Patients' experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study

Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis

OBJECTIVE

To systematically review the qualitative evidence for patient and clinician perspectives on self-measurement of blood pressure (SMBP) in the management of hypertension focussing on: how SMBP was discussed in consultations; the motivation for patients to start self-monitoring; how both patients and clinicians used SMBP to promote behaviour change; perceived barriers and facilitators to SMBP use by patients and clinicians.

METHODS

Medline, Embase, PsycINFO, Cinahl, Web of Science, SocAbs were searched for empirical qualitative studies that met the review objectives. Reporting of included studies was assessed using the COREQ framework. All relevant data from results/findings sections of included reports were extracted, coded inductively using thematic analysis, and overarching themes across studies were abstracted.

RESULTS

Twelve studies were included in the synthesis involving 358 patients and 91 clinicians. Three major themes are presented: interpretation, attribution and action; convenience and reassurance v anxiety and uncertainty; and patient autonomy and empowerment improve patient-clinician alliance.

CONCLUSIONS

SMBP was successful facilitating the interaction in consultations about hypertension, bridging a potential gap in the traditional patient-clinician relationship.

PRACTICE IMPLICATIONS

Uncertainty could be reduced by providing information specifically about how to interpret SMBP, what variation is acceptable, adjustment for home-clinic difference, and for patients what they should be concerned about and how to act.

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

Background

In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging.

Methods

We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings.

Results

Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors.

Conclusions

Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.

Experiences of front-line health professionals in the delivery of telehealth: a qualitative study

BACKGROUND

Telehealth is an emerging field of clinical practice but current UK health policy has not taken account of the perceptions of front-line healthcare professionals expected to implement it.

AIM

To investigate telehealth care for people with long-term conditions from the perspective of the front-line health professional.

DESIGN AND SETTING

A qualitative study in three sites within the UK (Kent, Cornwall, and the London Borough of Newham) and embedded in the Whole Systems Demonstrator evaluation, a large cluster randomised controlled trial of telehealth and telecare for patients with long-term and complex conditions.

METHOD

Semi-structured qualitative interviews with 32 front-line health professionals (13 community matrons, 10 telehealth monitoring nurses and 9 GPs) involved in the delivery of telehealth. Data were analysed using a modified grounded theory approach.

RESULTS

Mixed views were expressed by front-line professionals, which seem to reflect their levels of engagement. It was broadly welcomed by nursing staff as long as it supplemented rather than substituted their role in traditional patient care. GPs held mixed views; some gave a cautious welcome but most saw telehealth as increasing their work burden and potentially undermining their professional autonomy.

CONCLUSION

Health care professionals will need to develop a shared understanding of patient self-management through telehealth. This may require a renegotiation of their roles and responsibilities.

Implementation of Out-of-Office Blood Pressure Monitoring in the Netherlands: From Clinical Guidelines to Patients' Adoption of Innovation

Out-of-office blood pressure monitoring is promoted by various clinical guidelines toward properly diagnosing and effectively managing hypertension and engaging the patient in their care process. In the Netherlands, however, the Dutch cardiovascular risk management (CVRM) guidelines do not explicitly prescribe 24-hour ambulatory blood pressure measurement (ABPM) and home BP measurement (HBPM). The aim of this descriptive study was to develop an understanding of patients' and physicians' acceptance and use of out-of-office BP monitoring in the Netherlands given the CVRM recommendations.Three small focus group discussions (FGDs) with patients and 1 FGD with physicians were conducted to explore the mechanisms behind the acceptance and use of out-of-office BP monitoring and reveal real-world challenges that limit the implementation of out-of-office BP monitoring methods. To facilitate the FGDs, an analytical framework based on the technology acceptance model (TAM), the theory of planned behavior and the model of personal computing utilization was developed to guide the FGDs and analysis of the transcriptions of each FGD.ABPM was the out-of-office BP monitoring method prescribed by physicians and used by patients. HBPM was not offered to patients even with patients' feedback of poor tolerance of ABPM. Even as there was little awareness about HBPM among patients, there were a few patients who owned and used sphygmomanometers. Patients professed and seemed to exhibit self-efficacy, whereas physicians had reservations about (all of their) patients' self-efficacy in properly using ABPM. Since negative experience with ABPM impacted patients' acceptance of ABPM, the interaction of factors that determined acceptance and use was found to be dynamic among patients but not for physicians.In reference to the CVRM guidelines, physicians implemented out-of-office BP monitoring but showed a strong preference for ABPM even where there is poor tolerance of the method. We found that physicians' positive attitude to ABPM enabled the use of the method by patients which, in turn, impeded the diffusion of HBPM. For patients, the acceptance process of HBPM can only begin after the physician has adopted the innovation. Physicians are in a position to encourage as well as hinder out-of-office BP monitoring and self-management.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Supporting patients to self-monitor their oral anticoagulation therapy: recommendations based on a qualitative study of patients' experiences

