S Greenfield

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

BACKGROUNDnSelf-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.nnnAIMnTo explore health professionals views and experiences of patient self-management, particularly with respect to future implementation into routine care.nnnDESIGN AND SETTINGnQualitative 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.nnnMETHODnTaped and transcribed semi-structured interviews with 13 GPs, two practice nurses and one healthcare assistant. Constant comparative method of analysis.nnnRESULTSnPrimary 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.nnnCONCLUSIONnHealth 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.

Performance and persistence of a blood pressure self-management intervention: telemonitoring and self-management in hypertension (TASMINH2) trial

This study aimed to evaluate, in detail, the implementation of the self-management intervention used in the TASMINH2 trial. The intervention, comprising self-monitoring for the first week of each month and an individualised treatment self-titration schedule, was developed from a previous trial of self-management. Two hundred and sixty-three patients with poorly controlled but treated hypertension were randomised to receive this intervention and underwent training over two or three sessions. Participants were followed up for 12 months during which time process data were collected regarding the persistence and fidelity of actual behaviour compared with intervention recommendations. Two hundred and forty-one (92%) patients completed training of whom 188 (72%) self-managed their BP and completed at least 90% of expected self-monitoring measurements for the full year of the study. Overall, 268/483 (55%) of recommended medication changes were implemented. Only 25 (13%) patients had controlled BP throughout the year and so were not recommended any medication changes. Adherence to the protocol reduced over time as the number of potential changes increased. Of those self-managing throughout, 131 (70%) made at least one medication change, with 77 (41%) implementing all their recommended changes. In conclusion, self-management of hypertension was possible in practice with most participants making at least one medication change. Although adherence to the intervention reduced over time, implementation of treatment recommendations appeared better than equivalent trials using physician titration. Future self-management interventions should aim to better support patients’ decision making, perhaps through enhanced use of technology.

Interarm Difference in Systolic Blood Pressure in Different Ethnic Groups and Relationship to the "White Coat Effect": A Cross-Sectional Study

Abstract BACKGROUND Interarm differences (IADs) ≥10 mm Hg in systolic blood pressure (BP) are associated with greater incidence of cardiovascular disease. The effect of ethnicity and the white coat effect (WCE) on significant systolic IADs (ssIADs) are not well understood. METHODS Differences in BP by ethnicity for different methods of BP measurement were examined in 770 people (300 White British, 241 South Asian, 229 African-Caribbean). Repeated clinic measurements were obtained simultaneously in the right and left arm using 2 BPTru monitors and comparisons made between the first reading, mean of second and third and mean of second to sixth readings for patients with, and without known hypertension. All patients had ambulatory BP monitoring (ABPM). WCE was defined as systolic clinic BP ≥10 mm Hg higher than daytime ABPM. RESULTS No significant differences were seen in the prevalence of ssIAD between ethnicities whichever combinations of BP measurement were used and regardless of hypertensive status. ssIADs fell between the 1st measurement (161, 22%), 2nd/3rd (113, 16%), and 2nd–6th (78, 11%) (1st vs. 2nd/3rd and 2nd–6th, P < 0.001). Hypertensives with a WCE were more likely to have ssIADs on 1st, (odds ratio [OR] 1.73 (95% confidence interval 1.04–2.86); 2nd/3rd, (OR 3.05 (1.68–5.53); and 2nd–6th measurements, (OR 2.58 (1.22–5.44). Nonhypertensive participants with a WCE were more likely to have a ssIAD on their first measurement (OR 3.82 (1.77 to −8.25) only. CONCLUSIONS ssIAD prevalence does not vary with ethnicity regardless of hypertensive status but is affected by the number of readings, suggesting the influence of WCE. Multiple readings should be used to confirm ssIADs.

RANDOMISED CONTROLLED TRIAL OF TELEMONITORING AND SELF MANAGEMENT IN THE CONTROL OF HYPERTENSION: TELEMONITORING AND SELF MANAGEMENT IN HYPERTENSION (TASMINH2): ECONOMIC ANALYSIS

