Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial

Objective: The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management. Design: Unmasked randomised controlled trial with automated ascertainment of primary endpoint. Setting: 76 general practices in the United Kingdom. Participants: 622 people with treated but poorly controlled hypertension (>140/90 mm Hg) and access to the internet. Interventions: Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The digital intervention provided feedback of blood pressure results to patients and professionals with optional lifestyle advice and motivational support. Target blood pressure for hypertension, diabetes, and people aged 80 or older followed UK national guidelines. Main outcome measures: The primary outcome was the difference in systolic blood pressure (mean of second and third readings) after one year, adjusted for baseline blood pressure, blood pressure target, age, and practice, with multiple imputation for missing values. Results: After one year, data were available from 552 participants (88.6%) with imputation for the remaining 70 participants (11.4%). Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2 mm Hg in the intervention group and from 151.6/85.3 to 141.8/79.8 mm Hg in the usual care group, giving a mean difference in systolic blood pressure of −3.4 mm Hg (95% confidence interval −6.1 to −0.8 mm Hg) and a mean difference in diastolic blood pressure of −0.5 mm Hg (−1.9 to 0.9 mm Hg). Results were comparable in the complete case analysis and adverse effects were similar between groups. Within trial costs showed an incremental cost effectiveness ratio of £11 ($15, €12; 95% confidence interval £6 to £29) per mm Hg reduction. Conclusions: The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded. Trial registration: ISRCTN13790648

Genetic associations at 53 loci highlight cell types and biological pathways relevant for kidney function.

Reduced glomerular filtration rate defines chronic kidney disease and is associated with cardiovascular and all-cause mortality. We conducted a meta-analysis of genome-wide association studies for estimated glomerular filtration rate (eGFR), combining data across 133,413 individuals with replication in up to 42,166 individuals. We identify 24 new and confirm 29 previously identified loci. Of these 53 loci, 19 associate with eGFR among individuals with diabetes. Using bioinformatics, we show that identified genes at eGFR loci are enriched for expression in kidney tissues and in pathways relevant for kidney development and transmembrane transporter activity, kidney structure, and regulation of glucose metabolism. Chromatin state mapping and DNase I hypersensitivity analyses across adult tissues demonstrate preferential mapping of associated variants to regulatory regions in kidney but not extra-renal tissues. These findings suggest that genetic determinants of eGFR are mediated largely through direct effects within the kidney and highlight important cell types and biological pathways

The tracking project: a collaborative multi-agency database for shared clients/patients to inform policy development

The paper describes a feasibility study of the 'tracking project', a new method for examining health and social care agency overlap, repeat service use and shared patients. It demonstrates that this method is a practical and effective means of informing policy. The Tracking Project is the first project in this country to combine total population databases from a range of social, health care and criminal justice agencies. This has enabled, for the first time, the development of a multi-agency database for total health, mental health, social care and criminal justice populations in one county for a 2-year period, (number of cases = 97,162) through standardised anonymisation of agency databases, using SOUNDEX a software programme. The Tracking method has potential for developing screening instruments, through post-sample testing of predictive variables, in order to enable identification of multiple agency attenders for targeting or multi-disciplinary working. The authors discuss these data in the context of previous research evidence and current policy, examining reasons why particular clients might use many social and health care agencies and considering the potential of this method to inform service planning and implementation

A graphical method for assessing agreement with the mean between multiple observers using continuous measures

Background: Currently, we are not aware of a method to assess graphically on one simple plot agreement between more than two observers making continuous measurements on the same subjects. Methods: We aimed to develop a simple graphical method to assess agreement between multiple observers using continuous measurements. The Bland-Altman graphical method for assessing agreement between two observers using continuous measures was modified and extended to accommodate multiple observers. Mathematical formulae are derived and real data examples used to illustrate the proposed method. Results: The examples show that the proposed graphical method of assessing agreement provides clinically useful information. This information includes estimates of the limits of agreement with the mean and a visual means for determining these limits over the range of measurements. In a data example that included five readers' measurements of 40 lung lesions, the intra-class correlation (ICC) was 0.84 indicating readers can reliably measure the lesions. However, the estimated limits of agreement with the mean were -1.1 to 1.1 cm implying that the readers' measurements can plausibly differ from the mean estimated tumour size by more than 1 cm. This is a clinically significant difference according to the study authors. In addition, a plot of the limits of agreement with the mean by mean tumour size shows heterogeneous agreement presumably due to the varying degrees of definition at the edge of the lesions. Conclusions The proposed graphical method of assessing agreement can be used alongside other measures such as ICC for reporting on reproducibility in studies of multiple observers making continuous measurements