Nursing Introduction & PICOT Question Assignment

J Adv Nurs. 2022;78:1281–1293. wileyonlinelibrary.com/journal/jan  | 1281© 2022 John Wiley & Sons Ltd.

1  |  INTRODUCTION

Hypertension is a key risk factor for cardiovascular disease (CVD) (World Health Organisation, 2013) which, despite being preventable and treatable, is often poorly controlled (Unger et al., 2020). The rising global prevalence of hypertension is a grave concern given that elevated blood pressure (BP) leads to more CVD morbidity and mortality than

any other single biomedical factor (Mills et al., 2020). Hypertension is often present with other known risk factors such as smoking, nutrition, alcohol and physical activity status, thus increasing a person's absolute CVD risk (National Vascular Disease Prevention Alliance, 2012). There is a need to target evidence- based, person- centred interventions to- wards people with hypertension to prevent CVD events and improve health outcomes in this group (Buawangpong et al., 2020).

Received: 29 July 2021  | Revised: 14 December 2021  | Accepted: 16 December 2021

DOI: 10.1111/jan.15159

R E V I EW

Nurse-­led­interventions­to­manage­hypertension­in­general­ practice:­A­systematic­review­and­meta-­analysis

Catherine­Stephen1  |­­­Elizabeth­Halcomb1  |­­­Ritin­Fernandez1,2  |­­­Susan­McInnes1  |­­­ Marijka­Batterham3  |­­­Nick­Zwar4

1School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Illawarra Health & Medical Research Institute, Wollongong, New South Wales, Australia 2Centre for Research in Nursing and Health, Level 1 Research and Education Building, St George Hospital, Sydney, New South Wales, Australia 3Statistical Consulting Centre, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia 4Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia

Correspondence Catherine Stephen, Building 41, School of Nursing, Northfields Ave, Wollongong NSW 2522, Australia. Email: cstephen@uow.edu.au

Abstract To evaluate the impact of general practice nurse- led interventions for blood pres- sure control and cardiovascular disease risk factor reduction in patients with hyper- tension. Systematic review and meta- analysis of randomized control trials. CINAHL, Medline and Scopus databases were searched to identify peer- reviewed studies published between 2000 and 2021. A systematic review of randomized control trials was conducted using a structured search strategy. The Meta- Analysis of Statistics Assessment and Review Instrument (JBI- MAStARI) was used to appraise study qual- ity. Meta- analysis and narrative synthesis were performed to determine the effective- ness of the included interventions. Eleven trials comprising of 4454 participants were included in the review. Meta- analysis showed significant reductions in both systolic and diastolic blood pressure in trials with 6 months or less follow- up. Improvements were also demonstrated in reducing blood lipids, physical activity, general lifestyle measures and medication adherence. Evidence for dietary improvements and reduc- tion in alcohol and smoking rates was inconclusive. Nurse- led interventions for pa- tients with hypertension are heterogeneous in terms of the nature of the intervention and outcomes measured. However, nurse- led interventions in general practice dem- onstrate significant potential to improve blood pressure and support cardiovascular disease risk factor reduction. Future research should be directed towards elucidat- ing the successful elements of these interventions, evaluating cost- effectiveness and exploring translation into usual care. This review provides evidence that nurses in general practice could enhance current hypertension management through nurse- led interventions.

K E Y WO RD S cardiovascular risk, hypertension, lifestyle risk, nursing intervention, general practice nurse

1282  |    STEPHEN et al.

Lowering BP in those with hypertension (BP > 140/90 mm Hg) is a well- established strategy for reducing CVD risk (National Heart Foundation of Australia, 2016). Effectiveness is increased if other behavioural CVD risk factors are acknowledged, targeted and mod- ified (National Heart Foundation of Australia, 2016). Empowering individuals to modify risk in their lifestyle is complex, requiring a mul- tifaceted approach that matches intrinsic motivation to change with support from healthcare professionals (Prochaska and Velicer, 1997; James et al., 2019). Nurse- led interventions offer a feasible model to support people with hypertension to achieve CVD risk reduction in primary care (Chiang et al., 2018; Himmelfarb et al., 2016) . General practice offers an acceptable and accessible location for this activity (James et al., 2019).

1.1  |  Background

While models of primary care provision vary globally, in Europe and Australia, general practice is usually located in the community as the first point of health care service contact. General Practice manages both acute and chronic health issues and preventive health, with an emphasis on building continuing relationships over time (Baird et al., 2018).

The growth of multidisciplinary team- based models of care in general practice presents an opportunity to manage BP and life- style risk factors to optimize health outcomes (Zwar et al., 2017). Improvements in information systems such as e- health records, de- cision support and web resources have facilitated a systematic ap- proach to such proactive care in general practice (Baird et al., 2018).

General practice nurses (GPNs) play an essential role in multi- disciplinary, team- based care, collaborating with GPs to coordinate patient care through the identification, assessment and direction of brief interventions and follow- up for individuals at risk of mor- bidity and mortality (Heywood & Laurence, 2018). The prolonged engagement with consumers over time and the capacity to identify and support individuals at risk, who are ready for change, indicates great potential for GPN- led interventions for lifestyle risk reduction (Halcomb et al., 2008; James et al., 2019; Stephen et al., 2018).

