Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial

Objective: To determine the effectiveness of intensive structured care to optimise blood pressure control based on individual absolute risk targets in primary care. Design: Pragmatic multicentre randomised controlled trial. Setting General practices throughout Australia, except Northern Territory, 2009-11. Participants: Of 2185 patients from 119 general practices who were eligible for drug treatment for hypertension according to national guidelines 416 (19.0 ) achieved their individual blood pressure target during a 28 day run-in period of monotherapy. After exclusions, 1562 participants not at target blood pressure (systolic 150 (SD 17) mm Hg, diastolic 88 (SD 11) mm Hg) were randomised (1:2 ratio) to usual care (n=524) or the intervention (n=1038). Intervention: Computer assisted clinical profiling and risk target setting (all participants) with intensified follow-up and stepwise drug titration (initial angiotensin receptor blocker monotherapy or two forms of combination therapy using angiotensin receptor blockers) for those randomised to the intervention. The control group received usual care. Main outcome measures: The primary outcome was individual blood pressure target achieved at 26 weeks. Secondary outcomes were change in mean sitting systolic and diastolic blood pressure, absolute risk for cardiovascular disease within five years based on the Framingham risk score, and proportion and rate of adverse events. Results: On an intention to treat basis, there was an 8.8 absolute difference in individual blood pressure target achieved at 26 weeks in favour of the intervention group compared with usual care group (358/988 (36.2 ) v 138/504 (27.4 )): adjusted relative risk 1.28 (95 confidence interval 1.10 to 1.49, P=0.0013). There was also a 9.5 absolute difference in favour of the intervention group for achieving the classic blood pressure target of =140/90 mm Hg (627/988 (63.5 ) v 272/504 (54.0 )): adjusted relative risk 1.18 (1.07 to 1.29, P