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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Face-to-face interventions for promoting physical activity
© 2013 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: Primary: To compare the effectiveness of face-to-face interventions for PA promotion in community dwelling adults (aged 16 years and above) with a control exposed to placebo, no and/or minimal intervention. The influence of delivering the intervention to a group versus individually versus mixed (combined group and individually) will also be assessed. Secondary: If sufficient data exists, the following secondary objectives will be explored: to assess how the professional delivering the intervention (for example health professional, exercise specialist) influences the effectiveness in changing PA; to assess how the intensity of the intervention delivery (for example frequency, duration of contact) influences the effectiveness in changing PA; to assess how the prescription of the intervention (for example duration, frequency, intensity) influences the effectiveness in changing PA.
Face-to-face versus remote and web 2.0 interventions for promoting physical activity
This is the protocol for a review and there is no abstract. The objectives are as follows: Primary: To compare the effectiveness of face-to-face versus remote and web 2.0 interventions for PA promotion in community dwelling adults (aged 16 years and above). The influence of delivering the intervention to a group versus individually versus mixed (combined group and individually) will also be assessed. Secondary: If sufficient data exists, the following secondary objectives will be explored: to assess how the professional delivering the intervention (for example health professional, exercise specialist) influences the effectiveness in changing PA; to assess how the intensity of the intervention delivery (for example frequency, duration of contact) influences the effectiveness in changing PA; to assess how the prescription of the intervention (for example duration, frequency, intensity) influences the effectiveness in changing PA.
Outcome measurement in forensic mental health research: An evaluation
Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90-Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions. © 2011 Taylor & Francis.
A systematic review of outcome measures used in forensic mental health research with consensus panel opinion
Objective: To describe and assess outcome measures in forensic mental health research, through a structured review and a consensus panel. Data sources: A search of eight electronic databases, including CINAHL, EMBASE and MEDLINE, was conducted for the period 1990-2006. Review methods: In the structured review, search and medical subject heading terms focused upon two factors: the use of a forensic participant sample and the experimental designs likely to be used for outcome measurement. Data extraction included general information about the identity of the reference, specific information regarding the study and information pertaining to the outcome measures used. The consensus exercise was implemented in two stages. At the first stage, participants were asked to complete ratings about the importance of various potential areas of outcome measurement in a written consultation. At the second stage, they were asked to attend a consensus meeting to review and agree results relating to the domains, to consider and rate specific outcome instruments identified as commonly used from the structured review and to discuss strengths, weaknesses and future priorities for outcome measurement in forensic mental health research. Results: The final sample of eligible studies for inclusion in the review consisted of 308 separate studies obtained from 302 references. The consensus group agreed on 11 domains of forensic mental health outcome measurement, all of which were considered important. Nine different outcome measure instruments were used in more than four different studies. The most frequently used outcome measure was used in 15 studies. According to the consensus group, many domains beyond recidivism and mental health were important but under-represented in the review of outcomes. Current instruments that may show future promise in outcome measurement included risk assessment tools. The outcome measure of repeat offending behaviour was by far the most frequently used, occurring in 72% of the studies included in the review. Its measurement varied with position in the criminal justice system, offence specification and method of measurement. The consensus group believed that recidivism is only an indication of the amount of antisocial acts that are committed. Conclusions: A wide range of domains are relevant to assessing outcomes of interventions in forensic mental health services. Evaluations need to take account of public safety, but also clinical, rehabilitation and humanitarian outcomes. Recidivism is a very high priority; the public expects interventions that will reduce future criminal behaviour. Greater attention needs to be given to validity of measurement, given the enormous variety of approaches to measurement. More research is needed on methods to take account of the heterogeneity of seriousness of forms of recidivism in outcome measurement. Validity of self-report instruments regarding recidivism also needs examination by further research. Mental health is clearly also an important dimension of outcome. The review provides clear support for the view that domains such as quality of life, social function and psychosocial adjustment have not been extensively employed in forensic mental health research, but are relevant and important issues. The role of such instruments needs more consideration. © 2010 Queen's Printer and Controller of HMSO.