While models of care to reduce lifestyle risk factors that in- volve nurses in general practice are conceptually alluring (Halcomb et al., 2004), there have been few attempts to explore the impact of these interventions. Halcomb et al. (2007) published a systematic re- view of the effectiveness of GPN interventions in cardiac risk factor reduction among healthy adults and those with known risk factors. This review highlighted that there was variable evidence to support the efficacy of these interventions for the reduction of various risk factors and identified that further research was required to provide evidence to support these models of care (Halcomb et al., 2007). Therefore, this paper seeks to systematically review randomized controlled trials (RCTs) that investigate the effectiveness of GPN- led interventions in reducing BP and modifying other CVD risk factors in patients with known hypertension. If effective, such improvements

in the management of patients with hypertension would be ex- pected to decrease CVD related morbidity and mortality.

2  |  THE­REVIEW

2.1  | Aim

This review seeks to examine the impact of GPN- led interventions for BP control and CVD risk factor reduction in adult patients with hypertension.

2.2  | Design

This is a systematic review of RCTs. The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) were used to direct the conduct and reporting of the review (Page et al., 2021). The systematic review protocol was registered on the PROSPERO database (registration no CRD42020139932) (Chowdhury et al., 2020).

2.3  |  Search­methods

A search was conducted to identify peer- reviewed papers that reported RCTs of GPN- led interventions to reduce BP and other CVD risk factors in adults with hypertension. CINAHL, Medline and Scopus databases were searched from January 2000 to September 2021. This period was chosen given the changes in hy- pertension screening and management protocols. Resource con- straints precluded translation, therefore, only papers published in English language were included. Keywords allowed for interna- tional variation of terms (e.g., general practice and family practice) and were developed by experts in primary care and an academic librarian (Box 1).

2.4  |  Inclusion­and­exclusion­criteria

This review included RCTs of interventions undertaken in general practice by registered (baccalaureate or equivalent prepared) nurses to reduce BP in adults with hypertension. Trials that included other health professionals, such as doctors or allied health professionals, as part of the broader intervention (e.g., medication review) were included if the intervention was predominately nurse- led. The out- comes of interest were BP and CVD risk outcomes such as body mass index (BMI), smoking, physical activity, cholesterol, alcohol or medication use.

Studies were excluded if the intervention was delivered by a nurse practitioner or specialist cardiac nurse. Interventions that included a Registered Nurse educational and supportive role in

    | 1283STEPHEN et al.

medication management were included, however, nurse prescribing represents advanced practice, therefore trials on medication titra- tion and dispensing were excluded.

2.5  |  Search­outcomes

Database searches identified 936 records after the removal of duplicates (Figure 1). Results of all searches were imported into Endnote V8 (The EndNote Team, 2013) and titles were reviewed for relevancy. Abstracts of the remaining papers were assessed against the inclusion criteria independently by two reviewers (CS and EH). Where uncertainty existed, the full paper (n = 56) was retrieved for evaluation against the selection criteria. Reference lists of relevant retrieved papers were examined to identify fur- ther trials. Recently published protocols were also checked to see if trials had commenced and were suitable for inclusion. A total of 11 papers met the inclusion criteria and were included in the review.

2.6  | Quality­appraisal

The 11 included papers were subjected to critical appraisal (Supplementary Material S1). Two independent reviewers (CS and SM) critically appraised the papers using the Meta- Analysis of Statistics Assessment and Review Instrument MAStARI (Joanna Briggs Institute, 2014). This 10- item tool scores each item on a 3- point scale (Yes = 1, Unsure = 2 or No = 3), giving a maximum total score of 30.

Following independent appraisal, discrepancies were resolved by discussion and consensus was reached. As all included papers scored above 12, indicating limited methodological flaws (Joanna Briggs Institute, 2014), no paper was excluded due to methodolog- ical quality.

2.7  | Data­extraction

Data were extracted relating to intervention components, mode of delivery, follow- up periods and outcome measures by the first au- thor. These data were extracted into summary tables, constructed using the Cochrane Collaboration and Centre for Reviews and Dissemination as a guide (Table 1). Where trials contained multiple, distinct arms, the intervention that was contained the most GPN contact was selected for inclusion.

2.8  | Data­synthesis

Due to the heterogeneity between studies, meta- analysis was only conducted on BP outcomes. This meta- analysis was un- dertaken using Review Manager 5.2 software (The Cochrane Collaboration, 2014). Analysis of continuous data was undertaken using the mean and standard deviation values to derive weighted mean differences (WMD) and their 95% confidence intervals (CIs). Odds ratios and 95% CI were calculated for dichotomous data. Data unable to be pooled in a meta- analysis were extracted and presented in tabulated and narrative form. A narrative synthesis was conducted to gain insight into the impact of interventions on other CVD risk factors.

3  |  RESULTS

3.1  |  Summary­of­included­studies

All studies included hypertensive patients who had high BP at base- line, except Cicolini et al. (2014) who included participants with a previous diagnosis of hypertension (Table 1).

