department of primary health care sciences
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DEPARTMENT OF PRIMARY HEALTH CARE SCIENCES
Telemonitoring and self-
management of hypertension
in primary care.
Prof Richard McManus Richard McManus has received BP monitoring equipment for
research studies from Omron and Lloyds Pharmacy
Overview
Introduction & rationale
The TASMINH2 Trial:
Telemonitoring and self-management
How does telemonitoring fit into
hypertension care?
Self monitoring in hypertension
First reported in 1930 at the Mayo Clinic:
A 25 year old “intelligent male patient” –
monitored 3x per day for three years
Variation in BP observed with
– diet
– seasons
– weekends (“diversions of a young man” !)
Self monitoring background
First Trials in 1970s
Initial work largely relied on manual anaeroid
sphygmomanometers
Not until advent of accurate automated
sphygmomanometers did consumer market take off
(2000s)
Self monitoring background
First Trials in 1970s
Initial work largely relied on manual anaeroid
sphygmomanometers
Not until advent of accurate automated
sphygmomanometers did consumer market take off
(2000s)
Now widespread use by people with hypertension:
– US 55% self monitor
– Italy 75% self monitor
– UK 30% self monitor (primary care)
Many patients do not tell their physicians
Self-monitoring – who’s using it?
Survey of 625 GPs in UK (2011)
– 90% had patients who self monitor
– Self-monitoring for diagnosis - 37%
– Self-monitoring for management - 83%
– Telemonitoring for BP not widely available
Self-monitoring effects
Bray et al. Annals of Medicine 2010
Overall self-monitoring
reduces
– SBP by 3.8 mmHg
– DBP by 1.5 mmHg
Co-intervention present vs not
5.3 mmHg
2.5 mmHg
Weighted Mean diff.-30 -15 0 15 30
Study % Weight
Weighted Mean diff.
(95% CI)
-10.10 (-20.61,0.41) Mehos (2000) 5.4
-9.30 (-11.80,-6.80) Green b (2008) 15.3
-4.40 (-10.52,1.72) Zillich (2005) 9.9
-2.00 (-16.33,12.33) Broege(2001) 3.4
-25.60 (-41.78,-9.42) Artinian (2001) 2.8
-8.50 (-14.16,-2.84) Rudd (2004) 10.5
-3.40 (-5.91,-0.89) Green a (2008) 15.2
-0.20 (-3.84,3.44) Parati (2009) 13.6
-5.00 (-10.45,0.45) Mulhauser (1993) 10.8
-0.90 (-4.98,3.18) Freidman (1996) 12.9
-5.29 (-8.26,-2.32) Overall (95% CI)
Weighted Mean diff.-30 -15 0 15 30
Study % Weight
Weighted Mean diff.
(95% CI)
-0.14 (-2.05,1.77) Baque (2005) 15.3
5.00 (-6.07,16.07) Bailey (1999) 2.5
0.50 (-3.65,4.65) Verberk (2007) 9.8
-18.00 (-27.13,-8.87) Binstock (1988) 3.5
-2.30 (-5.47,0.87) McManus (2005) 12.1
-4.60 (-9.01,-0.19) Marquez-Contreras (2006) 9.2
-2.60 (-7.26,2.06) Midanik (1991) 8.7
-3.30 (-6.77,0.17) Soghikan (1992) 11.3
-0.50 (-3.07,2.07) Vetter (2000) 13.6
-3.10 (-7.93,1.73) Halme (2005) 8.4
-7.50 (-14.28,-0.72) Carnaham (1975) 5.5
-2.52 (-4.43,-0.61) Overall (95% CI)
Telemonitoring – theoretical attractions
Feedback to GP – opportunity to intervene
Promotes Dr / patient partnership
Self monitoring more frequent but information
management issue
Automated feedback possible
Reduce carer burden
Better control than self monitoring alone?
Might self-management be an effective
co-intervention?
Most research in other fields:
arthritis, asthma, diabetes
Greatest effects where combined with
self-titration
Hypertension different to many other
conditions due to lack of symptoms but
clinical inertia common place
One study from Canada in hypertension
suggested self management effective but trial
was small and short lived.
