8), and stroke survivors (50%, n = 7). Caregivers (n = 3, 21%) were under-represented. The James Lind Alliance priority setting method was most commonly used (50%, n = 7). Priorities were grouped into 10 thematic categories. Rehabilitation and follow-up was the most common priority theme (15%, n = 25 priorities), followed by psychological recovery (14%, n = 23), pathology (14%, n = 23), and caregivers and support (14%, n = 23). Priorities differed by year and case-mix (stakeholder group and demographics) of respondents. No article was judged high quality for all aspects of method or reporting. Common limitations were around inclusiveness and evaluation of the exercise.

CONCLUSION

Stroke research priorities are dynamic and context-specific. However, there was a common theme of prioritizing research that considered life after stroke. Future priority settings should consider the inclusion of nonindustrialized countries and stroke survivors with a range of impairments.

Research priorities for pregnancy hypertension: a UK priority setting partnership with the James Lind Alliance

OBJECTIVES

To identify research priorities for hypertensive disorders of pregnancy from individuals with lived experience and healthcare professionals.

DESIGN

Prospective surveys and consensus meetings using principles outlined by the James Lind Alliance.

SETTING

UK.

METHODS

A steering group was established and 'uncertainties' were gathered using an online survey and literature search. An interim online survey ranked long-listed questions and the top 10 research questions were reached by consensus at a final prioritisation workshop.

PARTICIPANTS

Women, partners, relatives and friends of those with lived experience of pregnancy hypertension, researchers and healthcare professionals.

RESULTS

The initial online survey was answered by 278 participants (180 women with lived experience, 9 partners/relatives/friends, 71 healthcare professionals and 18 researchers). Together with a literature search, this identified 764 questions which were refined into 50 summary questions. All summary questions were presented in an interim prioritisation survey that was answered by 155 participants (87 women with lived experience, 4 partners/relatives/friends, 49 healthcare professionals and 15 researchers). The top 25 highest ranked questions were considered by the final prioritisation workshop. The top 10 uncertainties were identified by consensus and ranked as follows in order of priority: long-term consequences of pregnancy hypertension (for the woman and baby), short-term complications of pregnancy hypertension (for the woman and baby), screening tests for pre-eclampsia, prevention of long-term problems (for the woman and baby), causes of pregnancy hypertension, prevention of recurrent pregnancy hypertension, educational needs of healthcare professionals, diagnosis of pre-eclampsia, management of pregnancy hypertension, provision of support for women and families.

CONCLUSIONS

Research priorities shared by those with lived experience of pregnancy hypertension and healthcare professionals have been identified. Researchers should use these to inform the choice of future studies in this area.

Priorities of patients, caregivers and health-care professionals for health research - A systematic review

Background

Based on subjective experience, patients can identify research priorities important for health services research. A systematic method for priority setting has been developed by the James Lind Alliance.

Objective

This article reviews the literature on the research priorities of patients, caregivers and health‐care professionals and presents the prioritized research themes and prioritization methods used.

Search strategy

Three electronic databases were searched on 22 May 2018. The search was not limited to any time period or language.

Inclusion criteria

The included studies reported the identification and prioritization of research priorities involving patients, relatives and caregivers. Each included paper addressed a specific ICD‐coded health problem, and at least one‐third of the sample involved in the prioritization process was affected by the health problem.

Data extraction and synthesis

The 10 top‐ranked research priorities were included in the thematic analysis. With an inductive approach, a system of identified themes and subthemes was developed from the research priorities. Each research priority was assigned to one research theme.

Main results

The priority lists of 34 publications involving 331 research priorities were included. Nine main themes represent the content of the research priorities. The most frequently represented main themes are ‘Treatment’, ‘Patients’ and ‘Health condition’. The distribution of the research priorities varied depending on the health conditions and prioritization methods.

Discussion and conclusions

This review provides a comprehensive overview of the overarching research themes in research priorities of affected individuals. The results can guide future patient‐oriented research.