Sample sizes ranged from 51 (Tonstad et al., 2007) to 1492 (Carrington et al., 2016) patients. The specific interventions

BOX­1 Search­strategy

1. ‘general practice’ OR ‘primary care’ OR ‘community’ OR ‘family practice’

2. ‘smoking cessation’ OR ‘cholesterol’ OR ‘diet’, ‘exercise’ OR ‘alcohol’ OR ‘physical

activity’ OR ‘BP,

3. ‘nursing intervention’ OR ‘nursing’ OR nurs* OR office nurs*

4. Clinical Trial OR Comparative Study OR Randomised controlled trial OR Evaluation

Research OR Prospective Study OR random*

5. Limit to English language

6. Limit to published in or after 2000

7. Limit to peer reviewed

1284  |    STEPHEN et al.

reported across studies were varied and multifaceted. All inter- ventions were delivered primarily by GPNs, however, several tri- als involved additional GP consultation (Cicolini et al., 2014; Zhu et al., 2018) and referral to community support facilities (Beune et al., 2014). Nurse consultations were delivered either face- to- face (Beune et al., 2014; Carrington et al., 2016; Hacihasanoğlu & Gözüm, 2011; Kastarinen et al., 2002; Sen et al., 2013; Tonstad et al., 2007; Ulm et al., 2010; Zhu et al., 2018), exclusively via tele- phone (Bosworth, Olsen, Dudley, et al., 2009, Bosworth, Olsen, Grubber, et al., 2009) or through a combination of email and tele- phone reminders (Cicolini et al., 2014). Additionally, several stud- ies augmented face- to- face consultation with telephone follow- up (Sen et al., 2013, Zhu et al., 2018; Hacihasanoğlu and Gözüm 2011). The duration and intensity of interventions also varied greatly,

with several studies opting for brief contacts lasting 4 (Zhu et al., 2018) or 6 months (Beune et al., 2014; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Carrington et al., 2016; Tonstad et al., 2007) to longer studies over 12 (Ulm et al., 2010; Sen et al., 2013) and 24 months (Bosworth, Olsen, Dudley, et al., 2009; Bosworth, Olsen, Grubber, et al., 2009).

Nurses measured BP in seven studies (Carrington et al., 2016; Cicolini et al., 2014; Hacihasanoğlu & Gözüm 2011; Sen et al., 2013; Tonstad et al., 2007; Ulm et al., 2010; Zhu et al., 2018), while four studies used blinded research assistants (Beune et al., 2014; Bosworth, Olsen, Dudley, et al., 2009; Bosworth, Olsen, Grubber, et al., 2009; Kastarinen et al., 2002). Only Ulm et al. (2010) com- bined 24- hour ambulatory BP monitoring with automated office BP monitoring.

F IGURE ­1 PRISMA flow diagram

936 Records identified through database searches

2 Additional records identified through other sources

910 records after duplicates removed

Id en

tif ic

at io

n S

cr ee

ni ng

E lig

ib ili

ty In

cl ud

ed

910 records screened for relevance

854 records excluded by title and abstract review

45 full-text articles excluded: 10 disease specific

8 not RCT 7 specialist nurse 6 not nurse led

6 outcomes not relevant 4 not General practice 3 not adult population 1 post-hoc analysis

56 full-text articles assessed for eligibility

11 studies included in review

    | 1285STEPHEN et al.

TA B LE ­1

  C

ha ra

ct er

is tic

s of

in cl

ud ed

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di es

A ut ho r/ co un tr y

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D ur at io n

O ut co m es

Be un

e et

a l.

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4) N

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s 14

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≥1 40

m m

H g)

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te rv

en tio

n (n

= 7

5) •

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30 m

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ou ns

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g se

ss io

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tu ra

lly a

pp ro

pr ia

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du ca

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• Re

fe rr

al s

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ac ili

tie s

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su al

c ar

e (n

= 7

1)

6 m

on th

s •

BP •

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ce to

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vi ce

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ed ic

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I

Bo sw

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ud le

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(2 00

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m er

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Pr es

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nt ih

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on th

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1. T

ai lo

re d

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le ph

on e

be ha

vi ou

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nt er

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(n =

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(n =

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on tr

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(n =

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n cl

in ic

al re

m in

de r

sy st

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l G ui

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24 m

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at ie

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B P

Bo sw

or th

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00 9)

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ai lo

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be ha

vi ou

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in te

rv en

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(n =

1 60

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se p

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ca tio

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m on

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tie nt

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bi ne

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(n =

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6, 12

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m on

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• A

dh er

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to a

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(2 01

6) A

us tr

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• A

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s •

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su al

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e (n

= 3

48 )

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ur se

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ar e

(n =

1 56

) •

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in e

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ith G

PN 3.

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nd ar

d in

te rv

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n (n

= 7

05 )

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ls ar

ta n

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bi na

tio n

th er

ap y

w ith

ou t G

PN

su pp

or t

4. N

ur se

- m ed

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d in

te rv

en tio

n (n

= 2

83 )

• Va

ls ar

ta n

m on

o or

c om

bi na

tio n

th er

ap y

w ith

s tr

uc tu

re d

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s up

po rt

.

