Does self-monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials

Figures & data

Figure 1. Flow chart of search results.

Table I. Summary of randomized studies of self-monitoring of blood pressure.

Study	Setting and subjects	Mean age (years)	Intervention subjects	Control subjects	Length of follow-up	Type and frequency of BP self-measurement	Description of the control group	Intervention group regimen over and above control plus self-monitoring	Adjustment made for self-measurement readings	Was physician adjusting medication aware of self-measurement readings?	Outcome measurement
Carnahan, 1975, USA (26)	Hospital clinic, patients starting treatment for hypertension, with DBP ≥90 mmHg	55	49	48	2–8 clinic visits per 6 months	Manual sphyg with built in stethoscope. Twice daily (upper arm)	Medication adjustment by fixed titration schedule based on clinic BP values done by nurse	No additional co-intervention	None specified	No: Nurses run clinic blind to home BP	Clinic BP (blinded). Compliance (pill count)
Haynes, 1976, USA (16)	Non-compliant men recruited via work-place screening programme; DBP ≥90 mmHg following initial treatment	No age quoted	20	18	0 and 6 months	Manual anaeroid. Daily (upper arm)	Not specified	Patient education and tailored to their rituals	None specified	Not clear	Blinded external BP measurement
Johnson (i), 1978, Canada (15)^a	Subjects recruited from screening in local shopping centre, DBP ≥95 mmHg despite treatment	54	36	36	0, 2 weeks, and 6 months	Manual sphyg. Daily (upper arm)	Neither home visits or self-recording	No additional co-intervention	None specified	Yes	External blinded measurement of BP and compliance (pill count and interview)
Johnson (ii), 1978, Canada (15)^a	Subjects recruited from screening in local shopping centre, DBP ≥95 mmHg despite treatment	54	35	36	0, 2 weeks, and 6 months	Manual sphyg. Daily (upper arm)	Neither home visits or self-recording	Home visits every 4 weeks	None specified	Yes	External blinded measurement of BP and compliance (pill count and interview)
Earp, 1982, USA (27)	Treated hypertensives with a medication change in previous 2 months recruited from hospital and community clinics	48	99	63	24 months; 5–6 visits	Sphyg type unclear	Routine medical care	Home visit and significant others involved	None specified	Not clear	DBP control
Stahl, 1984, USA (28)	Hospital clinic. Raised DBP under care of nurse practitioner	47.5	144	173	36 months, variable number of visits	Mercury sphyg	Not specified	No additional co-intervention	None specified	Yes	Unblinded physician-measured
Binstock, 1988, USA (17)	Treated hypertensives	Not stated	23	32	0 and 12 months	Not stated. Readings done at home	Education programme	Educational programme plus self-monitoring	None specified	Not stated	Change in SBP and DBP
Midanik, 1991, USA (29)	Untreated with BL DBP 90–95 mmHg and SBP <180 mmHg	47	102	102	0 and 12 months	Digital device. 2 consecutive readings, twice a week	Usual care	No additional co-intervention	None specified	Yes	Change in SBP and DBP
Soghikhanm 1992, USA (12)	Health maintenance organization centres. Hypertension patients	54	215	215	0 and 12 months	Electronic sphyg. Twice weekly	Usual care	No additional co-intervention	None specified	Yes	Study BP by trained technicians (blinded)
Muhlhauser, 1993, Germany (30)^b	Primary care; BP > 160 and/or 95 mmHg	51	86	74	0 and 18 months	Twice daily until satisfactory values achieved, then less frequently	Normal care	Patient education	None specified	Yes	Hypertensive prescription, physician visits
Friedman, 1996, USA (31)	Community physicians' clinics. Treated hypertensives with SBP ≥ 160 mmHg and/or DBP ≥90 mmHg	77	133	134	0 and 6 months	Automated. Weekly (?upper arm)	Usual care	Patient education and telemetry	None specified	‘TLC’ data transmitted to patient's own physician	BP measured on home visit; protocol for measurement not clear if blinded
Bailey, 1999, Australia (32)	Primary care. Hypertensive patients not practising self-measurement, with or without current treatment	55	31	29	0 and 8 weeks	Electronic. Twice daily (upper arm)	ACE inhibitor or diuretic	No additional co-intervention	None specified	Yes	Externally measured BP (study nurse). Probably not blinded
Vetter, 2000, Switzerland (33)	Primary care. Newly diagnosed or known hypertensives with BP 160–200/ 95–215 mmHg	58	296	326	0, 2, and 8 weeks	Automated (wrist). Twice daily	Losartan 15 mg	No additional co-intervention	None specified	Not applicable (patients were only reviewed at the beginning and end of the 8-week study period)	Unblinded own physician measurement (mercury sphyg). Control of BP (% < 90 mmHg DBP). Change in BP
Mehos, 2000, USA (34)	Primary care patients with treated hypertension and BP between 140–179/ 90–109 mmHg	59	18	18	0 and 6 months	Manual electronic. Daily (upper arm)	Routine care with no restrictions on number of office visits	Phone call from pharmacist	None specified	Yes	Clinic measurements before and after; not clear if blinded
