Telemonitoring at scale for hypertension in primary care: An implementation study

English version

Autoři: Vicky Hammersley ^aff001; Richard Parker ^aff001; Mary Paterson ^aff001; Janet Hanley ^aff002; Hilary Pinnock ^aff001; Paul Padfield ^aff001; Andrew Stoddart ^aff001; Hyeon Gyeong Park ^aff001; Aziz Sheikh ^aff001; Brian McKinstry ^aff001
Působiště autorů: Usher Institute, University of Edinburgh, Edinburgh, United Kingdom ^aff001; School of Health and Social Care. Edinburgh Napier University, Edinburgh, United Kingdom ^aff002
Vyšlo v časopise: Telemonitoring at scale for hypertension in primary care: An implementation study. PLoS Med 17(6): e32767. doi:10.1371/journal.pmed.1003124
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003124

Souhrn

Background

While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care.

Methods and findings

This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants’ views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56–70, range 22–89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6–10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy.

Conclusions

Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative.

Klíčová slova:

Blood pressure – Comparators – Data management – Hypertension – Patients – Primary care – Primary hypertension – Urban areas

Zdroje

1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224–60. doi: 10.1016/S0140-6736(12)61766-8 23245609

2. World Health Organization. A global brief on hypertension—silent killer, global public health crisis. Geneva: World Health Organization; 2013 [cited 2020 May 29]. https://www.who.int/cardiovascular_diseases/publications/global_brief_hypertension/en/.

3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487–97. doi: 10.1056/NEJMra050100 16079372

4. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension. 2006;47(3):345–51. doi: 10.1161/01.HYP.0000200702.76436.4b 16432045

5. Hanley J, Ure J, Pagliari C, Sheikh A, McKinstry B. Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study. BMJ open. 2013;3(5):e002671. doi: 10.1136/bmjopen-2013-002671 23793649

6. Public Health Scotland. GP consulations/Practice Team Information (PTI) statistics. Edinburgh: Public Health Scotland; 2020 [cited 2020 May 29]. https://www.isdscotland.org/Health-Topics/General-Practice/GP-Consultations/.

7. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142–61. doi: 10.1161/01.HYP.0000150859.47929.8e 15611362

8. NHS Digital. General and personal medical services, England. March 2018: provisional experimental statistics. Leeds: NHS Digital; 2018 [cited 2020 May 29]. https://files.digital.nhs.uk/63/5DF8AA/General%20and%20Personal%20Medical%20Services%20-%20Provisional%20March%202018.pdf.

9. NHS Digital. Appointments in general practice, October 2018 [PAS]. Leeds: NHS Digital; 2018 [cited 2019 May 25]. https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/oct-2018.

10. National Health Service. The NHS long term plan. London: National Health Service; 2019 [cited 2020 May 29]. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.

11. Scottish Government. Scotland’s digital health and care strategy: enabling, connecting and empowering. Edinburgh: Scottish Government; 2018 [cited 2020 May 29]. https://www.gov.scot/publications/scotlands-digital-health-care-strategy-enabling-connecting-empowering/.

12. Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57(1):29–38. doi: 10.1161/HYPERTENSIONAHA.110.160911 21115879

13. Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. PLoS Med. 2017;14(9):e1002389. doi: 10.1371/journal.pmed.1002389 28926573

14. Kaambwa B, Bryan S, Jowett S, Mant J, Bray EP, Hobbs FD, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis. Eur J Prev Cardiol. 2014;21(12):1517–30. doi: 10.1177/2047487313501886 23990660

15. Monahan M, Jowett S, Nickless A, Franssen M, Grant S, Greenfield S, et al. Cost-effectiveness of telemonitoring and self-monitoring of blood pressure for antihypertensive titration in primary care (TASMINH4). Hypertension. 2019;73(6):1231–9. doi: 10.1161/HYPERTENSIONAHA.118.12415 31067190

16. McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, et al. Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial. BMJ 2013;346:f3030. doi: 10.1136/bmj.f3030 23709583

17. Shahaj O, Denneny D, Schwappach A, Pearce G, Epiphaniou E, Parke HL, et al. Supporting self-management for people with hypertension: a meta-review of quantitative and qualitative systematic reviews. J Hypertens. 2019;37(2):264–79. doi: 10.1097/HJH.0000000000001867 30020240

18. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018;24(1):4–12. doi: 10.1177/1357633X16674087 29320966

19. Taylor J, Coates E, Brewster L, Mountain G, Wessels B, Hawley MS. Examining the use of telehealth in community nursing: identifying the factors affecting frontline staff acceptance and telehealth adoption. J Adv Nurs. 2015;71(2):326–37. doi: 10.1111/jan.12480 25069605

20. Davidson E, Simpson CR, Demiris G, Sheikh A, McKinstry B. Integrating telehealth care-generated data with the family practice electronic medical record: qualitative exploration of the views of primary care staff. Interact J Med Res. 2013;2(2):e29. doi: 10.2196/ijmr.2820 24280631

21. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795. doi: 10.1136/bmj.i6795 28264797

22. Florence. Manchester: Florence; 2020 [cited 2020 May 29]. http://www.getflorence.co.uk.

23. Paterson M, McAulay A, McKinstry B. Integrating third-party telehealth records with the general practice electronic medical record system: a solution. J Innov Health Inform. 2017;24(4):915. doi: 10.14236/jhi.v24i4.915 29334351

24. Docman. Castleford (UK): Docman; 2020 [cited 2020 May 28]. http://www.docman.com/.

25. Scottish Government. Technology enabled care. Edinburgh: Scottish Government; 2014 [cited 2020 Jun 1]. https://news.gov.scot/news/technology-enabled-care.

26. Hanley J, Pinnock H, Paterson M, McKinstry B. Implementing telemonitoring in primary care: learning from a large qualitative dataset gathered during a series of studies. BMC Fam Pract. 2018;19(1):118. doi: 10.1186/s12875-018-0814-6 30021535

27. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi: 10.1186/1748-5908-6-42 21513547

28. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629. doi: 10.1111/j.0887-378X.2004.00325.x 15595944

29. Miech EJ, Rattray NA, Flanagan ME, Damschroder L, Schmid AA, Damush TM. Inside help: an integrative review of champions in healthcare-related implementation. SAGE Open Med. 2018;6 : 2050312118773261. doi: 10.1177/2050312118773261 29796266

30. Scottish Government. The Scottish Index of Multiple Deprivation. Edinburgh: Scottish Government; 2016 [cited 2020 May 29]. https://www2.gov.scot/Topics/Statistics/SIMD.

31. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Clinical guideline [CG127]. London: National Institute for Health and Care Excellence; 2011.

32. WHO Collaborating Centre for Drug Statistics Methodology. International language for drug utilization research—ATC/DDD. Olso: WHO Collaborating Centre for Drug Statistics Methodology; 2020 [cited 2020 May 29]. https://www.whocc.no/.

33. Hanley J, Fairbrother P, Krishan A, McCloughan L, Padfield P, Paterson M, et al. Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA). Trials. 2015;16 : 117. doi: 10.1186/s13063-015-0628-y 25873155

34. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet. 2010;376(9736):163–72. doi: 10.1016/S0140-6736(10)60964-6 20619448

35. McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson J, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391(10124):949–59. doi: 10.1016/S0140-6736(18)30309-X 29499873

36. Wild SH, Hanley J, Lewis SC, McKnight JA, McCloughan LB, Padfield PL, et al. Supported telemonitoring and glycemic control in people with type 2 diabetes: the Telescot Diabetes Pragmatic Multicenter Randomized Controlled Trial. PLoS Med. 2016;13(7):e1002098. doi: 10.1371/journal.pmed.1002098 27458809

37. Parker RA, Paterson M, Padfield P, Pinnock H, Hanley J, Hammersley VS, et al. Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland. BMJ Open. 2018;8(1):e019431. doi: 10.1136/bmjopen-2017-019431 29391369

38. Greiver M, Kalia S, Voruganti T, Aliarzadeh B, Moineddin R, Hinton W, et al. Trends in end digit preference for blood pressure and associations with cardiovascular outcomes in Canadian and UK primary care: a retrospective observational study. BMJ Open. 2019;9(1):e024970. doi: 10.1136/bmjopen-2018-024970 30679298

39. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. doi: 10.1136/bmj.b1665 19454737

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