26 w

ee ks

• BP

a t i

nd iv

id ua

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ge t

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i e t a

l. (2

01 4)

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3 •

H yp

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O r

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P ≥1

40 m

m H

g or

D BP

≥9

0 m

m H

g

1. N

ur se

- le d

in te

rv en

tio n

(n =

1 02

) •

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ly s

el f -

a ss

es sm

en t,

w ee

kl y

em ai

l a nd

p ho

ne li

fe st

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re m

in de

rs •

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ed uc

at io

na l p

ro gr

am 2.

U su

al c

ar e

(n =

1 01

)

3 an

d 6 m

on th

s •

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W ei

gh t

• W

ai st

c irc

um fe

re nc

e •

Sm ok

in g

• A

lc oh

ol •

So di

um in

ta ke

/F ru

it/ ve

ge ta

bl e.

• Ph

ys ic

al a

ct iv

ity •

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ic at

io n

ad he

re nc

e •

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d gl

uc os

e •

Li pi

ds

1286  |    STEPHEN et al.

A ut ho r/ co un tr y

Sa m pl e­ si ze

In cl us io n­ cr ite ria

In te rv en tio n­ co m po ne nt s

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an oğ

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nd

G öz

üm (2

01 1)

Tu rk

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13 0

• A

ge ≥

3 5

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n (≥

14 0/

90 m

m H

g) •

A nt

ih yp

er te

ns iv

e m

ed ic

at io

n ≥1

2 m

on th

s

1. G

ro up

A (n

= 4

3) •

M on

th ly

n ur

se e

du ca

tio n—

fo ur

c lin

ic a

nd tw

o ho

m e

vi si

ts (3

0 m

in ) f

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se d

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ed ic

at io

n ad

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nc e.

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th ly

p ho

ne c

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G ro

up B

(n =

4 3)

• In

te rv

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n A

a nd

n ur

se - le

d he

al th

y lif

es ty

le e

du ca

tio n

(4 5

m in

). 3.

C on

tr ol

g ro

up (n

= 4

4) •

BP a

nd w

ei gh

t m ea

su re

m en

ts a

t c en

tr e

an d

in h

om e

• Te

le ph

on e

ap po

in tm

en t r

em in

de rs

6 m

on th

s •

BP •

W ei

gh t

• M

ed ic

at io

n ad

he re

nc e

• Li

fe st

yl e

be ha

vi ou

rs

K as

ta rin

en e

t a l.

(2 00

2) Fi

nl an

d 71

5 •

A ge

d 25

– 7 4

ye ar

s. •

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be tw

ee n

14 0

an d1

79 m

m H

g an

d/ or

• D

BP b

et w

ee n

90 a

nd 1

09 m

m H

g

or •

C ur

re nt

ly o

n an

tih yp

er te

ns iv

e m

ed ic

at io

n

1. N

ur se

- le d

lif es

ty le

c ou

ns el

lin g

(n =

3 60

) •

Se ve

n in

di vi

du al

v is

its a

nd tw

o gr

ou p

m ee

tin gs

. N ur

se s

m on

ito re

d, c

ou ns

el le

d an

d pr

ov id

ed fe

ed ba

ck o

n lif

es ty

le b

eh av

io ur

s. •

W rit

te n

ac tio

n pl

an •

Fe ed

ba ck

o n

4- da

y fo

od re

co rd

2. U

su al

c ar

e (n

= 3

55 )

12 a

nd

24 m

on th

s •

BP •

BM I/

W ei

gh t

• Ph

ys ic

al a

ct iv

ity •

W ai

st a

nd h

ip

ci rc

um fe

re nc

e •

Li pi

ds •

Sa lt

in ta

ke •

A lc

oh ol

• Sm

ok in

g

Se n

et a

l. (2

01 3)

Sw ed

en 16

6 •

A ge

≥ 1

8 ye

ar s

• U

nc on

tr ol

le d

hy pe

rt en

si on

o n

do ct

or s

vi si

t

1. B

P ca

rd (n

= 5

7) •

BP s

el f-

m ea

su re

m en

t a nd

ta rg

et c

ar d

2. B

P ca

rd a

nd p

ed ag

og ic

n ur

si ng

in te

rv en

tio n

(n =

5 9)

• In

di vi

du al

iz ed

p la

nn in

g an

d w

rit te

n in

fo rm

at io

n •

N ur

se p

ho ne

c al

ls /v

is its

3. U

su al

c ar

e (n

= 5

0)

12 m

on th

s •

BP –

p ro

po rt

io n

of

pa tie

nt s

ac hi

ev in

g ta

rg et

To ns

ta d

et a

l. (2

00 7)

N or

w ay

51 •

A ge

d 30

– 6 9

ye ar

s •

SB P

14 0–

16 9

m m

H g

• D

BP b

et w

ee n

90 a

nd 9

9 m

m H

g at

≥3

re ad

in gs

1. In

te rv

en tio

n (n

= 3

1) •

M on

th ly

n ur

se c

ou ns

el lin

g x

30 m

in fo

r 6 m

on th

s •

St ag

e m

at ch

ed b

eh av

io ur

al c

ou ns

el lin

g an

d ed

uc at

io n

2. C

on tr

ol (n

= 2

0) •

Br ie

f a dv

ic e

• Re

co m

m en

de d

to v

is it

pr im

ar y

ca re

p hy

si ci

an

6 m

on th

s •

BP •

BM I/

W ei

gh t

• W

ai st

a nd

H ip

ci

rc um

fe re

nc e

• Tr

ig ly

ce rid

es /L

ip id

/ C

ho le

st er

ol •

G lu

co se

c on

ce nt

ra tio

n

U lm

e t a

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    | 1287STEPHEN et al.

