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We agree with Dr Smith and his colleagues that as part of routine care patients should be fully informed about blood pressure and how it may be ameliorated. We also know that there are well defined, agreed guidelines for blood pressure control with which doctors, for one reason or another, do not comply. This intervention was an attempt to empower patients, partly through education and partly through exhortation to challenge their care, to ensure that they were getting the best possible treatment. Clearly, it would have been better if their care had been superb and such intervention was unnecessary, but we believe the practice that undertook this study at the time was little different from most others with regard to the management of blood pressure.
We included patients whose blood pressure was already controlled because a significant portion of such patients will become uncontrolled over time. If that were not the case then there would be little point in following up patients once control was achieved.
We anticipated that the biggest impact on the HADS of the intervention would be shortly after patients had read the guideline and possibly became concerned about their care. In fact the HADS score for both intervention and control information fell significantly in the 2 weeks after the guideline was distributed (P = 0.02 for the anxiety component and P = 0.001 in the depression component). The rise at the end was not statistically significant.
We agree that well organised care is an effective method of managing blood pressure, but our trial was to determine if a simple patient intervention (such as is being proposed for many chronic illnesses) improved outcomes. Our work, for all its limitations suggest that this is not a course of action, despite its seeming logic, that should be undertaken without further study.