BACKGROUND

Clinical trials suggest that oral anticoagulation therapy (OAT) self-monitoring is safe and effective, however little is known about the patient experience of this process. There is a lack of understanding about how best to train and support patients embarking on OAT self-monitoring.

AIM

To collect in-depth information about patients' experiences of OAT self-monitoring outside of clinical trial conditions and to produce a set of recommendations on how best to support such patients.

DESIGN AND SETTING

Semi-structured qualitative interviews with patients who self-monitor and live in England.

METHOD

In total, 26 of the 267 (9.7%) who participated in the Cohort study of Anticoagulation Self-Monitoring (CASM) and were still self-monitoring after 12 months' follow-up were interviewed. Topics discussed included experiences of OAT self-monitoring, healthcare support, training, and decision making. Framework analysis was used.

RESULTS

Following initial problems using the monitoring device, interviewees described a mostly positive experience. Although less effort was expended attending monitoring appointments with health professionals, effort was required to conduct self-monitoring tests and to interpret and act on the results. Desire to self-manage was variable, especially when dosing advice systems worked promptly and reliably. Interviewees overcame patchy healthcare system knowledge and support of self-monitoring by educating themselves. Family and friends provided support with learning to use the monitor and managing OAT dosage adjustments.

CONCLUSION

Better, more-consistent training and health-service support would have alleviated a number of problems encountered by these patients who were self-monitoring. This training and support will become even more important if self-monitoring becomes more accessible to the general population of people on OAT.

Assessing the implementability of telehealth interventions for self-management support: a realist review

Background

There is a substantial and continually growing literature on the effectiveness and implementation of discrete telehealth interventions for health condition management. However, it is difficult to predict which technologies are likely to work and be used in practice. In this context, identifying the core mechanisms associated with successful telehealth implementation is relevant to consolidating the likely elements for ensuring a priori optimal design and deployment of telehealth interventions for supporting patients with long-term conditions (LTCs).

Methods

We adopted a two-stage realist synthesis approach to identify the core mechanisms underpinning telehealth interventions. In the second stage of the review, we tested inductively and refined our understanding of the mechanisms. We reviewed qualitative papers focused on COPD, heart failure, diabetes, and behaviours and complications associated with these conditions. The review included 15 papers published 2009 to 2014.

Results

Three concepts were identified, which suggested how telehealth worked to engage and support health-related work. Whether or not and how a telehealth intervention enables or limits the possibility for relationships with professionals and/or peers. Telehealth has the potential to reshape and extend existing relationships, acting as a partial substitute for the role of health professionals. The second concept is fit: successful telehealth interventions are those that can be well integrated into everyday life and health care routines and the need to be easy to use, compatible with patients’ existing environment, skills, and capacity, and that do not significantly disrupt patients’ lives and routines. The third concept is visibility: visualisation of symptoms and feedback has the capacity to improve knowledge, motivation, and a sense of empowerment; engage network members; and reinforce positive behaviour change, prompts for action and surveillance.

Conclusions

Upfront consideration should be given to the mechanisms that are most likely to ensure the successful development and implementation of telehealth interventions. These include considerations about whether and how the telehealth intervention enables or limits the possibility for relationships with professionals and peers, how it fits with existing environment and capacities to self-manage, and visibility-enabling-enhanced awareness to self and others.