3.2  |  Blood­pressure

Although all 11 studies measured BP, due to the heterogene- ity in terms of reporting and timing of BP measurement, only nine could be pooled in a meta- analysis. Six studies had a follow- up of six months or less, ranging from three (Zhu et al., 2018) to six months (Beune et al., 2014; Carrington et al., 2016; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Tonstad et al., 2007). The other three studies had follow- up for over six months, ranging from 12 (Sen et al., 2013; Ulm et al., 2010) to 24 months (Bosworth, Olsen, Dudley, et al., 2009). The statistical tests on which each p- value is based are presented in Table S2.

3.2.1  |  Mean systolic BP at follow- up

Overall pooled data demonstrated a statistically significant reduction in mean systolic BP (4.7 mm Hg) in the intervention group compared with the control group (95% CI −8.68, −0.71) (Figure 2) (Bosworth, Olsen, Dudley, et al., 2009; Beune et al., 2014; Carrington et al., 2016; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Sen et al., 2013; Tonstad et al., 2007; Ulm et al., 2010; Zhu et al., 2018). However, sub- group analysis demonstrated this statistically significant reduction in mean systolic BP was only in the six month or less follow- up group (MD −6.29; 95% CI −11.44, −1.14) and not in the greater than six month follow- up group (MD −1.34; 95% CI −4,42, 1.75).

3.2.2  |  Mean change in systolic BP from baseline to follow- up

A statistically significant mean change in systolic BP from baseline to follow- up in the intervention group compared with the standard care

group (MD 4.84; 95% CI 2.62, 7.06) was demonstrated by pooled data from four studies (Carrington et al., 2016; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Zhu et al., 2018). Subgroup analysis demonstrated that this change was only apparent in the six months or less follow- up group (MD 5.06; 95% CI 2.58, −7.53) and not in the greater than six month follow- up group (MD 3.96; 95% CI −1.07, 8.98). In the remaining two studies, one (Kastarinen et al., 2002) reported no statistically significant difference and the other (Bosworth, Olsen, Grubber, et al., 2009) demonstrated a significant reduction in systolic BP of 3.3 mmHg from baseline to follow- up in the intervention group compared with standard care at the greater than six month follow- up period.

3.2.3  |  Mean diastolic BP at follow- up

A statistically significant reduction in diastolic BP (3.01 mm Hg) in the intervention group compared with the standard care group (95% CI −5.58, −0.44) was demonstrated by pooled data from eight stud- ies (Figure 3) (Beune et al., 2014; Carrington et al., 2016; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Sen et al., 2013; Tonstad et al., 2007; Ulm et al., 2010; Zhu et al., 2018). Subgroup analysis revealed that this reduction was present only in the six month or less follow- up group (MD −4.15; 95% CI −7.01, −1.29) and not in the greater than six month follow- up group.

3.2.4  |  Mean change in diastolic BP from baseline to follow- up

Pooled data from four studies demonstrated a statistically signifi- cant mean change in diastolic BP from baseline to follow- up in the intervention group compared with the standard care group (MD

F IGURE ­2 Mean difference in systolic BP at ≤6 and at >6 months

1288  |    STEPHEN et al.

2.06; 95% CI 0.84, 3.27)(Beune et al., 2014; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Zhu et al., 2018). However, subgroup analysis demonstrated that the change in diastolic BP from baseline to follow- up in the intervention group compared with the standard care group was only in the six month or less follow- up group (MD 2.86; 95% CI 1.49, −4.22) and not in the greater than six month fol- low- up group (MD −0.91; 95% CI −3.55, 1.73).

3.3  |  CVD­risk­factor­reduction

Seven papers reported CVD risk factors as secondary out- comes (Beune et al., 2014; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Kastarinen et al., 2002; Tonstad et al., 2007; Ulm et al., 2010; Zhu et al., 2018) (Table 2). The variations in outcomes and outcomes measures between studies make comparison difficult and precluded meta- analysis.

3.3.1  |  Diet

Of the four studies that reported dietary outcomes (Beune et al., 2014; Cicolini et al., 2014; Kastarinen et al., 2002; Ulm et al., 2010), only one demonstrated a significant between- group increase in self- reported fruit consumption (Cicolini et al., 2014) (p < .001). No significant changes were found in blood glucose, serum insulin, sodium excretion or sodium consumption in any study.

3.3.2  |  Anthropometry

Six studies investigated anthropomorphic data, measuring weight (Kastarinen et al., 2002; Tonstad et al., 2007; Ulm et al., 2010),

BMI (Beune et al., 2014; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011), waist circumference (Kastarinen et al., 2002; Tonstad et al., 2007) and obesity prevalence (Cicolini et al., 2014).

