Do patients actually do what we ask: patient fidelity and persistence to the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups blood pressure self-management intervention

A scoping review of hospital to home transitional care programmes for stroke survivors

AIM

The study was aimed at exploring the current scope of hospital to home transitional care programmes for stroke survivors.

BACKGROUND

Stroke survivors face the dilemma of solving many complex problems that leave survivors at high risk for readmission as they discharge from hospital. The transitional care model has proved to be effective in reducing readmissions and mortality, thereby improving health outcomes and enhancing patient satisfaction for survivors with stroke.

DESIGN

A scoping review.

METHODS

Conducted in accordance with the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.

DATA SOURCES

A comprehensive search was conducted in nine databases, including PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL, Medline, China Knowledge Net-work, Wanfang Database and China Biomedical Literature Database (SinoMed) from January 2014 to June 2023.

RESULTS

Title and abstract screening was performed on 10,171 articles resulting in 287 articles for full-text screening. Full-text screening yielded 49 articles that met inclusion criteria.

CONCLUSION

This study identified transitional care programmes for stroke survivors, as well as areas for future consideration to be explored in more depth to help improve transitional care for stroke survivors as they transition from hospital to home.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This study demonstrates that multidisciplinary collaboration becomes an integral part of the transitional care model for stroke survivors, which provides comprehensive and precise medical care to them.

REPORTING METHOD

PRISMA checklist for scoping reviews.

PATIENT AND PUBLIC CONTRIBUTION

No patient or public contribution was part of this study.

Prognostic value of home blood pressure monitoring in patients under antihypertensive treatment

The prognostic value of home blood pressure monitoring (HBPM) has been investigated in several studies in the general population, demonstrating its independent association with cardiovascular events. However, in the case of treated hypertensive subjects, evidence is controversial. Our purpose was to evaluate the prognostic value of HBPM in this population. Medicated hypertensive patients who performed a 4-day HBPM (Omron® HEM-705CP-II) between 2008 and 2015 were followed up for a median of 5.9 years, registering the occurrence of a composite primary outcome of fatal and non-fatal cardiovascular events. Cox regression models were used to analyze the prognostic value of HBPM, considering 4-day measurements, discarding the first day, and analyzing morning, afternoon and evening periods separately. We included 1582 patients in the analysis (33.4% men, median age 70.8 years, on an average of 2.1 antihypertensive drugs). During follow-up, 273 events occurred. HBPM was significantly associated with cardiovascular events in all five scenarios in the unadjusted models. When adjusting for office BP and other cardiovascular risk factors, the association remained marginally significant for the 4-day period, discarding first-day measurements HBPM (HR 1.04 [95% CI 1-1.1] and 1.04 [95% CI 1-1.1], respectively) and statistically significant for all separate periods of measurement: HR 1.32 (95% CI 1.01-1.72); 1.33 (95% CI 1.02-1.72); and 1.30 (95% CI 1.01-1.67), for morning, afternoon and evening, respectively. When analyzing separately fatal and non-fatal events, statistical significance was held for the former only. In conclusion, HBPM is an independent predictor of cardiovascular events in hypertensives under treatment.

Medication self-management interventions for persons with stroke: A scoping review

The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.

Virtual management of hypertension: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension

The coronavirus disease 2019 pandemic caused an unprecedented shift from in person care to delivering healthcare remotely. To limit infectious spread, patients and providers rapidly adopted distant evaluation with online or telephone-based diagnosis and management of hypertension. It is likely that virtual care of chronic diseases including hypertension will continue in some form into the future. The purpose of the International Society of Hypertension's (ISH) position paper is to provide practical guidance on the virtual management of hypertension to improve its diagnosis and blood pressure control based on the currently available evidence and international experts' opinion for nonpregnant adults. Virtual care represents the provision of healthcare services at a distance with communication conducted between healthcare providers, healthcare users and their circle of care. This statement provides consensus guidance on: selecting blood pressure monitoring devices, accurate home blood pressure assessments, delivering patient education virtually, health behavior modification, medication adjustment and long-term virtual monitoring. We further provide recommendations on modalities for the virtual assessment and management of hypertension across the spectrum of resource availability and patient ability.

White Coat Uncontrolled Hypertension in Teleconsultation: A New and Frequent Entity

Introduction

Cardiovascular risk seems not to be greater in patients with white coat uncontrolled hypertension (WUCH) than in patients with sustained blood pressure (BP) control. Therefore, its detection is important to avoid overtreatment. The COVID-19 pandemic determined a massive migration of hypertension consultations from the face-to-face modality to teleconsultations, and it is unknown whether WUCH exists in this context.

Aim

We aimed to evaluate the prevalence of WUCH through home BP monitoring (HBPM) in treated hypertensive patients evaluated by teleconsultation.