Introduction: Self management of hypertension including self monitoring and self titration of antihypertensives is a novel intervention aiming to improve blood pressure control. Very little evidence exists regarding the cost effectiveness of self monitoring of blood pressure in general and self management in particular. This study aimed to evaluate whether self management of hypertension was cost effective. Methods: The telemonitoring and self-management in hypertension trial (TASMINH2) was a primary care based randomised controlled trial comparing home monitoring of blood pressure with telemonitoring and self titration of anti hypertensive medication to usual care in people with poorly controlled hypertension. An embedded economic evaluation ran parallel to the main trial. It took a base case of costs from a UK Health Service perspective and analysed both cost per reduction in unit blood pressure and costs per QALY. Sensitivity analyses examined cost effectiveness from a societal point of view as well as evaluating the effect of missing values, different assumptions and bias due to high cost patients. Results: Self management of hypertension with telemonitoring was cost effective with an ICER for blood pressure reduction of £19/mm Hg (&U20AC;15/mm Hg) – implying that using self management with telemonitoring and titration of antihypertensive medication to reduce systolic BP by 1 mm Hg costs on average £19 (&U20AC;15). In terms of quality of life, compared to usual care, using self management with telemonitoring and titration of antihypertensive medication was associated with a gain of 0.0179 QALYs translating into a mean cost of just over £5,600 (&U20AC;4,462) per QALY gained. There was an 85% chance of this being cost effective given a willingness to pay of £20,000 (&U20AC;15,936) per QALY gained. This result was robust to sensitivity analysis around the assumptions made including from a societal perspective and removing high cost patients. Conclusions: Self monitoring with self titration of antihypertensives and telemonitoring of blood pressure measurements is cost effective as well as leading to reduced blood pressure. Figure 1. No caption available.

Do Patients Actually Do What We Ask? Patient Fidelity and Persistence to the TASMIN-SR Blood Pressure Self-Management Intervention

Objective: Self-management of hypertension can reduce and control blood pressure (BP) compared with clinic monitoring. However, self-management relies on patients following an algorithm, which may be variably adhered to. This study reports fidelity of high-risk patients to the self-management algorithm set by the TASMIN-SR trial. Methods: Patients with hypertension, above target clinic BP and one or more of stroke, diabetes, coronary heart disease or chronic kidney disease, were invited to self-monitor following an individualized self-titration algorithm. Home BP readings and medication change details were submitted monthly for 12 months. Readings downloaded from patients’ electronic monitors were compared with written submissions, and protocol fidelity was assessed. Results: Two hundred and seventy-six patients were randomized to self-management and 225 (82%) completed the required training sessions. Of these, 166 (74%) completed self-management. A total of 11385 (89.6%) submitted readings were accurate compared with corresponding downloaded monitor readings. Mean error rate was 5.2% per patient, which increased with age but not comorbidities. Patients made 475 of 683 (69.5%) algorithm-recommended medication changes, equating to nearly three medication changes per patient. Mean SBP for patients who completed training and made all recommended changes dropped from 141u200ammHg (95% CI 138.26–144.46) to 121u200ammHg (95% CI 118.30–124.17u200ammHg) compared with 129u200ammHg (95% CI 125.27–136.73u200ammHg) for patients who made none. Conclusion: Most patients randomized to self-management completed training; however, 36% of these had dropped out by 12 months. Self-monitoring was largely undertaken properly and accurately recorded. Fidelity with self-management was associated with lower achieved SBP. Successful implementation of self-management into daily practice requires careful training and should be accompanied by monitoring of fidelity.

SELF-MONITORING IS NOT JUST FOR A STUDY, SELF-MONITORING IS FOR LIFE: ANALYSIS OF PATIENT LIKELIHOOD TO CONTINUE SELF-MONITORING FOLLOWING A HYPERTENSION SELF-MANAGEMENT STUDY

Objective: Self-management in the TASMIN-SR trial successfully reduced and controlled blood pressure (BP) compared to clinic monitoring over 12 months. This study aimed to assess how self-management affected patient preference towards future management of BP. Design and Methods: Patients with hypertension, above target clinic BP and one-or-more of stroke, diabetes, coronary heart disease or chronic kidney disease, were randomised to a self-management intervention (self-monitoring with self-titration) or usual clinic BP management. At baseline and 12 months patients were asked to rank methods of BP measurement and at 12 month follow-up were asked: “Are you planning to continue/start to self-monitor your BP after the study? Why?” Responses were coded thematically by trial arm and according to whether patients planned to continue self-monitoring. Themes were identified from the resulting codes. Scientific Data: Quantitative data regarding ranked preference for self-monitoring plus qualitative data from free text responses. Results and Conclusions: At baseline, self-monitoring was ranked as the preferred method of BP measurement by both intervention and usual care groups, but only intervention patients continued to rank self-monitoring as their preferred choice at 12 months, usual care patients preferring health professional measurement. Self-management patients were three times more likely to want to continue self-monitoring following the trial (OR 3.9 (95% CI 2.62 – 5.87; pu200a<u200a0.0001). Overarching themes summarising reasons expressed by patients who wanted to continue self-monitoring included: “Positive effects of self-monitoring”; “Concern about high BP and the overall effect on health”; “Self-monitoring already part of the patients’ routine/lifestyle”; and “Inspired by the study”. For patients who did not want to continue/start self-monitoring, comments fell into five overarching themes: “Anxiety or concerns about self-monitoring”; “BP measured at the surgery”; “Feels BP is controlled”; “Not interested in self-monitoring”; “Never considered self-monitoring or had the opportunity to do it”. Self-management provides additional features over-and-above self-monitoring including: a medication plan in advance, training patients to understand and interpret BP targets, when to increase medication and links with a health professional. These features appear to keep patients motivated to use self-monitoring as a way of managing their BP long-term and should be considered when starting patients to self-monitor.