Outcome measures used in forensic mental health research: A structured review
Background: The evidence base for forensic mental health (FMH) services has been developing since the late 1990s. Are outcome measures sound enough for the evaluation tasks? Aims: To identify, from published literature, outcome measures used in FMH research and, where feasible, assess their quality. Method: A structured review was undertaken of trials and intervention studies published between 1990 and 2006. Details of outcome variables and measures were abstracted. Evidence regarding most frequently occurring outcome measures was assessed. Results: Four hundred and fifty different instruments were used to assess outcomes, incorporating 1038 distinct variables. Very little evidence could be found to support the measurement properties of commonly used instruments. Conclusions and implications for practice: There is little consistency in the use of outcome measure in FMH research. Effort is required to reach consensus on validated outcome measures in this field in order to better inform practice. Copyright © 2009 John Wiley & Sons, Ltd.
Interventions for promoting physical activity
Background: Little is known about the effectiveness of strategies to enable people to achieve and maintain recommended levels of physical activity. Objectives: To assess the effectiveness of interventions designed to promote physical activity in adults aged 16 years and older, not living in an institution. Search methods: We searched The Cochrane Library (issue 1 2005), MEDLINE, EMBASE, CINAHL, PsycLIT, BIDS ISI, SPORTDISCUS, SIGLE, SCISEARCH (from earliest dates available to December 2004). Reference lists of relevant articles were checked. No language restrictions were applied. Selection criteria: Randomised controlled trials that compared different interventions to encourage sedentary adults not living in an institution to become physically active. Studies required a minimum of six months follow up from the start of the intervention to the collection of final data and either used an intention-to-treat analysis or, failing that, had no more than 20% loss to follow up. Data collection and analysis: At least two reviewers independently assessed each study quality and extracted data. Study authors were contacted for additional information where necessary. Standardised mean differences and 95% confidence intervals were calculated for continuous measures of self-reported physical activity and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% confidence intervals were calculated. Main results: The effect of interventions on self-reported physical activity (19 studies; 7598 participants) was positive and moderate (pooled SMD random effects model 0.28 95% CI 0.15 to 0.41) as was the effect of interventions (11 studies; 2195 participants) on cardio-respiratory fitness (pooled SMD random effects model 0.52 95% CI 0.14 to 0.90). There was significant heterogeneity in the reported effects as well as heterogeneity in characteristics of the interventions. The heterogeneity in reported effects was reduced in higher quality studies, when physical activity was self-directed with some professional guidance and when there was on-going professional support. Authors' conclusions: Our review suggests that physical activity interventions have a moderate effect on self-reported physical activity, on achieving a predetermined level of physical activity and cardio-respiratory fitness. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions.
LifeAPP: self-monitoring of blood pressure after preterm preeclampsia: a randomized controlled feasibility trial
OBJECTIVE: This was a pilot study to investigate the feasibility of developing a low-cost mobile technology-based intervention to encourage blood pressure (BP) monitoring and adoption of healthy lifestyle habits. METHODS: This was a prospective, controlled, randomized, non-blinding feasibility study that involved the use of electronic BP monitor and smartphone. Eligible participants in the intervention group were instructed to send the BP measurements to members of the LifeAPP team digitally from an application for smartphones linked to the BP device by Bluetooth and also via WhatsApp. The LifeAPP team sent feedback containing information as follows: a) safety of the BP levels; b) motivational messages aiming at maintaining self-monitoring; c) motivational messages aiming at the importance of developing healthy lifestyle habits. The primary outcome was feasibility: recruitment capacity, retention, and compliance with follow-up rates. RESULTS: Between 1 June 2020 and 24 January 2021, 48 participants were randomized to the intervention group, and 48 participants were randomized to the control group. The recruitment capacity of the participating centers proved to be adequate. Among the participants recruited for intervention group, 21 (43.7%) attended predefined visits at 3 months and only 12 (25%) attended predefined visits at 6 months. Similar loss to follow-up was observed in the control group. CONCLUSION: Despite successful recruitment of a cohort of women following preterm preeclampsia, there was no sufficient retention of participants. Therefore, new strategies for long-term follow-up of women who developed preeclampsia are needed before a further study in this group of patients can be contemplated.