Filling gaps in type 1 diabetes and exercise research: a scoping review and priority-setting project

Our team examined the characteristics of patient engagement (PE) practices in exercise-based randomized trials in type 1 diabetes (T1D), and facilitated T1D stakeholders in determining the top 10 list of priorities for exercise research. Two methodological approaches were employed: a scoping review and a modified James Lind Alliance priority-setting partnership. Published (Medline, Embase, CINAHL and Central databases) and grey literature (www.clinicaltrials.gov) were searched to identify randomized controlled trials of exercise interventions lasting minimum 4 weeks and available in English. We extracted information on PE and patient-reported outcomes (PROs) to identify if patient perspectives had been implemented. Based on results, we set out to determine exercise research priorities as a first step towards a patient-engaged research agenda. An online survey was distributed across Canada to collect research questions from patients, caregivers and healthcare providers. We qualitatively analyzed submitted questions and compiled a long list that a 12-person stakeholder steering committee used to identify the top 10 priority research questions. Of 9962 identified sources, 19 published trials and 4 trial registrations fulfilled inclusion criteria. No evidence of PE existed in any included study. Most commonly measured PROs were frequency of hypoglycemia (n=7) and quality of life (n=4). The priority-setting survey yielded 194 submitted research questions. Steering committee rankings identified 10 priorities focused on lifestyle factors and exercise modifications to maintain short-term glycemic control. Recent exercise-based randomized trials in T1D have not included PE and PROs. Patient priorities for exercise research have yet to be addressed with adequately designed clinical trials.

Patients, clinicians and researchers working together to improve cardiovascular health: a qualitative study of barriers and priorities for patient-oriented research

OBJECTIVES

The overall goal of this study is to identify priorities for cardiovascular (CV) health research that are important to patients and clinician-researchers. We brought together a group of CV patients and clinician-researchers new to patient-oriented research (POR), to build a multidisciplinary POR team and form an advisory committee for the Libin Cardiovascular Institute of Alberta.

DESIGN

This qualitative POR used a participatory health research paradigm to work with participants in eliciting their priorities. Therefore, participants were involved in priority setting, and analysis of findings. Participants also developed a plan for continued engagement to support POR in CV health research.

SETTING

Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Canada.

PARTICIPANTS

A total of 23 participants, including patients and family caregivers (n=12) and clinician-researchers (n=11).

RESULTS

Participants identified barriers and facilitators to POR in CV health (lack of awareness of POR and poor understanding on the role of patients) and 10 research priorities for improving CV health. The CV health research priorities include: (1) CV disease prediction and prevention, (2) access to CV care, (3) communication with providers, (4) use of eHealth technology, (5) patient experiences in healthcare, (6) patient engagement, (7) transitions and continuity of CV care, (8) integrated CV care, (9) development of structures for patient-to-patient support and (10) research on rare heart diseases.

CONCLUSIONS

In this study, research priorities were identified by patients and clinician-researchers working together to improve CV health. Future research programme and projects will be developed to address these priorities. A key output of this study is the creation of the patient advisory council that will provide support and will work with clinician-researchers to improve CV health.

Comparative efficacy of exercise and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: A network meta-analysis

Aims

This analysis aims to estimate the comparative efficacy of anti-hypertensive medications and exercise interventions on systolic and diastolic blood pressure reduction in people with hypertension.

Methods

A systematic review was conducted focusing on randomised controlled trials (RCTs) of exercise interventions and first-line anti-hypertensives where blood pressure reduction was the primary outcome in those with hypertension. Network meta-analyses were conducted to generate estimates of comparative efficacy.

Results

We identified 93 RCTs ( N = 32,404, mean age in RCTs: 39–70 years) which compared placebo or usual care with first-line antihypertensives including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazide-like diuretics and exercise interventions including aerobic training and dynamic resistance training. Of these, there were 81 (87%) trials related to medications ( n = 31,347, 97%) and 12 (13%) trials related to exercise ( n = 1057, 3%). The point estimates suggested that antihypertensive medications were more effective than exercise but there was insufficient evidence to suggest that first-line medications significantly reduced blood pressure to a greater extent than did the exercise interventions. Of the first-line treatments, angiotensin receptor blockers and calcium channel blockers had the highest treatment ranking, while exercise had the second lowest treatment ranking, followed by control conditions.