TASMINH2 Research Questions
Does self management with telemonitoring and titration of antihypertensive medication by people with poorly controlled treated hypertension result in:
1. Better control of blood pressure?
2. Changes in reported adverse events or health behaviours or costs?
3. Is it achievable in routine practice and is it acceptable to patients?
The Trial
Eligibility
– Age 35-85
– Treated hypertension (no more than 2 BP meds)
– Baseline BP >140/90 mmHg
– Willing to self monitor and self titrate medication
Patients individually randomised to self-management vs usual care stratified by practice and minimised on sex, baseline SBP, DM status,
Practice GPs determine management
Intervention
Blood Pressure Targets:
– NICE (140/90 or 140/80 mmHg)
– minus 10/5 mmHg i.e. 130/85 mmHg or 130/75 mmHg
Patients agreed titration schedule with their GP after randomisation
Traffic Light system to adjust medication
Outcomes
Follow up at 6 & 12 months
Main outcome Systolic Blood Pressure
Secondary outcomes: Diastolic BP / costs /
anxiety / health behaviours/ patient
preferences / systems impact
Recruitment target 480 patients (240 x 2)
Sufficient to detect 5mmHg difference
between groups
Qualitative study - methods
Purposive selection of intervention patients for interview – Age, gender, deprivation, surgery, BP change, medication change(s)
Semi-structured interviews in patient‟s home
Topics covered: – Knowledge and understanding of BP
– Experience of the trial
– Preference for self management v usual care
Interviews audio-taped and transcribed
Analysis by constant comparative method
Results
Invited (n = 7637)
Declined Invitation
(n = 5987)
Assessed for eligibility (n = 1650)
Excluded (n = 1123) Not Eligible (n = 1044)
Declined to participate (n=79)
Control (n = 264) Received usual care
(n = 264)
Randomised (n = 527)
Analysed (n = 246) Incomplete cases excluded
(n = 18)
Did not attend follow up
(n=14)*
Discontinued usual care
(n = 0)
Intervention (n = 263) Received intervention
training (n = 241)
Did not attend follow up
(n=26)#
Discontinued intervention
(n = 53)
Analysed (n = 234) Incomplete cases excluded
(n = 29)
110% recruitment
91% follow up
80% completed
intervention
Results - medications
212 (80%) self managed for full 12 months
148 (70%) made at least one
medication change
At 12m intervention group prescribed
0.46 (0.34, 0.58) additional antiHT (p=0.001)
Main changes seen in thiazides and
calcium channel blockers
(60% on ACEI/ARB at baseline)
Results – cost effectiveness
Mean ICER of €22/mm Hg or €9500/QALY
-£200
-£100
£0
£100
£200
£300
£400
-0.02 -0.01 0 0.01 0.02 0.03 0.04 0.05 0.06
Difference in QALY gain
Co
st
dif
fere
nce
Results – Interviews (Monitoring)
Patients generally positive about self-monitoring
Surprised at difference between home and
surgery readings
Majority thought that monitoring for 1 week/month
was „about right‟, but some found it excessive
Most managed telemonitoring but failure in
approx 10%
Jones BJGP 2012
Results – Interviews (Medication)
Patients did not like having to take medication but
accepted they had to
All said they took their medication regularly
Patients more comfortable about making a
medication change if their BP readings were
substantially above target
Patients reluctant to implement a medication
change if only just raised and several chose not to
Bottom line
Self Management & telemonitoring results in
significantly lower blood pressure than usual care
which is sustained after 12 months
Increased medication likely to be main
mechanism
Cost effective under UK criteria
Impact of telemonitoring largely as safety net
Patients are willing to be more involved in
decisions on medication
Omboni Telemonitoring SR AJH 2011
12 studies
Mean reduction clinic BP with telemonitoring 5.6/2.8 mmHg (11 comparisons)
Less effect on ABP: 2.3/1.4 mmHg (3 comparisons)
Evidence that effects = due to better drug titration
Significant heterogeneity and evidence of reporting bias for negative studies
At least two more studies since have shown greater ABP reductions
Telemonitoring in hypertension
conclusions
Feedback to physician X not enough alone
Promotes Dr / patient partnership yes
Self monitoring more frequent but information
management issue / X needs integration
Automated feedback possible yes
Reduce carer burden / X not yet clear
Better control vs self monitoring alone? yes
Acknowledgements
Prof Jonathan Mant Dr Emma Bray Dr Miren Jones Amanda Davies Miriam Banting Roger Holder Billy Kaambwa Dr Sheila Greenfield Prof Paul Little Prof Stirling Bryan Prof Bryan Williams Prof Richard Hobbs
Acknowledgements
•This work was commissioned and funded by the Policy Research
Programme of the Department of Health,
•It received joint funding from the NIHR National Coordinating
Centre for Research Capacity Development and Midlands
Research Practices Consortium (MidReC).
•Service support costs were obtained from the Department of
Health in collaboration with MidReC.
•Views expressed are not necessarily those of the DoH
•The work would not have been possible without the collaboration
of both patients and practices whom we thank.
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