Kastarinen et al. (2002) reported net reductions in weight (inter- vention vs. usual care) at both 12 and 24 months with −1.5 kg inter- vention versus −0.03 control difference in change (95% CI −1.2 kg −1.7, −0.7) at 24 months. Of the three studies that measured BMI, both Cicolini et al. (2014) and Hacihasanoğlu and Gözüm (2011) demonstrated statistically significant between- group reductions. Although improvements were seen in the intervention groups in two studies measuring waist circumference (Kastarinen et al., 2002; Tonstad et al., 2007), no significant between- group differences were found. Additionally, Tonstad et al. (2007) reported that all partici- pants increased waist circumference, however, the overall gain was significantly smaller in the intervention group (p = .04). The only study which measured obesity prevalence reported a statistically significant between- group reduction in obesity (p < .01) (Cicolini et al., 2014).

3.3.3  |  Physical activity

Three studies demonstrated improved physical activity (Cicolini et al., 2014; Kastarinen et al., 2002; Ulm et al., 2010). At six months, Cicolini et al. (2014) reported a significant between- group increase in mean minutes of daily physical activity (p ≤ .01). Despite a mod- est higher increase in physical activity in the intervention group at 12 months in Ulm et al.'s (2010) study (1 vs. 0.2 h/week) this was not statistically significant. Similarly, Kastarinen et al. (2002) reported that significantly more intervention participants achieved recom- mended physical activity levels in comparison with the control group at 24 months (difference in change [95% CI] 11.3 [1.8, 20.8]), how- ever, this was not statistically significant.

F IGURE ­3 Mean difference in diastolic BP at ≤6 and at >6 months [Correction added on 19 April 2022, after first online publication: The correct image for Figure 3 has been inserted.]

    | 1289STEPHEN et al.

TABLE ­2 Secondary outcomes

Outcome Outcome­measure Reference Follow-­up­ (months) Resulta

Diet Daily fruit servings (Mean) Cicolini et al. (2014) 6 ↑consumption p ≤ .001*

Blood glucose (Mean) Cicolini et al. (2014) 6 n/s p = .076

Tonstad et al. (2007) 6 n/s

Serum insulin (Mean) Kastarinen et al. (2002) 24 n/s

spoons daily salt (Mean) Cicolini et al. (2014) 6 p = .078

Sodium excretion (Mean) Beune et al. (2014) 6 n/s

Kastarinen et al. (2002) 24 n/s

Alcohol Weekly alcohol units Kastarinen et al. (2002) 24 n/s

Alcohol per day (Mean units) Cicolini et al. (2014) 6 ↓consumption p ≤ .05*

<1 Alcoholic drink daily Ulm et al. (2010) 12 n/s

Blood lipids Total cholesterol (Mean) Cicolini et al. (2014) 6 p < .05*

Kastarinen et al. (2002) 24 ↓0.10 (−0.20, −0.01) (95% CI)

Tonstad et al. (2007) 6 n/s

LDL cholesterol (Mean) Cicolini et al. (2014) 6 p < .001*

Kastarinen et al. (2002) 24 ↓0.15 (−0.23, −0.05) (95% CI)

Triglycerides (Mean) Cicolini et al. (2014) 6 p < .001*

Kastarinen et al. (2002) 24 n/s

Tonstad et al. (2007) 6 p = .03

Anthropometry BMI (Mean) Beune et al. (2014) 6 ↓0.016 p = .10 n/s

Cicolini et al. (2014) 6 p ≤ .001*

Hacihasanoğlu and Gözüm (2011) 6 p ≤ .05*

Weight (Mean) Kastarinen et al. (2002) 24 ↓1.2 kg

Ulm et al. (2010) 12 n/s

Tonstad et al. (2007) 6 n/s

Waist circumference (Mean) Kastarinen et al. (2002) 24 ↓1.4

Prevalence of obesity Cicolini et al. (2014) 6 ↓16%

Smoking Cigarettes per day (Mean) Cicolini et al. (2014) 6 ↓Daily cigarette consumption p ≤ .01

Smoking status (%) Ulm et al. (2010) 12 ↓14.7%– 7% p = n/s

Physical Activity (PA)

Daily PA (Mean mins) Cicolini et al. (2014) 6 ↑ PA p ≤ .01*

PA hours weekly Ulm et al. (2010) 12 ↑1 h

Target PA (%) Kastarinen et al. (2002) 24 Diff. in change 95% CI 11.3 (1.8, 20.8)

General Lifestyle Self- reported lifestyle behaviours Beune et al. (2014) 6 ↑Lifestyle adherence p = .003

Health promotion lifestyle profile scale

Hacihasanoğlu and Gözüm (2011) 6 ↑Healthier lifestyle behaviours p ≤ .001*

Adherence to non- pharmacological advice

Zhu et al. (2018) 4 p < .001*

% of adherence to therapy hours Cicolini et al. (2014) 6 91% p = .082

Medication Self- reported MMAS- 8 Beune et al. (2014) 6 p = .74 n/s

MASES score Hacihasanoğlu and Gözüm (2011) 6 p ≤ .001*

Compliance with medication (%) Cicolini et al. (2014) 6 100% p = .9

Compliance with therapy dose (%) Cicolini et al. (2014) 6 100% p = .078

Adherence to antihypertensive medication (%)

Zhu et al. (2018) 4 p ≤ .01*

*indicates satistically significant values. aThe statistical tests on which each p- value is based are presented in (Table S2).