Artinian, 2001, USA (35)	Family community centre. African-American men and women with BP ≥ 140 and/or 90 mmHg (diabetic range ≥ 130/85)	59	6	9	0 and 3 months	Electronic, at home, minimum 3 times/week	Usual care; visits to primary care provider at intervals requested by the primary care provider	Telemetry, patient education, and nurse visit	None specified	Yes	Community centre pre and post by researcher who was blinded
Broege, 2001, USA (22)	Hypertension centre or community health centre. Hypertensive patients with BP < 150/90 mmHg if on treatment or > 150/90 mmHg off treatment	73	20	20	0, 1, 2, and 3 months	Semiautomatic, 3 times morning and evening	Usual clinic treatment	Monthly clinic visit and nurse phone call	No adjustment	Yes	Clinic and ambulatory SBP and DBP readings
Rudd, 2004, USA (36)	Primary care clinics. Hypertensive patients with BP ≥ 140/90 mmHg or on anti-hypertensives, eligible for treatment under JNC VI criteria	59.5	74	76	0, 3, and 6 months	Automated, twice daily, at home	Routine care as received before study	Patient education and nurse phone call	Adjustment of 10/5 mmHg	Yes	Blinded readings at 3 and 6 months. Drug monitoring using electronic pill count bottles
Baque, 2005, Spain (37)^b	Primary care centres. Hypertensive patients with BP ≥ 140/90 mmHg	61	622	703	0, 6, 8, 14, 16, and 24 weeks	Automated, 15 days at weeks 6–8 and 14–16; 3 measurements in morning prior to medication, 2 in evening prior to supper	None specified	No additional co-intervention	None specified	Encouraged to share with physician.	Control of BP (SBP <140 mmHg, DBP <90 mmHg)
Halme, 2005, Finland (38)	Primary health care. Patients with essential hypertension, taking anti-hypertensive treatment or BP ≥ 140/90 mmHg	57	113	119	0 and 6 months	Automatic home readings; 1 week every 2 months, twice daily	Usual care; at regular local practice	No additional co-intervention	Adjustment of 5/5 mmHg	Yes	Office BP taken with the home monitor. Change in SBP and DBP
McManus, 2005, UK (6)	Primary care. Treated hypertensives with BP 140–200/85–100 mmHg	62	214	227	0, 6, and 12 months	Electronic, upper arm, monthly in practice waiting room	Usual care	No additional co-intervention	No adjustment	Patients encouraged to share readings (approx. 50% did)	Independently measured BP at 0, 6, and 12 months
Zillich, 2005, USA (39)^b	Community pharmacies. Treated hypertensives with BP 145–179/95–109 mmHg (diabetic 135–179/90–109 mmHg)	65	64	61	0, 4, and 12 weeks	Automatic; 2 readings separated with 5 min rest, once daily in the morning	3 pharmacy visits over 3 months where BP measured and referred to physician if > 140/90 mmHg	Patient education. Additional visit to implement treatment developed based on self-readings	No adjustment	Yes	Change in SBP and DBP
Marquez-Contreras, 2006, Spain (19)	Primary care centres. Mild-moderate hypertension, requiring treatment (not all on treatment at BL)	59	100	100	0, 1, 3, and 6 months	Automatic; 3 days a week, twice before breakfast and twice before supper	Usual treatment from General Practitioner	No additional co-intervention	None specified	No, readings given to investigator who altered medications	Mean decrease in SBP and DBP
Verberk, 2007, the Netherlands (13)	Setting not clear. Office BP >139 and/or 89 mmHg	55	214	216	0 and 12 months	Automated; 6 times a day for 7 days	Step-wise anti-hypertensive treatment based on office readings.	No additional co-intervention	No adjustment	Yes	Blinded. BP control and reduction
Green (i), 2008, USA (14)^a	Medical centres. Uncontrolled treatment hypertension	59	259	258	0 and 12 months	Automated. At least 2 days per week, twice per occasion	Usual care	Received hypertension pamphlet and patient web site pamphlet. Use of web site plus patient education	Adjustment of 5/5 mmHg	Yes	Blinded. BP control and changes in SBP and DBP
Green (ii), 2008, USA (14)^a	Medical centres. Uncontrolled treatment hypertension	59	261	258	0 and 12 months	Automated. At least 2 days per week, twice per occasion	Usual care	Received hypertension pamphlet and patient web site pamphlet Use of web site and pharmacist plus patient education	Adjustment of 5/5 mmHg	Yes	Blinded. BP control and changes in SBP and DBP
Madsen, 2008, Denmark (23)	General practices. Newly diagnosed or treated but not controlled, office BP > 150/95 mmHg	56	113	123	0 and 6 months	Semiautomatic. 3×/week in first 3 months, then once a week during last 3 months; 3 readings each time	Usual care	Telemonitoring	Adjustment of 5/5 mmHg	Yes	Mean decrease in systolic and diastolic day-time ABPM.
Parati, 2009, Italy (18)	Uncontrolled essential hypertension, BP ≥ 140/90, plus ABPM ≥ 130/80 with or without treatment	57.5	187	111	0, 4, 12, and 24 weeks	Variable	Office-based BP management	Nurse phone call and telemetry	Adjustment of 5/5 mmHg	Yes	Change in SBP and DBP