Patient and professional user experiences of simple telehealth for hypertension, medication reminders and smoking cessation: a service evaluation

OBJECTIVES

To establish patient and professional user satisfaction with the Advice & Interactive Messaging (AIM) for Health programme delivered using a mobile phone-based, simple telehealth intervention, 'Florence'.

DESIGN

A service evaluation using data extracted from Florence and from a professional user electronic survey.

SETTING

425 primary care practices across 31 Clinical Commissioning Groups in England.

PARTICIPANTS

3381 patients registered on 1 of 10 AIM protocols between March 2013 and January 2014 and 77 professional users.

INTERVENTION

The AIM programme offered 10 clinical protocols, in three broad groups: (1) hypertension diagnosis/monitoring, (2) medication reminders and (3) smoking cessation. Florence sent patients prompts to submit clinical information, educational messages and user satisfaction questions. Patient responses were reviewed by their primary healthcare providers.

PRIMARY OUTCOME MEASURES

Patients and professional user experiences of using AIM, and within this, Florence.

RESULTS

Patient activity using Florence was generally good at month 1 for the hypertension protocols (71-80%), but reduced over 2-3 months (31-60%). For the other protocols, patient activity was 0-39% at 3 months. Minimum target days of texting were met for half the hypertension protocols. 1707/2304 (74%) patients sent evaluative texts responded at least once. Among responders, agreement with the adapted friends and family statement generally exceeded preproject aspirations. Professional responders were generally positive or equivocal about the programme.

CONCLUSIONS

Satisfaction with AIM appeared optimal when patients were carefully selected for the protocol; professional users were familiar with the system, the programme addressed a problem with the previous service delivery that was identified by users and users took an active approach to achieve clinical goals. However, there was a significant decrease in patients' use of Florence over time. Future applications may be optimised by identifying and addressing reasons for the waning use of the service and enhancing support during implementation of the service.

Patient experiences with self-monitoring renal function after renal transplantation: results from a single-center prospective pilot study

BACKGROUND

After a kidney transplantation, patients have to visit the hospital often to monitor for early signs of graft rejection. Self-monitoring of creatinine in addition to blood pressure at home could alleviate the burden of frequent outpatient visits, but only if patients are willing to self-monitor and if they adhere to the self-monitoring measurement regimen. A prospective pilot study was conducted to assess patients' experiences and satisfaction.

MATERIALS AND METHODS

For 3 months after transplantation, 30 patients registered self-measured creatinine and blood pressure values in an online record to which their physician had access to. Patients completed a questionnaire at baseline and follow-up to assess satisfaction, attitude, self-efficacy regarding self-monitoring, worries, and physician support. Adherence was studied by comparing the number of registered with the number of requested measurements.

RESULTS

Patients were highly motivated to self-monitor kidney function, and reported high levels of general satisfaction. Level of satisfaction was positively related to perceived support from physicians (P<0.01), level of self-efficacy (P<0.01), and amount of trust in the accuracy of the creatinine meter (P<0.01). The use of both the creatinine and blood pressure meter was considered pleasant and useful, despite the level of trust in the accuracy of the creatinine device being relatively low. Trust in the accuracy of the creatinine device appeared to be related to level of variation in subsequent measurement results, with more variation being related to lower levels of trust. Protocol adherence was generally very high, although the range of adherence levels was large and increased over time.

CONCLUSION

Patients' high levels of satisfaction suggest that at-home monitoring of creatinine and blood pressure after transplantation offers a promising strategy. Important prerequisites for safe implementation in transplant care seem to be support from physicians and patients' confidence in both their own self-monitoring skills and the accuracy of the devices used.

Patient self-monitoring of blood pressure and self-titration of medication in primary care: the TASMINH2 trial qualitative study of health professionals' experiences

BACKGROUND

Self-monitoring with self-titration of antihypertensives leads to reduced blood pressure. Patients are keen on self-monitoring but little is known about healthcare professional views.

AIM

To explore health professionals' views and experiences of patient self-management, particularly with respect to future implementation into routine care.