1290  |    STEPHEN et al.

3.3.4  |  Smoking

Only two papers investigated smoking status (Cicolini et al., 2014; Ulm et al., 2010). At six months, Cicolini et al. (2014) demon- strated a statistically significant between- group difference in self- reported daily cigarette consumption (p ≤ .01). At 12 months, Ulm et al. (2010) reported a reduction in the percentage of self- identified 'smokers' in the intervention group from 14.7% to 7.0%, however, when compared with a change of 9.2%– 8.8% in usual care participants, the between- group difference was not statisti- cally significant.

3.3.5  |  Alcohol

Alcohol consumption was investigated in three studies (Cicolini et al., 2014; Kastarinen et al., 2002; Ulm et al., 2010). In their study, Cicolini et al. (2014) found a statistically significant between- group reduction in the mean units of alcohol consumed daily (p < 0.005). In contrast, studies of longer duration did not report significant changes in alcohol consumption. At 12 months, Ulm et al. (2010) re- ported a reduction in alcohol consumption among both the interven- tion participants and control group. While Kastarinen et al. (2002) found that alcohol consumption fell significantly among intervention participants at 12 months, this was not maintained in the second year. These data raise questions about the sustainability of reduced alcohol consumption over time.

3.3.6  |  Blood lipids

Three studies measured the effect of GPN interventions on blood lipids with mixed outcomes (Cicolini et al., 2014; Kastarinen et al., 2002; Tonstad et al., 2007). At six months, Cicolini et al. (2014) found a statistically significant reduction in LDL and total choles- terol in the intervention group versus usual care, but no between- group difference in serum triglycerides. Despite no change in mean total cholesterol, Tonstad et al. (2007) reported significantly re- duced serum triglycerides in intervention participants (p = .03) at six months. In contrast, Kastarinen et al. (2002) demonstrated at 24 months intervention participants had greater net reductions in total cholesterol (−0.10 mmol/L) and LDL- C (−0.15 mmol/L) com- pared with usual care.

3.3.7  |  General lifestyle measures

Four studies reported general lifestyle changes using various out- come measures (Hacihasanoğlu & Gözüm, 2011; Beune et al., 2014; Zhu et al., 2018; Cicolini et al., 2014). Significant improvements were seen in the intervention group in terms of adherence to non- pharmacological advice at three (p < .001) and four months (p = .023)(Zhu et al., 2018), self- reported lifestyle behaviours

(p = .003) (Beune et al., 2014) and average scores on the health promotion lifestyle profile scale (p < .001)(Hacihasanoğlu & Gözüm, 2011).

Although Cicolini et al., (2014) reported a 91% compliance to therapy hours at six months, this was not significant when compared with the high rates of therapy compliance seen in the usual care group.

3.3.8  |  Adherence to medication

Adherence to antihypertensive medication was measured in four studies (Beune et al., 2014; Cicolini et al., 2014; Hacihasanoğlu & Gözüm, 2011; Zhu et al., 2018). Only one of these studies included a General Practitioner medication review in the intervention (Zhu et al., 2018). Although other studies incorporated pharmacotherapy optimization (Carrington et al., 2016) and nurse education about medication use (Bosworth, Olsen, Grubber, et al., 2009) these studies did not report medication adherence outcomes (Bosworth, Olsen, Grubber, et al., 2009; Carrington et al., 2016).

Two studies demonstrated significant improvements in medica- tion adherence in the intervention group compared with usual care (Hacihasanoğlu & Gözüm, 2011; Zhu et al., 2018), while the other two studies showed non- significant improvements due to high rates of medication adherence across both groups Cicolini et al. (2014) and Beune et al. (2014). In their three- arm trial, Hacihasanoğlu and Gözüm (2011) found a significant increase in medication use at six months (p < .001). Zhu et al. (2018) also demonstrated a statis- tically significant increase in adherence to antihypertensive medica- tion (p < .01).

4  | DISCUSSION

This meta- analysis demonstrated that GPN- led interventions are effective in reducing both systolic and diastolic BP in studies with follow- up periods of up to six months. The positive effect on both systolic and diastolic BP was less in those studies with more than six months of follow- up. The narrative review of the impact of GPN- led interventions on other CVD risk factors showed mixed results. Improvements were generally seen in blood lipids, physi- cal activity, general lifestyle measures and medication adherence. Despite promising results, the evidence on dietary and alcohol outcomes remains unclear. However, the relatively small number of heterogeneous studies identified in this review demonstrates the limitations in the current evidence around the impact of nurse- delivered interventions to reduce BP and CVD risk in adults with hypertension.

This review is consistent with previous literature in identifying some evidence of improved outcomes with nurse- led intervention for CVD risk reduction (Halcomb et al., 2007). A previous meta- analysis by Clark et al. (2011) found improved outcomes in nurse- led manage- ment of BP in people with diabetes. Similarly, in Crowe et al.'s (2019)

    | 1291STEPHEN et al.

review of nurse- led intervention for diabetes management, significant improvements in BP were demonstrated. However, this literature also highlights the heterogeneity of the existing evidence and variation between some studies (Halcomb et al., 2007; Clark et al., 2011; Crowe et al., 2019). As such, further investigation is required to specifically elucidate the successful elements of the interventions and the out- comes for which they can achieve significant impact.