^aStudy had three groups so included twice, once for each comparison.

^bStudies were cluster-randomized by practice.

ACE = angiotension converting enzyme; BL = baseline; JNC = Joint National Committee; Sphyg = sphygmomanometer; TLC = telephone-linked computer.

Figure 2. Overall office systolic BP results.

Table II. Results from the main meta-regression analyses.

	Overall backward elimination model			Single moderator model P
Moderator	Coeff.	P	95% CI
Systolic office meta-regression
Follow-up	−0.17	0.57	−0.77 to 0.44	0.42
Age	0.39	0.31	−0.40 to 1.18	0.80
Male	0.09	0.43	−0.14 to 0.31	0.66
DBP	0.50	0.88	−6.55 to 7.56	0.93
Co-interventions	−4.10	0.25	−11.47 to 3.26	0.28
Adjusted BP	−2.16	0.56	−9.89 to 5.56	0.48
Constant	−24.65	0.28	−72.06 to 22.75
Diastolic office meta-regression
Follow-up	0.04	0.68	−0.16 to 0.24	0.55
Age	0.02	0.90	−0.26 to 0.30	0.22
Male	0.04	0.31	−0.04 to 0.12	0.22
DBP	−0.41	0.75	−3.04 to 2.24	0.59
Co-interventions	−1.67	0.24	−4.52 to 1.19	0.13
Adjusted BP	−0.96	0.52	−3.99 to 2.10	0.83
Constant	−2.57	0.77	−20.06 to 15.09
Target office meta-regression
Follow-up	−0.0002	0.99	−0.06 to 0.06	0.65
Age	0.008	0.83	−0.08 to 0.10	0.43
Male	−0.005	0.72	−0.04 to 0.03	0.60
DBP	−0.087	0.81	−0.94 to 0.76	0.92
Co-interventions	0.41	0.14	−0.17 to 0.99	0.04
Adjusted BP	0.19	0.54	−0.52 to 0.90	0.33
Constant	−0.60	0.84	−7.31 to 6.12

Figure 3. Overall office diastolic BP results.

Figure 4. Office target BP results.

Figure 5. A: Day-time ambulatory SBP results; B: Day-time ambulatory DBP results.

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