DESIGN AND SETTING

Qualitative study embedded within a randomised controlled trial of healthcare professionals participating in the TASMINH2 trial of patient self-monitoring with self-titration of antihypertensives from 24 West Midlands general practices.

METHOD

Taped and transcribed semi-structured interviews with 13 GPs, two practice nurses and one healthcare assistant. Constant comparative method of analysis.

RESULTS

Primary care professionals were positive about self-monitoring, but procedures for ensuring patients measured blood pressure correctly were haphazard. GPs interpreted home readings variably, with many not making adjustment for lower home blood pressure. Interviewees were satisfied with patient training and arrangements for blood pressure monitoring and self-titration of medication during the trial, but less sure about future implementation into routine care. There was evidence of a need for training of both patients and professionals for successful integration of self-management.

CONCLUSION

Health professionals wanted more patient involvement in hypertension care but needed a framework to work within. Consideration of how to train patients to measure blood pressure and how home readings become part of their care is required before self-monitoring and self-titration can be implemented widely. As home monitoring becomes more widespread, the development of patient self-management, including self-titration of medication, should follow but this may take time to achieve.

Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned

BACKGROUND

Prior telemonitoring trials of blood pressure and blood glucose have shown improvements in blood pressure and glycemic targets. However, implementation of telemonitoring in primary care practices may not yield the same results as research trials with extra resources and rigid protocols. In this study we examined the process of implementing home telemonitoring of blood glucose and blood pressure for patients with diabetes in six primary care practices.

MATERIALS AND METHODS

Grounded theory qualitative analysis was conducted in parallel with a randomized controlled effectiveness trial of home telemonitoring. Data included semistructured interviews with 6 nurse care coordinators and 12 physicians in six participating practices and field notes from exit interviews with 93 of 108 randomized patients.

RESULTS

The three stakeholder groups (patients, nurse care coordinators, and physicians) exhibited some shared themes and some unique to the particular stakeholder group. Major themes were that practices should (1) understand the capabilities and limitations of the technology and the willingness of patient and physician stakeholders to use it, (2) understand the workflow, flow of information, and human factors needed to optimize use of the technology, (3) engage and prepare the physicians, and (4) involve the patient in the process. Although there was enthusiasm for a patient-centered medical home model that included between-visit telemonitoring, there was concern about the support and resources needed to provide this service to patients.

CONCLUSIONS

As with many technology interventions, careful consideration of workflow and information flow will help enable effective implementations.

Patients' preference for ambulatory versus home blood pressure monitoring

Patient's preference might influence compliance with antihypertensive treatment and thereby long-term blood pressure (BP) control. This study compared patients' preference in using ambulatory (ABPM) versus home BP monitoring (HBPM). Subjects referred for hypertension were evaluated with 24-h ABPM and 7-day HBPM. Participants filled a questionnaire including demographics and Likert scale questions regarding their acceptance, preference, disturbance, activity restriction and feasibility of using ABPM and HBPM. A total of 119 patients were invited and 104 (87%) were included (mean age 51±11 years, 58% men, 38% time to work >8 h). A total of 82% reported a positive overall opinion for HBPM versus 63% for ABPM (P<0.05). 62% considered ABPM as more reliable than HBPM but 60% would choose HBPM for their next BP evaluation (P<0.05 for both comparisons). Moderate to severe discomfort from ABPM was reported by 55% and severe restriction of their daily activities by 30% compared with 13% and 7%, respectively, from HBPM (P<0.001 for both comparisons). The overall score for HBPM and ABPM (range 4-25; higher score indicating worse performance) was 6.6±2.5 and 10±4.0 (mean difference 4.4±4.6, P<0.001), respectively. In binary logistic regression models, neither previous experience with BP monitoring nor demographic characteristics appeared to influence patients' preference. These data suggest that HBPM is superior to ABPM in terms of overall acceptance and preference by hypertensive patients. Patients' preference deserves further research and should be taken into account in decision making in clinical practice.

Home blood pressure monitoring in hypertensive stroke patients: a prospective cohort study following a randomized controlled trial

BACKGROUND

We found little data on long-term home blood pressure monitoring in stroke patients.