Conclusion

The current evidence base with a bias towards medication research may partly explain the circumspection around the efficacy of exercise in guidelines and practice. Clinicians may justifiably consider exercise for low risk hypertension patients who confirm a preference for such an approach.

The James Lind Alliance process approach: scoping review

OBJECTIVE

To summarise study descriptions of the James Lind Alliance (JLA) approach to the priority setting partnership (PSP) process and how this process is used to identify uncertainties and to develop lists of top 10 priorities.

DESIGN

Scoping review.

DATA SOURCES

The Embase, Medline (Ovid), PubMed, CINAHL and the Cochrane Library as of October 2018.

STUDY SELECTION

All studies reporting the use of JLA process steps and the development of a list of top 10 priorities, with adult participants aged 18 years.

DATA EXTRACTION

A data extraction sheet was created to collect demographic details, study aims, sample and patient group details, PSP details (eg, stakeholders), lists of top 10 priorities, descriptions of JLA facilitator roles and the PSP stages followed. Individual and comparative appraisals were discussed among the scoping review authors until agreement was reached.

RESULTS

Database searches yielded 431 potentially relevant studies published in 2010-2018, of which 37 met the inclusion criteria. JLA process participants were patients, carers and clinicians, aged 18 years, who had experience with the study-relevant diagnoses. All studies reported having a steering group, although partners and stakeholders were described differently across studies. The number of JLA PSP process steps varied from four to eight. Uncertainties were typically collected via an online survey hosted on, or linked to, the PSP website. The number of submitted uncertainties varied across studies, from 323 submitted by 58 participants to 8227 submitted by 2587 participants.

CONCLUSIONS

JLA-based PSP makes a useful contribution to identifying research questions. Through this process, patients, carers and clinicians work together to identify and prioritise unanswered uncertainties. However, representation of those with different health conditions depends on their having the capacity and resources to participate. No studies reported difficulties in developing their top 10 priorities.

The effectiveness of electronic health interventions on blood pressure control, self-care behavioural outcomes and psychosocial well-being in patients with hypertension: A systematic review and meta-analysis

OBJECTIVES

Hypertension is a global health issue. Electronic health (eHealth) is a potential alternative for managing hypertension and modifying hypertension-related self-care set of behaviour. This review aims to identify the delivery mode and strategies used by current eHealth interventions and examine the effectiveness of eHealth on blood pressure control, self-care behavioural outcomes and psychosocial well-being.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Ten English databases (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, Joanna Briggs Institute EBP Database, MEDLINE, CINAHL Plus, PsycINFO, SCOPUS, Web of Science and INSPEC) and two Chinese databases (China Journal Net and WanFang Data) were searched from January 2000 to November 2017.

REVIEW METHODS

This review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. Two reviewers independently selected potential articles and extracted the details of each eligible article. The Randomized Controlled Trial Checklist of Joanna Briggs Institute was used to assess the methodological quality of the included articles. Meta-analysis was conducted using Review Manager 5.3 for at least two studies reporting the same outcome. Otherwise, narrative synthesis was performed.

RESULTS

Fifteen articles from fourteen studies satisfied the inclusion criteria. The pooled result of 13 studies reported that eHealth intervention significantly affected the reduction of systolic blood pressure (mean difference [MD]: -5.96 mmHg, 95% confidence interval [CI]: -9.21 to -2.70, p < .001) and diastolic blood pressure (MD: -3.35 mmHg, 95% CI: -6.36 to -0.35, p < .05). eHealth interventions significantly decreased the proportion of patients with inadequate blood pressure control (risk ratio: 0.69, 95% CI: 0.57-0.84, p < .001) and their body weight (MD: -1.08 kg, 95% CI: -2.04 to -0.13, p < .05). Regarding self-care behavioural outcomes, the pooled results show that eHealth interventions significantly reduced the sodium intake.