Blood pressure measurement at kiosks in public spaces: systematic review and consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability endorsed by the International Society of Hypertension and the World Hypertension League
Kiosk devices for unsupervised self-measurement of blood pressure (BP) are being used in public spaces and healthcare settings in several countries. This statement by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability provides a review of the published evidence on kiosk BP devices and consensus recommendations for their requirements and clinical use. A systematic literature search identified 54 relevant studies. Kiosk BP measurements appeared to be close to office BP [mean difference systolic 0.2 mmHg (95% confidence intervals -1.3 to 1.8); diastolic -0.4 mmHg (-3.5 to 2.7)], and higher than daytime ambulatory and home BP [mean difference 6.0 mmHg (1.6-10.4)/5.0 (2-8) and 8.1 mmHg (-2.6 to 18.9)/0.2 (-9.6 to 10.0), respectively]. Randomized or observational studies using kiosk BP measurements for hypertension screening or for assessing hypertension control were also included, as well as studies investigating users' and healthcare professionals' opinions, acceptability, and perspectives regarding kiosk BP measurements, and validation studies of kiosk BP devices. These studies had considerable heterogeneity in design, setting, methodology, measurement protocol, and sample size. Thus, at present, the clinical utility of kiosk BP measurements is uncertain. This ESH consensus statement acknowledges the potential of kiosk BP measurement as an emerging method for unsupervised self-measurement in the context of opportunistic screening for hypertension in apparently healthy people and the long-term monitoring of people with diagnosed hypertension. Requirements for the design, validation, function, and use of kiosk BP monitors are provided, together with the pending research questions on their optimal implementation in clinical practice.
A systematic review and meta-analysis of digital interventions targeting lifestyle factors in patients with hypertension
Hypertension is a major risk factor for cardiovascular disease, for which the management involves both lifestyle modification (diet, exercise etc) and medication. Digital interventions (mobile applications, websites, and SMS messages) are being developed to facilitate lifestyle change, but their effectiveness remains uncertain. This review aimed to establish whether digital interventions targeting lifestyle factors are effective in reducing blood pressure in individuals with hypertension. A systematic search was run through MEDLINE, EMBASE and the Cochrane Library. 5302 records were screened for eligibility and data on the primary outcome (systolic blood pressure (SBP)) and secondary outcomes (diastolic blood pressure (DBP) and change in lifestyle factors) were extracted from eligible papers. Where sufficient data were available, meta-analysis was undertaken using a random effects model. 17 randomised controlled trials were eligible for inclusion (3040 patients). 12 studies were suitable for meta-analysis. Lifestyle change mediated by digital interventions were associated with a larger SBP reduction than controls (mean difference (MD) −2.91 mmHg; 95% confidence interval (CI) −4.11, −1.71; p value (p) <0.0001). A significant difference was also seen in DBP reduction between groups (MD −1.13 mmHg; CI −1.91, −0.35; p = 0.005). Reporting of other secondary outcomes relating to lifestyle change was too heterogenous for meta-analysis. Digital interventions targeting lifestyle factors were associated with an improvement in blood pressure in patients with hypertension, but interpretation of the results is limited by significant heterogeneity between studies. Further research is required to understand which lifestyle factors, when targeted with digital interventions, result in maximal blood pressure reduction.
European guidelines for hypertension in 2024: a comparison of key recommendations for clinical practice
Hypertension is the most prevalent modifiable risk factor for cardiovascular disease and for cardiovascular and all-cause mortality globally. Suboptimal control of elevated blood pressure places a substantial burden on health-care systems worldwide. Several factors contribute to this suboptimal control, such as limited awareness of hypertension, lack of appropriate diagnosis and poor control of blood pressure among those with a diagnosis. These factors can be due to patient non-adherence to treatment, inertia among health-care professionals and low uptake and implementation of clinical guideline recommendations. From 2003 to 2018, the European Society of Hypertension and the European Society of Cardiology jointly published four sets of guidelines on hypertension. However, the two societies released separate guidelines on hypertension in 2023 and 2024, respectively. These two sets of European guidelines agree on most recommendations, but some differences have been identified. In this Expert Recommendation, we highlight the key consensus recommendations from the two guidelines; compare differing approaches to the definition, classification, diagnosis and treatment of hypertension; and aim to help health-care professionals in their decision-making to improve the management of hypertension and to reduce the burden of hypertension-associated outcomes and premature deaths.