OBJECTIVES

After completing a 12-month trial of home monitoring in hypertensive stroke patients, we investigated the following: 1. The proportion of 118 control patients offered a monitor at the end of the trial without nurse support who used it at least monthly after 6 months. 2. The proportion of 119 intervention patients continuing to use their monitor monthly after 18 months. 3. Possible predictors of monitoring weekly in the first month after receiving a monitor: age, gender, ethnicity, cognition, anxiety, disability, ability to monitor blood pressure unaided and smoking.

METHODS

Participants (mean age 71, 34% with disability and 21% from ethnic minorities) were surveyed 1 and/or 6 months after the trial ended by postal and/or telephone questionnaire.

RESULTS

Of 237 potential participants, 53 (22%) declined, 16 (6%) were lost and 9 (4%) died during follow-up. Overall, reported monthly use of the monitor without nurse support was 47% [54/114, 95% confidence interval (CI) 38.2-56.5] at 6 months and 50% (57/114, 95% CI 40.8-59.2) at 18 months. Participants who monitored weekly after 1 month were more likely than the remainder to have no disability [Rankin score ≤ 1; relative risk (RR) 1.2; 95% CI 1.0-1.5] and low anxiety levels (FEAR score = 0; RR 1.5; 95% CI 1.1-2.0).

CONCLUSION

Around half of hypertensive stroke patients offered a blood pressure monitor but no support continued to use it after 6 and 18 months. Monitoring in the first month was common in those who were not anxious or disabled.

Interpreting and acting upon home blood pressure readings: a qualitative study

Background

Recent guidelines recognize the importance of home blood pressure monitoring (HBPM) as an adjunct to clinical measurements. We explored how people who have purchased and use a home blood pressure (BP) monitor make sense of, and act upon, readings and how they communicate with their doctor about the practice of home monitoring.

Methods

A qualitative study was designed and participants were purposively recruited from several areas in England, UK. Semi-structured in-depth interviews were conducted with 18 users of home BP monitors. The transcribed data were thematically analysed.

Results

Interpretation of home BP readings is complex, and is often characterised by uncertainty. People seek to assess value normality using ‘rules of thumb’, and often aim to identify the potential causes of the readings. This is done by drawing on lay models of BP function and by contextualising the readings to personal circumstances. Based on the perceived causes of the problematic readings, actions are initiated, mostly relating to changes in daily routines. Contacting the doctor was more likely when the problematic readings persisted and could not be easily explained, or when participants did not succeed in regulating their BP through their other interventions. Most users had notified their doctor of the practice of home monitoring, but medical involvement varied, with some participants reporting disinterest or reservations by doctors.

Conclusions

Involvement from doctors can help people overcome difficulties and resolve uncertainties around the interpretation of home readings, and ensure that the rules of thumb are appropriate. Home monitoring can be used to strengthen the patient-clinician relationship.

Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study

OBJECTIVES

To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of remote blood pressure (BP) telemonitoring supported by primary care. To identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice.

DESIGN

Qualitative study adopting a qualitative descriptive approach.

PARTICIPANTS

25 patients, 11 nurses and 9 doctors who were participating in an RCT of BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought.

SETTING

6 primary care practices in Scotland.

METHOD

Data were collected via taped semistructured interviews. Initial thematic analysis was inductive. Multiple strategies were employed to ensure that the analysis was credible and trustworthy.

RESULTS

Prior to the trial, both patients and professionals were reluctant to increase the medication based on single BP measurements taken in the surgery. BP measurements based on multiple electronic readings were perceived as more accurate as a basis for action. Patients using telemonitoring became more engaged in the clinical management of their condition. Professionals reported that telemonitoring challenged existing roles and work practices and increased workload. Lack of integration of telemonitoring data with the electronic health record was perceived as a drawback.

CONCLUSIONS

BP telemonitoring in a usual care setting can provide a trusted basis for medication management and improved BP control. It increases patients' engagement in the management of their condition, but supporting telemetry and greater patient engagement can increase professional workloads and demand changes in service organisation. Successful service design in practice would have to take account of how additional roles and responsibilities could be realigned with existing work and data management practices. The embedded qualitative study was included in the protocol for the HITS trial registered with ISRCTN no. 72614272.

