“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.
- When and where do nurse led interventions for hypertension improve outcomes, compared with usual care?
- What is the association between migraine—with or without aura—and risk of haemorrhagic stroke?
- Is migraine associated with increased mortality from cardiovascular disease, other causes, and all causes?
- What factors affect decision making by family carers on behalf of people with dementia?
Cardiovascular risks of migraine with aura
The Women’s Health Study was a randomised, double blind, placebo controlled trial in which nearly 40, 000 female health professionals were randomly assigned to vitamin E or placebo, and to aspirin or placebo. Randomisation ended in 1996 and the primary endpoint was risk of all important vascular events (a composite of nonfatal myocardial infarction, nonfatal stroke, and total cardiovascular death) and of total epithelial cell cancers. Follow-up of nearly 30<thin>000 of the trial cohort continued until March 2009, prompting a wide range of subsequent research questions.
Tobias Kurth and colleagues report this week that women who had migraine with aura at baseline in the study—when compared with women without migraine—went on to have four additional haemorrhagic strokes per 10, 000 women per year (in all 85 haemorrhagic strokes occurred during the 13 year follow-up period). Larus Gudmundsson and colleagues looked at a different cohort: 18, 725 men and women from Reykjavik, finding that migraine with aura was an independent risk factor for cardiovascular and all cause mortality in both men and women. It was a weaker risk factor than many others, however, such as smoking, diabetes, and high blood pressure.
So what should doctors say to patients with migraine? In a linked editorial Klaus Berger and Stefan Evers urge caution, and argue that “for many people the information [from these and other similar observational studies] will cause an unwarranted amount of anxiety, although others may use the opportunity to modify their lifestyle and risk factors accordingly.”
Blood pressure services delivered by nursesThe interventions in this systematic review by Christopher E Clark and colleagues included nurse support delivered by telephone (seven studies), community monitoring (defined as home or other non-healthcare setting; eight studies), and nurse led clinics held in primary (13 studies) or secondary care (six studies). Their findings concur with common sense: clinical outcomes are best when nurses use algorithms to deliver care for hypertension. The quality of the studies was only moderate, however, and the authors particularly note the lack of high quality studies of nurse led care for uncomplicated hypertension in the UK.
For these and other new research articles see www.bmj.com/channels/research.dtl
Implementation of nationwide electronic health records
Although introduction of a standardised national electronic records system will no doubt improve patient care, you won’t be surprised to find out that implementing such a service throughout an organisation as huge and diverse as the NHS “will be a long, complex, and iterative process.” That’s the bottom line of Ann Robertson and colleagues’ research into the NHS Care Records Service, which evaluated the experiences of five “early adopter” secondary care trusts. Implementation has been stymied by following a “top-down,” centrally driven policy and has evolved to be more responsive to the needs of individual trusts. But a “bottom-up” approach would be equally ineffectual, warn the authors; a “middle-out” approach that combines increased local autonomy with central support for national goals and common standards would be most appropriate.