Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial

Abstract

Objective To determine if an intervention consisting of telemonitoring and supervision by usual primary care clinicians of home self measured blood pressure and optional patient decision support leads to clinically important reductions in daytime systolic and diastolic ambulatory blood pressure in patients with uncontrolled blood pressure.Design Multicentre randomised controlled trial.Setting 20 primary care practices in south east Scotland.Participants 401 people aged 29-95 years with uncontrolled blood pressure (mean daytime ambulatory measurement ≥135/85 mm Hg but ≤210/135 mm Hg).Intervention Self measurement and transmission of blood pressure readings to a secure website for review by the attending nurse or doctor and participant, with optional automated patient decision support by text or email for six months.Main outcome measures Blinded assessment of mean daytime systolic ambulatory blood pressure six months after randomisation.Results 200 participants were randomised to the intervention and 201 to usual care; primary outcome data were available for 90% of participants (182 and 177, respectively). The mean difference in daytime systolic ambulatory blood pressure adjusted for baseline and minimisation factors between intervention and usual care was 4.3 mm Hg (95% confidence interval 2.0 to 6.5; P=0.0002) and for daytime diastolic ambulatory blood pressure was 2.3 mm Hg (0.9 to 3.6; P=0.001), with higher values in the usual care group. The intervention was associated with a mean increase of one general practitioner (95% confidence interval 0.5 to 1.6; P=0.0002) and 0.6 (0.1 to 1.0; P=0.01) practice nurse consultations during the course of the study.Conclusions Supported self monitoring by telemonitoring is an effective method for achieving clinically important reductions in blood pressure in patients with uncontrolled hypertension in primary care settings. However, it was associated with increase in use of National Health Service resources. Further research is required to determine if the reduction in blood pressure is maintained in the longer term and if the intervention is cost effective.Trial registration Current Controlled Trials ISRCTN72614272.

Home Blood Pressure Monitoring and Hypertension Control

“…They found that telemonitoring of home BP readings led to greater sharing of data between patients and clinic and there was significant improvement in BP control compared to the self-reporting group. This is consistent with analysis of data from a multicenter randomized clinical control trial which showed that HBPM with telemonitoring of BP readings to a secure website for review by providers resulted in clinically important BP reduction among patients with uncontrolled hypertension, and tele-monitored measurements were perceived to be more accurate and improve reliability of shared data [40]. Other studies have also reported improved BP control using HBPM with telemonitoring when incorporated with a patient support system [41,42].…”

Why are doctors still measuring blood pressure?

“…Self-monitoring or even self-management with self-titration may become the preferred approach, given the potential for patient empowerment, enhanced adherence, and reduction in workload. 11,12 Given that around one-third of people with hypertension now self-monitor, such an approach is becoming more feasible although the inability to prescribe sphygmomanometers and the logistics of ensuring regular checks or recalibration of patients' own devices are issues which will need to be broached. [13][14][15] Regardless of this, it appears anachronistic to continue to pay GPs on the basis of a single blood pressure reading differentiated only by its proximity to the end of a 'pay for performance' financial year.…”

Expert panel consensus recommendations for home blood pressure monitoring in Asia: the Hope Asia Network

“…The percentage of patients with daytime BP normalisation was higher with home-based teletransmission (62%) compared with usual care (50%; P < 0.05). Another RCT that compared usual care with self-measurement and transmission of BP readings to a secure website for review by a nurse or doctor showed a mean difference in daytime ambulatory BP of 4.3/2.3 mm Hg that favoured telemonitoring [35]. However, the intervention was associated with increased use of healthcare resources.…”

“…Successful utilisation of ICT-based HBPM has been demonstrated [35,38], and is now available and set up in some medical centres to receive home BP transmission from registered patients. Immediate consultation can be made from those patients living in remote areas as well as poststroke or disabled patients without having to travel or being transferred to see their doctors.…”