This innovative simple interactive telehealth system has demonstrated rapid improvement in historically difficult to treat hypertension using just a home blood pressure monitor and interactive SMS texting between clinician and patient with a mobile telephone. Patient satisfaction with the system was high. Pragmatic use of the system during has demonstrated that there may be a place for this technology in diagnosing, refuting a diagnosis of or managing a pre-existing diagnosis of hypertension.
Aims and objectives
Reasons for implementing your project
The demographic and health profile of the local population within parts of Staffordshire is such that the management of blood pressure for (i) CKD patients and (ii) those at risk of stroke and/or falls is a key priority and integral to core programmes focusing on self-management and health improvement for NHS Stoke-on-Trent. At baseline, of the 275,000 people registered as patients in Stoke-on-Trent, 28,000 were diagnosed with diabetes, CHD, hypertension or CKD stages 3, - 5 with many more undiagnosed. The area historically has high levels of material deprivation and poor health. Stoke-on-Trent is the 11th most deprived Local Authority area in England; 58 of its 60 wards are significantly deprived.
Originally it was planned that the intervention would help to control patients' blood pressure according to the NICE Hypertension guidelines. However, during implementation, it became apparent that there was a useful role for this type of service provision in confirming/refuting a diagnosis of hypertension, according to the home blood pressure monitoring option, also outlined in the NICE hypertension guidelines.
How did you implement the project
The Simple Telehealth system Florence ('Flo') was configured with a specific protocol for the project which, once activated for a patient, would automatically:
- Remind patients to take their blood pressure (BP) and to report (by texting) the result at a clinically appropriate frequency.
- Send a second reminder if the patient had not reported their BP within two hours of the first prompt.
- Respond immediately to a patients reported BP, acknowledging receipt.
- Provide one educational hypertension or home monitoring message each four days.
- If a reported BP was higher than the personalised safe clinical limits the patient was asked to take and report a second reading from the other arm. If the second reading remained high, the patient would be advised to seek immediate medical assistance from their GP or out of hours service.
- Ask the patient to answer survey questions each four weeks and at week 13 (for service evaluation purposes)
The intervention protocol was designed to run over 13 weeks and allowed the target alert parameters, messages and frequency of prompts and readings to be personalised for each patient. Each patient was required to 'opt-in' via an SMS message after receiving an SMS invitation to join the service. Practices identified three patients as controls for each patient recruited to the Florence telehealth service. These were the three patients nearest in age to the patient of same gender with hypertension. Data about the control patients' BP readings and healthcare usage was extracted from their notes. The clinical protocol for this simple telehealth mobile phone texting system was developed in line with NICE guidance. Such clinical protocols act as fundamental building blocks to secure clinical engagement by increasing confidence in the outputs of the intervention.
Despite additional financial incentives and administrative support being offered at the end of the programme 10 practices had recruited 124 patients instead of the expected 16 volunteer practices recruiting an overall 200 patients. The most significant barrier to participation and recruitment was not use of the telehealth system but data collection for the corresponding evaluation, which would not be a feature of a wider roll out of the project.
The greatest average reduction in SBP among participating patients were noted among those patients recruited for uncontrolled hypertension, without CKD Stages 3-5 who were hypertensive at recruitment. No significant improvement in BP control was noted among participating patients with CKD Stages 3-4. Patient satisfaction was high. They found the system easy to use, were satisfied with the feedback about their BP from their GP, found the advice sent useful and preferred to use this service rather than attending the practice for monthly BP checks. Overall satisfaction with the system was 4.81/5.00 at week 13 of the programme. Other advantages of being enrolled with Florence were improved education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur at a time that suited the patient rather than their practice. Patients also recognised the importance of robust diagnosis and monitoring of their BP, as outlined by the NICE hypertension guidelines, as a few commented on the variation according to their environment/circumstance. The likely benefits of improved BP control among intervention patients relate to reduced healthcare service use and reduction in BP associated comorbidity. However, the impact of reducing BP on these factors will be delayed while the costs of reducing the BP (using simple telehealth system and appointments used training patients to use the system) and increased changes to medication) are realised now.
Key learning points
Use only light-touch evaluation methods. Although the telehealth system and associated clinical management was not too onerous, practices found it hard to provide the level of data required to undertake a robust evaluation and this became a negative driver against recruitment onto the scheme. A clinical champion in each practice team is essential to provide support for the innovation and to aid implementation by all the team.
Minimise any additional workload for clinicians from an innovative change in the delivery of care, by making best use of administrative support.