Methods

We included treated hypertensive patients that owned a digital BP monitor. During teleconsultation, patients were asked to perform two BP measurements and then a 7-day HBPM, using the same device. Patients were classified as having WUCH if BP was ≥ 140 and/or 90 mmHg in teleconsultation and < 135/85 mmHg on HBPM. The prevalence of WUCH and its 95% confidence interval were estimated. One-way ANOVA, the Chi-square test or Fisher’s exact test were used to compare the characteristics of these patients with the other groups.

Results

We included 341 patients (45.2% male, mean age 62.3 years). The prevalence of WUCH was 33.1% (95% CI 28.3–38.3%). Significant differences were found in terms of age, the number of antihypertensive drugs and the use of calcium channel blockers, all lower in the WUCH group as compared with the groups with elevated BP on HBPM.

Conclusion

WUCH exists in teleconsultation and is very frequent. It can be easily detected though HBPM, thus avoiding overmedication, and its potential impact on side-effects and health costs.

Optimizing a digital intervention for managing blood pressure in stroke patients using a diverse sample: Integrating the person-based approach and patient and public involvement

BACKGROUND

Having a stroke or transient ischaemic attack increases the risk of a subsequent one, especially with high blood pressure (BP). Home-based BP management can be effective at maintaining optimal BP.

OBJECTIVE

To describe the optimization of a digital intervention for stroke patients and the value of participant diversity, using the person-based approach (PBA) and integral patient and public involvement (PPI).

SETTING AND PARTICIPANTS

Stroke patients recruited from primary care and community settings, and health-care professionals in primary care, in England and Ireland.

DESIGN

Three linked qualitative studies conducted iteratively to develop an intervention using the PBA, with integral PPI.

INTERVENTION

The BP: Together intervention, adapted from existing BP self-monitoring interventions, is delivered via mobile phone or web interface to support self-monitoring of BP at home. It alerts patients and their clinicians when a change in antihypertensive medication is needed.

FINDINGS

Feedback from a diverse range of participants identified potential barriers, which were addressed to improve the intervention accessibility, feasibility and persuasiveness. Easy-to-read materials were developed to improve usability for patients with aphasia and lower literacy. The importance of including family members who support patient care was also highlighted. Feedback messages regarding medication change were refined to ensure usefulness for patients and clinicians.

DISCUSSION

Input from PPI alongside qualitative research with a diverse study sample allowed the creation of a simple and equitable BP management intervention for stroke patients.

PATIENT INVOLVEMENT

Two PPI co-investigators contributed to design, conduct of study, data interpretation and manuscript preparation; community PPI sessions informed early planning. Study participants were stroke patients and family members.

How Should We Measure and Deal with Office Blood Pressure in 2021?

Arterial hypertension is a major risk factor for cardiovascular disease worldwide. Office blood pressure measurements (OBPMs) are still recommended for diagnosis and follow-up by all major guidelines; however, the recommended procedures differ significantly. In analogy, major outcome studies usually apply OBPMs, again, with a variety of procedures. This variety of OBPM procedures complicates the comparability between studies and challenges daily clinical practice. In this narrative review, we compile the most recent recommendations for office blood pressure measurement together with the major limitations and strategies and how these could be overcome.

Impact of Self-Monitoring of Blood Pressure on Processes of Hypertension Care and Long-Term Blood Pressure Control

Background Self-monitoring of blood pressure (SMBP) improves blood pressure (BP) outcomes at 12-months, but information is lacking on how SMBP affects hypertension care processes and longer-term BP outcomes. Methods and Results We pooled individual participant data from 4 randomized clinical trials of SMBP in the United Kingdom (combined n=2590) with varying intensities of support. Multivariable random effects regression was used to estimate the probability of antihypertensive intensification at 12 months for usual care versus SMBP. Using these data, we simulated 5-year BP control rates using a validated mathematical model. Trial participants were mostly older adults (mean age 66.6 years, SD 9.5), male (53.9%), and predominantly white (95.6%); mean baseline BP was 151.8/85.0 mm Hg. Compared with usual care, the likelihood of antihypertensive intensification increased with both SMBP with feedback to patient or provider alone (odds ratio 1.8, 95% CI 1.2-2.6) and with telemonitoring or self-management (3.3, 2.5-4.2). Over 5 years, we estimated 33.4% BP control (<140/90 mm Hg) with usual care (95% uncertainty interval 27.7%-39.4%). One year of SMBP with feedback to patient or provider alone achieved 33.9% (28.3%-40.3%) BP control and SMBP with telemonitoring or self-management 39.0% (33.1%-45.2%) over 5 years. If SMBP interventions and associated BP control processes were extended to 5 years, BP control increased to 52.4% (45.4%-59.8 %) and 72.1% (66.5%-77.6%), respectively. Conclusions One year of SMBP plus telemonitoring or self-management increases the likelihood of antihypertensive intensification and could improve BP control rates at 5 years; continuing SMBP for 5 years could further improve BP control.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current "one-size-fits-all" approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.