Despite this varied evidence base, the previous investigation of nurse- led interventions with populations at high CVD risk reported improvements in smoking (Halcomb et al., 2015), alcohol (Platt et al., 2016; Clossick & Woodward, 2014), weight (Sargent et al., 2012), physical activity (Chudowolska- Kiełkowska & Małek, 2020) and medication adherence (Georgiopoulos et al., 2018). The limited ev- idence on dietary interventions to improve nutritional quality and anthropomorphic outcomes compares to previous reviews which found some, yet inconsistent effect in both nurse (McElwaine et al., 2016) and multidisciplinary nutritional interventions in primary care (Mitchell et al., 2017). Given the variable results, intervention delivery could be a factor as GPNs perceive their role to include nutritional advice, yet express the need to extend their nutritional knowledge, confidence and motivational counselling skills (Cass et al., 2014, Stephen et al., 2018) Furthermore, uncertainties around knowledge translation may hinder effective lifestyle risk communi- cation (James et al., 2019).

Patient satisfaction and economic analysis were largely miss- ing from the included studies, however, existing literature associ- ates nurse- led intervention with good levels of patient satisfaction (Edelman et al., 2015; Crowe et al., 2019; Stephen et al., 2018), cost- effectiveness (Crowe et al., 2019; Odnoletkova et al., 2016; Doherty et al., 2018) and potential to reach wide population base through digital/telehealth delivery (Odnoletkova et al., 2016; Young et al., 2014). As the economic impact and patient experience repre- sent multifactorial and nuanced variables of nurse- led intervention, further investigation of these issues is warranted.

4.1  |  Limitations

While this is the first review of GPN- led interventions focussed on reducing BP and CVD risk in adults with hypertension, there are sev- eral limitations. Despite a comprehensive search strategy informed by an academic librarian and checking of reference lists of included papers, a limited number of studies were identified. This highlights the paucity of high- quality evidence in this area. In addition, limiting the search to English language may have resulted in missing studies published in other languages.

Meta- analysis of BP outcomes is a significant strength of this review, however, variation in outcome measures and reporting across included studies precluded meta- analysis of additional CVD risk factors. As these data were unable to be pooled, a narra- tive synthesis was conducted to gain insight into the intervention effect. Overall heterogeneity of included studies makes it difficult

to elucidate the individual intervention elements that contribute to the specific outcomes. Additionally, the interaction between GPNs and other health professionals in the delivery of multidis- ciplinary care was not clearly described. Given the complexity of some interventions, it is possible that the impact of these in- dividual elements was not apparent. The variation in outcomes measured and reported both between and within groups requires caution in the interpretation of findings.

4.2  |  Implications­for­research­and­practice

The challenges facing general practice are significant in terms of chronic conditions and population ageing. Finding ways to effec- tively reduce BP and CVD risk represents an important strategy to prevent or delay the onset of CVD and reduce exacerbation in peo- ple with existing CVD. Nurses play a key role in the multidisciplinary management of BP, especially in terms of lifestyle counselling and supporting behaviour change.

Evidence from this review highlights the potential to leverage GPN- delivered interventions to reduce CVD risk and improve health outcomes. However, further research is required to explore the spe- cific elements of these interventions that are most effective, evalu- ate the economic impact of the intervention and patient satisfaction levels, as well as looking at how to translate these interventions into usual care.

4.3  |  Conclusions

GPN- led interventions to manage BP in patients with hyperten- sion are heterogeneous in terms of the scope and style of inter- vention. This review establishes that nurse intervention in general practice is associated with improvements in BP and additional positive impacts on some CVD risk factors. GPN- led interven- tions show significant potential to improve BP control and support people to reduce CVD risk factors. There is a clear need to direct future research towards elucidating the successful elements of these interventions and evaluating the wider economic impact of translation to usual care.

AUTHORS' ­CONTRIBUTIONS

CS, EH, MB and SM completed the data extraction and quality assessment of included papers. CS and RF conducted the meta- analysis. All authors participated in the manuscript preparation, pro- viding critical feedback and approved the final manuscript.

DATA­AVAILABILITY­STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request.

1292  |    STEPHEN et al.

ORCID Catherine Stephen https://orcid.org/0000-0002-3864-1300 Elizabeth Halcomb https://orcid.org/0000-0001-8099-986X Ritin Fernandez https://orcid.org/0000-0002-6143-7703 Susan McInnes https://orcid.org/0000-0003-3113-2930 Marijka Batterham https://orcid.org/0000-0002-9520-6508 Nick Zwar https://orcid.org/0000-0001-6462-9121

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SUPPORTING­INFORMATION Additional supporting information may be found in the online version of the article at the publisher’s website.

How­to­cite­this­article:­Stephen, C., Halcomb, E., Fernandez, R., McInnes, S., Batterham, M., & Zwar, N. (2022). Nurse- led interventions to manage hypertension in general practice: A systematic review and meta- analysis. Journal of Advanced Nursing, 78, 1281–1293. https://doi.org/10.1111/jan.15159

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