[OP.6C.03] DO PATIENTS ACTUALLY DO WHAT WE ASK? PATIENT PERFORMANCE AND PERSISTENCE IN THE TASMIN-SR BLOOD PRESSURE SELF-MANAGEMENT TRIAL.

Objective: This study assessed how accurately patients reported their blood pressure (BP) and titrated their antihypertensive medications according to the protocol set out by the TASMIN-SR trial. Design and method: The TASMIN-SR self-management intervention involved patients with above target clinic BP and stroke, diabetes, CHD or CKD, self-monitoring their BP for the first week of every month followed by implementation of an individualised self-titration schedule. 276 patients were randomised to the intervention and 226 (80%) successfully completed 2 or 3 training sessions. Patients were followed up for 12 months and during this time submitted written records of home BP readings, and details of any medication changes made, on a monthly basis. BP readings were downloaded from each patients monitor at 6 and 12 month follow-up clinics and these were compared to those submitted along with an assessment of protocol fidelity. Results: Of 226 patients who were successfully trained, 174 (77%) completed self-management. 10,038/11,684 (85.9% (95% CI, 85.3 – 86.5) of all readings submitted were reported accurately, when compared to the readings downloaded from the monitor, and 164 patients (95%) reported their readings with at least 80% accuracy. There was an average error rate of 6.7% per patient and the only characteristic affecting this was age, under 65 years compared to those above (4.5%, (95% CI 3.2 – 5.6) vs 7.7%, (95% CI 6.4 – 9.0), pu200a<u200a0.005). In terms of protocol fidelity, 1811 (98%) of submitted records were sufficient to make a decision on whether a medication change was necessary according to the algorithm. Patients made 58.6% (370/631) of suggested medication changes, equating to 2.1/3.6 changes per patient. Baseline mean systolic BP for patients who completed the training was 143.1u200ammHg. Mean 12 month systolic BP was 120.9u200ammHg for patients who made all recommended changes, and 131.2u200ammHg for patients who did not make any of the recommended changes, resulting in an overall mean SBP of 126.1u200ammHg. Conclusions: In conclusion the majority of higher risk patients with hypertension successfully monitored and reported their home BP readings and persisted with the protocol over the study resulting in significantly lower BP.

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

BACKGROUNDnSelf-management of hypertension, comprising self-monitoring of blood pressure with self-titration of medication, improves blood pressure control, but little is known regarding the views of patients undertaking it.nnnAIMnTo explore patients views of self-monitoring blood pressure and self-titration of antihypertensive medication.nnnDESIGN AND SETTINGnQualitative study embedded within the randomised controlled trial TASMINH2 (Telemonitoirng and Self Management in the Control of Hypertension) trial of patient self-management of hypertension from 24 general practices in the West Midlands.nnnMETHODnTaped and transcribed semi-structured interviews with 23 intervention patients were used. Six family members were also interviewed. Analysis was by a constant comparative method.nnnRESULTSnPatients were confident about self-monitoring and many felt their multiple home readings were more valid than single office readings taken by their GP. Although many patients self-titrated medication when required, others lacked the confidence to increase medication without reconsulting with their GP. Patients were more comfortable with titrating medication if their blood pressure readings were substantially above target, but were reluctant to implement such a change if readings were borderline. Many planned to continue self-monitoring after the study finished and report home readings to their GP, but few wished to continue with a self-management plan.nnnCONCLUSIONnParticipants valued the additional information and many felt confident in both self-monitoring blood pressure and self-titrating medication. The reluctance to change medication for borderline readings suggests behaviour similar to the clinical inertia seen for physicians in analogous circumstances. Additional support for those lacking in confidence to implement prearranged medication changes may allow more patients to undertake self-management.

Telemonitoring and self-management in the control of hypertension (TASMINH2): A randomised controlled trial

BACKGROUNDnControl of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care.nnnMETHODSnThis randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681.nnnFINDINGSn527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022).nnnINTERPRETATIONnSelf-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care.nnnFUNDINGnDepartment of Health Policy Research Programme, National Coordinating Centre for Research Capacity Development, and Midlands Research Practices Consortium.