The evidence base: the management of hypertension

Susan Royer

In July 2010, WSDAN News reported on the publication of the results of a recent UK randomised control trial on telemonitoring and self-management in the control of hypertension (TASMINH2).

Publication:  This article was taken from the Whole Systems Demonstrator Action Research Network (WSDAN) database

Despite the fact that identification and treatment of hypertension is widespread in the UK, this study found that only around 50 per cent of patients have their blood pressure checked and managed at nationally recommended levels. [1] Given this context, the research team looked at new approaches to tackle this common long-term condition, setting out to evaluate how a combination of telemonitoring and self-management might improve poorly controlled blood pressure.

For the purposes of the study, self-management comprised both self-monitoring and self-titration. Following instruction and parameter-setting, participants in the intervention group were empowered to request changes to their medication in response to consistent 'above target' blood pressure readings. These changes were possible without a GP visit.  Telemonitoring involved patients’ own readings being communicated to health care professionals.

More than 500 patients were involved in the trial, in which the primary outcome measure was systolic blood pressure change from baseline to six months, and then twelve months. The control group received usual hypertension care, which included an annual review.

At 12 months, data from 480 patients revealed a 'significant' change in blood pressure for the intervention group, with greater reductions recorded than for the control group. The absolute blood pressure reduction in the self-management/telemonitoring group was greater by 5.4/2.7 mmHg, compared with the control group. The research team calculated that this meant a reduction in risk of stroke of more than 20 per cent, and a drop in the risk of coronary heart disease of more than 10 per cent. Most self-managing patients (n=148) availed themselves of the option to change their medication, and this is likely to have contributed to resulting reductions in systolic blood pressure. Lowered readings were also recorded for the control group during the same time period, probably – according to the research – associated with increased medication over the life of the trial. The study concluded that self-management was a valuable and effective method in the control of hypertension.

Telehealth evidence database

As of August 2010, the telehealth evidence database held 20 entries on hypertension, including studies from Europe and the United States. Electronic monitoring, mobile phones, video and internet technologies have all been trialled by researchers to study the management of this condition. However, the studies have primarily measured levels of satisfaction and compliance with the technology and/or monitoring protocols, rather than examining outcomes related to lower blood pressure levels. For example:

  • In the UK, a feasibility study on the use of mobile phones for monitoring blood pressure found a general willingness on the part of both health care professionals and patients to try the technology. [2]
  • A 2004 Spanish study concluded that text messages and reminders received via mobile did not improve patients' medication compliance. [3]
  • A range of 'supportive measures' were utilised in a 34-week German trial, including timers, home blood pressure monitors and reminder stickers. [4] Mixed results were recorded for adherence, compliance and persistence, with higher persistence ratings for those patients receiving the supportive measures.
  • A US research team studied telemonitoring of blood pressure via telephone landlines and found that some patients would require more support than others to use such a system successfully. [5]
  • A Dutch study found that pill counting, in conjunction with electronic monitoring, yielded useful information on adherence to hypertension treatment. [6]

A few studies in the database, however, do examine how technology-supported interventions affected hypertension control directly:

  • Research in Sweden which trialled videoconferencing as a method of hypertension control found that patients who had a video link to their physicians were more likely to be within blood pressure target levels than those receiving 'usual care'. [7]
  • A major study on the effects of Kaiser Permanente's secure doctor–patient email system focused on performance against the Healthcare Effectiveness Data and Information Set (HEDIS) measures. [8] Results suggested improved performance in terms of managing blood pressure on the part of those who used the email facility.
  • A Canadian trial, involving 31 randomised patients over eight weeks, reported significant blood pressure reductions in those who self-managed, compared with their usual care counterparts. [9]

Conclusions

A variety of methods to control hypertension have been trialled, with mixed success rates. In some studies, control group results have been comparable to those of intervention patients. Outcomes have been affected by issues such as adherence, as well as acceptance and general take-up of practices – for example, communicating blood pressure readings via telephone, or heeding advice received by text message.

From a cost perspective, the studies suggest that there is potential to make financial savings through the use of new technologies that promote self-care, as this can lead to reductions in the number of visits a patient has to make to a clinic. Health professionals can be alerted to, and act upon, unsafe blood pressure levels in a more timely fashion through remote monitoring. Any such savings must, however, be weighed against the time commitments involved in instructing patients in the use of equipment, ongoing technical support, and maintaining a two-way relationship, albeit at a distance (for example, in responding to patients’ emails or being available for videoconferences). The high incidence of hypertension appears to justify ongoing research into improving its management, and we can perhaps expect that more conclusive evidence will emerge in the future, as technologies are adapted and adopted to achieve this end.

References

1. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, Kaambwa B, Banting M, Bryan S, Little P, Williams B, Hobbs FD (2010). 'Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial'. The Lancet, vol 376, issue 9736, pp 163-72. Epub 2010 Jul 8.

2. Bostock Y, Hanley J, McGown D, Pinnock H, Padfield P, McKinstry B (2009). 'The acceptability to patients and professionals of remote blood pressure monitoring using mobile phones'. Primary Health Care Research & Development, vol 10, pp 299-308.  doi:10.1017/S1463423609990107

3. Márquez Contreras E, de la Figuera von Wichmann M, Gil Guillén V, Ylla-Catalá A, Figueras M, Balaña M, Naval J (2004). 'Effectiveness of an intervention to provide information to patients with hypertension as short text messages and reminders sent to their mobile phone (HTA-Alert)'. Aten Primaria, vol 34, no 8, pp 399-405.

4. Düsing R, Handrock R, Klebs S, Tousset E, Vrijens B (2009). 'Impact of supportive measures on drug adherence in patients with essential hypertension treated with valsartan: the randomized, open-label, parallel group study VALIDATE.' Journal of Hypertension,  vol 27, no 4, pp 894-901.

5. McCant F, McKoy G, Grubber J, Olsen MK, Oddone E, Powers B, Bosworth HB (2009). 'Feasibility of blood pressure telemonitoring in patients with poor blood pressure control'. Journal of Telemedicine and Telecare, vol 15, pp 281-5. doi:10.1258/jtt.2009.090202

6. van Onzenoort HA, Verberk WJ, Kessels AG, Kroon AA, Neef C, van der Kuy PH, de Leeuw PW (2009). 'Assessing medication adherence simultaneously by electronic monitoring and pill count in patients with mild-to-moderate hypertension'. American Journal of Hypertension,  vol 23, no 2, pp149-54. Epub 2009 Nov 19.

7. Nilsson M, Rasmark U, Nordgren H, Hallberg P, Skönevik J, Westman G, Rolandsson O (2009). 'The physician at a distance: the use of videoconferencing in the treatment of patients with hypertension'. Journal of Telemedicine and Telecare, vol 15, pp 397-403. doi:10.1258/jtt.2009.090509

8. Zhou YY, Kanter MH, Wang JJ, Garrido T (2010). 'Improved quality at Kaiser Permanente through email between physicians and patients'. Health Affairs, vol 29, no 7, pp 1370-5. doi: 10.1377/hlthaff.2010.0048

9. Zarnke KB, Feagan BG, Mahon JL, Feldman RD (1997). 'A randomized study comparing a patient-directed hypertension management strategy with usual office-based care'. American Journal of Hypertension, vol 10, no 1, pp 58-67.

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