Development of a novel tool for engaging children and parents in asthma self-management

This paper describes the development and evaluation of an innovative application designed to engage children and their parents in weekly asthma self-monitoring and self-management to prompt an early response to deteriorations in chronic asthma control, and to provide their physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The evaluation included 2 iterative usability testing cycles with 6 children with asthma and 2 parents of children with asthma to assess user performance and satisfaction with the application. Several usability problems were identified and changes were made to ensure acceptability of the application and relevance of the content. This novel application is unique compared to existing asthma tools and may shift asthma care from the current reactive, acute care model to a preventive, proactive patient-centered approach where treatment decisions are tailored to patients' individual patterns of chronic asthma control to prevent acute exacerbations.

Using simple telehealth in primary care to reduce blood pressure: a service evaluation

OBJECTIVES

This service evaluation examines how efficiently an innovative, simple and interactive blood pressure (BP) management intervention improves BP control in general practice.

DESIGN

Prospective service evaluation.

SETTING

Ten volunteer general practitioner (GP) practices in Stoke on Trent, UK.

PARTICIPANTS

Practice staff identified 124 intervention patients and invited them to participate based on two inclusion criteria: (1) patient has chronic kidney disease (CKD) stages 3 or 4 with BP persistently >130/85 mm Hg or (2) patient is >50 years-old (without CKD stages 3-5) with BP persistently >140/90 mm Hg despite prescribed antihypertensive medication. Three selected hypertensive control patients per intervention patient underwent usual clinical care (n=364).

INTERVENTIONS

Intervention patients used 'Florence', a simple, interactive mobile phone texting service with BP management intervention for 3 months, or for less time if their BP became controlled. Patients measured their BP, text their readings to Florence, received an immediate automatic response and had results reviewed by their GP/practice nurse at least weekly.

MAIN OUTCOME MEASURES

Baseline data including recent BP readings and medications were collected; similar information was obtained for 6 months for both control and intervention patients. Average BP readings and medication usage were determined.

RESULTS

At final data collection, five intervention patients had not yet completed the full programme. Control and intervention patients were well matched except that intervention patients had significantly greater baseline BP. Greatest BP reductions were among hypertensive intervention patients without CKD stages 3-5. Intervention patients had significantly more BP readings and more changes in medication over the 3-month data collection period.

CONCLUSIONS

Simple telehealth is acceptable and effective in reducing patients' BP. In future, poorly controlled patients could be targeted to maximise BP reductions or broader use could improve diagnostic accuracy and accessibility for patients who struggle to regularly attend their GP surgery.

A cross-sectional survey and service evaluation of simple telehealth in primary care: what do patients think?

OBJECTIVE

To determine the patient experience of using a simple telehealth strategy to manage hypertension in adults.

DESIGN

As part of a pragmatic service evaluation, the acceptability of, satisfaction with and ease of use of a simple telehealth strategy was determined via text, cross-sectional questionnaire survey administered by telephone, case studies, discussion groups and informal feedback from practices. This simple telehealth approach required patients to take home blood pressure (BP) readings and text them to a secure server ('Florence') for immediate automatic analysis and individual healthcare professional review.

PARTICIPANTS

124 intervention patients who used the Florence system.

SETTING

10 volunteer general practitioner's (GP) practices in Stoke on Trent, UK, with poor health and high levels of material deprivation took part.

RESULTS

Patient satisfaction was high. In particular, patients found the system easy to use, were very satisfied about the feedback from their GP regarding their BP readings, found the advice sent via Florence useful and preferred to send BP readings using Florence rather than having to go to the practice monthly to get BP checked. Overall satisfaction with the system was 4.81/5.00 at week 13 of the programme. Other advantages of being enrolled with Florence were improved education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur at a time that suited the patient rather than their practice.

CONCLUSIONS

This simple telehealth strategy for managing hypertension in the community was met with high levels of patient satisfaction and feelings of control and support. This management approach should thus be considered for widespread implementation for clinical management of hypertension and other long-term conditions involving monitoring of patients' bodily measurements and symptoms as a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.