Transcript Telemonitoring and self management in hypertension

TASMINH2:
Telemonitoring and Self
Management in
Hypertension
Dr Richard McManus
Clinical Senior Lecturer
Department of Primary Care and General Practice
University of Birmingham
Research Team
• Dr Richard McManus: (CI) GP
• Dr Jonathan Mant: Public Health / Stroke (Prevention)
Specialist
• Dr Emma Vince & Dr Miren Jones (RFs)
• Prof Richard Hobbs (Primary Care CVD)
• Mr Roger Holder (Statistics)
• Dr Sheila Greenfield (Sociology / Qualitative)
• Prof Paul Little (Primary Care Trials, BP monitoring)
• Prof Stirling Bryan (Health Economics)
• Prof Bryan Williams (Cardiology / Hypertension)
Why bother about
hypertension?
Hypertension is important
 Key risk factor for cardiovascular disease
 5mmHg reduction in systolic BP leads to reduction of stroke risk
by
15-20% and coronary heart disease risk by 5-10%
Hypertension is common
 30-40% of adults affected
 Second most common reason for an adult to attend their GP
Hypertension is poorly controlled in the community
 12% treated and 45% of treated controlled <140/90 mmHg
Why bother with
hypertension?
• Treating hypertension is expensive…
– £1-1.5 m per PCT per year in drugs alone
– Approximately 20,000 consultations per
PCT per year for treated hypertension
alone
• …But not treating it is even worse
– Direct cost of CHD and Stroke in UK
approx £4-5b / year
Why poor control?
Patient factors
 Adherence
 Side effects
 Mis-match of ideals
Professional factors
• Workload
• Lack of professional
•
action
Ever changing
guidelines
What do we know about self
monitoring?
• First reported in 1930: Mayo Clinic
• 19 RCTs, one UK based (TASMINH
•
•
trial)
Most with small numbers and / or short
FU
Bottom line to date (Cappuccio 2004)
–SBP – 4.2 mmHg (95% CI 1.5-6.9)
–DBP – 2.4 mmHg (1.2 – 3.5)
(Overall standardised mean differences)
What do we know about self
management?
• Most research in other fields: arthritis,
•
•
asthma, diabetes.
One study from Canada in hypertension
suggests self management effective but
trial was small and short lived.
Hypertension different to many other
conditions due to lack of symptoms
Theoretical basis for self
management
Patients
 Increased patient involvement in management

decisions will result in:
 Cues to action
Adherence
 Increased self efficacy
Behaviour
change
Better use of medication likely to have most effect
Professionals
• Systematic titration of medication effective
• Evidence of clinical inertia
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?
RCTs of telemonitoring in
hypertension
Friedman 1996 (US):
–
–
–
–
267 subjects followed up for 6 months
Weekly monitoring
TLC system of automated feedback to patient & Dr
Benefit for DBP (5 mmHg) not SBP (adjustment)
Rogers 2001 (US)
– 121 subjects followed up for at least 8 weeks
– Monitoring 3 days per week; feedback to physician
monthly
– Reduction in mean arterial pressure 3 mmHg
Mehos 2000 (US) & Artinian 2001 (US) small &
showed feasibility alone
Policy
• NSFs & associated NICE Guidelines for Hypertension,
CHD, Older People (Stroke), Renal Disease &
Diabetes:
– Blood Pressure control key objective
– Flagged up paucity of evidence for self monitoring /
management
• NHS Plan: advocates independence and patient
centred care
• National strategic programme for information
technology: developing suitable technology for home
monitoring
• National Strategy for Carers: reduction of carer burden
• Building on the Best: promoting choice of
User Input
• Users involved in developing and
piloting intervention
• Recruited from TASMINH study
• Tested different modes of self
monitoring and telemonitoring
• Piloting of research materials
(questionnaires) by members of
university of third age
TASMINH2:
Telemonitoring and Self
Management in
Hypertension
The Trial
• RCT: Self Management vs Usual Care
• Patients identified by practice computer
search (check for suitability)
• Invited to attend practice based
baseline clinic – eligibility, consent,
questionnaires, BP measurement,
• Randomisation to intervention or usual
care
• Practice GPs determine management
Eligibility
• Age 35-74
• Treated hypertension (no more than 2 BP
meds)
• Invite on basis of practice BP reading
>140/90
• Need to have reading at baseline >140/90
• Willing to self monitor and self titrate
medication
Intervention
• Self Monitoring – 1st week of every
month
Intervention
• Blood Pressure Targets:
– NICE (140/90 or 140/80) minus 10/5
– i.e. 130/85 or 130/75
• 4 or more BPs per week over target for 2
months in a row triggers drug change (sticker
on repeat)
• 2 drug changes between each GP visit (ie
6m)
• “Red zones” for very high and very low
readings
Traffic Light System
Training
• Two training sessions for patients to
teach self monitoring and self titration
• Assessments to ensure participants are
competent in carrying out study
requirements prior to starting
• Training for practice staff regarding
protocol and drug changes
• Safety net for High / Low readings and
0800 number for queries
Practice input
• GP to see all patients at baseline
– Medication Review (usual care)
– Agree medication changes (intervention)
• Subsequent reviews depending on BP
control
– intervention 2 changes between reviews
(6mth)
– control as per normal care
• Review patients if very high (or low) BP
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 Sub Study
• Aims to generate data regarding the
acceptability and likely generalisability
of self management into daily practice
• One to one interviews with patients,
carers, health professionals and
technology reps
• Grounded theory methodology with
constant comparative analysis
Progress to date
• Intervention developed and piloted
• Outcome measures and trial materials
finalised
• Staff in post
• Ethical / Trust approval in progress
• 13 practices recruited to date
• First Patient recruitment planned March
07
TASMINH2:
Telemonitoring and Self
Management in
Hypertension