Innovations in blood pressure measurement and reporting technology: International Society of Hypertension position paper endorsed by the World Hypertension League, European Society of Hypertension, Asian Pacific Society of Hypertension, and Latin American Society of Hypertension
Blood pressure (BP) is a key contributor to the lifetime risk of preclinical organ damage and cardiovascular disease. Traditional clinic-based BP readings are typically measured infrequently and under standardized/resting conditions and therefore do not capture BP values during normal everyday activity. Therefore, current hypertension guidelines emphasize the importance of incorporating out-of-office BP measurement into strategies for hypertension diagnosis and management. However, conventional home and ambulatory BP monitoring devices use the upper-arm cuff oscillometric method and only provide intermittent BP readings under static conditions or in a limited number of situations. New innovations include technologies for BP estimation based on processing of sensor signals supported by artificial intelligence tools, technologies for remote monitoring, reporting and storage of BP data, and technologies for BP data interpretation and patient interaction designed to improve hypertension management ("digital therapeutics"). The number and volume of data relating to new devices/technologies is increasing rapidly and will continue to grow. This International Society of Hypertension position paper describes the new devices/technologies, presents evidence relating to new BP measurement techniques and related indices, highlights standard for the validation of new devices/technologies, discusses the reliability and utility of novel BP monitoring devices, the association of these metrics with clinical outcomes, and the use of digital therapeutics. It also highlights the challenges and evidence gaps that need to be overcome before these new technologies can be considered as a user-friendly and accurate source of novel BP data to inform clinical hypertension management strategies.
Comparison of Patients Classified as High-Risk between International Cardiovascular Disease Primary Prevention Guidelines
Background: Cardiovascular disease (CVD) primary prevention guidelines classify people at high risk and recommended for pharmacological treatment based on clinical criteria and absolute CVD risk estimation. Despite relying on similar evidence, recommendations vary between international guidelines, which may impact who is recommended to receive treatment for CVD prevention. Objective: To determine the agreement in treatment recommendations according to guidelines from Australia, England and the United States. Methods: Cross-sectional analysis of the National Health and Nutrition Examination Survey (n = 2647). Adults ≥ 40 years were classified as high-risk and recommended for treatment according to Australia, England and United States CVD prevention guidelines. Agreement in high-risk classification and recommendation for treatment was assessed by Kappa statistic. Results: Participants were middle aged, 49% were male and 38% were white. The proportion recommended for treatment was highest using the United States guidelines (n = 1318, 49.8%) followed by the English guidelines (n = 1276, 48.2%). In comparison, only 26.6% (n = 705) of participants were classified as recommended for treatment according to the Australian guidelines. There was moderate agreement in the recommendation for treatment between the English and United States guidelines (κ = 0.69 [0.64–0.74]). In comparison, agreement in recommendation for treatment was minimal between the Australian and United States guidelines (κ = 0.47 [0.43–0.52]) and weak between the Australian and English guidelines (κ = 0.50 [0.45–0.55]). Conclusions: Despite similar evidence underpinning guidelines, there is little agreement between guidelines regarding the people recommended to receive treatment for CVD prevention. These findings suggest greater consistency in high-risk classification between CVD prevention guidelines may be required.
Personalized Antihypertensive Treatment Optimization With Smartphone-Enabled Remote Precision Dosing of Amlodipine During the COVID-19 Pandemic (PERSONAL-CovidBP Trial)
BACKGROUND: The objective of the PERSONAL-CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension During the COVID-19 Pandemic) trial was to assess the efficacy and safety of smartphone-enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID-19 pandemic. METHODS AND RESULTS: This was an open-label, remote, dose titration trial using daily home self-monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5–7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10–12)/7 (95% CI, 6–7) mm Hg, P<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events. CONCLUSIONS: Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hyper-tension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App-assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long-term care. REGISTRATION: URL: clinicaltrials.gov. Identifier: NCT04559074.