CONCLUSIONS

This study reported that eHealth interventions positively affect blood pressure control and thus could be a promising alternative in the management of hypertension. However, their effectiveness on self-care behavioural change and psychosocial well-being is insufficient. Therefore, additional eHealth interventions with rigorous experimental design on hypertension self-care are needed to provide a robust evidence for a wide population and to address the increasing health care needs of patients with hypertension.

Study Protocol: Determining Research Priorities of Young Albertan Families (The Family Research Agenda Initiative Setting Project-FRAISE)-Participatory Action Research

Introduction: Pregnancy and childrearing can be an exciting and stressful time for new parents. The maternal-child health landscape has changed dramatically over the last few decades and research priorities need to address these rapid changes. There have been limited attempts to engage and collaborate with members of the public to develop research priorities for families who are expecting or parenting an infant to age 24 months. The work that has been completed has attempted to identify parental preference for information delivery and barriers to uptake of parenting programs but has not investigated parental research priorities. Methods: In collaboration with provincial research units and strategic clinical networks (SCN), we will use principles of participatory action research (PAR) as our theoretical framework/method, and a modified James Lind Alliance priority setting approach to prioritize a list of research questions that parents/knowledge users believe will support the health of their families. This will result in a top 10 list of parent/knowledge user-identified research priorities. This project will consist of three phases. In the first phase, we developed a steering committee of parents/knowledge users, healthcare providers, community agencies, and researchers to design a survey about health priorities for families. In the second phase, we will distribute the survey to diverse groups of parents/knowledge users/providers and hold a series of meetings to identify and prioritize potential questions from new parents about health issues from conception to age 24 months. In the third phase, we will collaboratively disseminate and translate findings. Discussion: This study will highlight parental health concerns and recommend parent-identified research priorities to inform future research projects needed to support the health of families between conception to age 24 months. Understanding the health research priorities of families in the community will help ensure future research contributes to meaningful changes in the health of young children, parents/knowledge users, and families. Ethics: This study and protocol have received ethical approved from the Conjoint Health Research Ethics Board at the University of Calgary (REB17-0014). Dissemination: The top 10 research priorities will be published and additional findings from the study will be distributed through pamphlets and newsletters.

Comparative effectiveness of physical activity interventions and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: protocol for a systematic review and network meta-analysis

BACKGROUND

The prevalence of hypertension is a major public health challenge. Despite it being highly preventable, hypertension is responsible for a significant proportion of global morbidity and mortality. Common methods for controlling hypertension include prescribing anti-hypertensive medication, a pharmacological approach, and increasing physical activity, a behavioural approach. In general, little is known about the comparative effectiveness of pharmacological and behavioural approaches for reducing blood pressure in hypertension. A previous network meta-analysis suggested that physical activity interventions may be just as effective as many anti-hypertensive medications in preventing mortality; however, this analysis did not provide the comparative effectiveness of these disparate modes of intervention on blood pressure reduction. The primary objective of this study is to use network meta-analysis to compare the relative effectiveness, for blood pressure reduction, of different approaches to increasing physical activity and different first-line anti-hypertensive therapies in people with hypertension.

METHODS

A systematic review will be conducted to identify studies involving randomised controlled trials which compare different types of physical activity interventions and first-line anti-hypertensive therapy interventions to each other or to other comparators (e.g. placebo, usual care) where blood pressure reduction is the primary outcome. We will search the Cochrane Library, MEDLINE and PsycInfo. For studies which meet our inclusion criteria, two reviewers will extract data independently and assess the quality of the literature using the Cochrane Risk of Bias Tool. Network meta-analyses will be conducted to generate estimates of comparative effectiveness of each intervention class and rankings of their effectiveness, in terms of reduction of both systolic and diastolic blood pressure.

DISCUSSION

This study will provide evidence regarding the comparability of two common first-line treatment options for people with hypertension. It will also describe the extent to which there is direct evidence regarding the comparative effectiveness of increasing physical activity and initiating anti-hypertensive therapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017070579.