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.
This example was originally submitted to demonstrate implementation of NICE guideline CG127. The guideline has now been updated and replaced by NG136. The example has been reviewed and practice it describes remains consistent with the updated guidance.
Aims and objectives
This service improvement project aimed to use simple telehealth to improve blood pressure control and management of patients with hypertension and those with hypertension and chronic kidney disease (CKD) stages 3 or 4. This method of service delivery was utilised with the aim of improving patient self-management and education. As a result of the improved blood pressure management, the longer term goals of the project were to reduce hospital outpatient referrals and admissions for deterioration of CKD from stage 3 to 5 and to reduce hospital admission due to stroke (due to inadequate management of hypertension) and falls (resulting from overmedication of hypertension).
Reasons for implementing your project
It is estimated that one in three adults in the UK have hypertension and poor blood pressure control results in thousands of avoidable deaths and hospital admissions every year. Awareness and treatment of hypertension have improved significantly during the past decade, however its management remains suboptimal. Many initiatives to manage patients diagnosed with hypertension are resource intensive- involving frequent monitoring at a GP practice, increased drug treatments, interventions from specialist teams and/or the use of telehealth monitoring systems located in the patient's home. Although the benefits of telehealth for a condition such as hypertension are clear, locally, there had been negative experiences with complex telehealthcare equipment. Therefore new technologies were required to provide resource effective implementation of joint management of specific long term conditions and enhancing motivation of patients to comply with their medication to achieve greater stability in their condition.
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
For the intervention to succeed, patients had to (i) have their own mobile phone, (ii) have the cognitive ability to use SMS texting, (iii) be willing to engage actively in their healthcare.
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 use of this simple interactive telehealth intervention in a real life clinical primary care setting across ten general practices resulted in patients using Florence having a significantly greater average reduction in SBP, compared with their associated controls, during the initial three month programme. Average SBP and DBP readings for all intervention patients fell to within the normotensive range (140/90mmHg for clinic readings, <135/85mmHg for home readings) from month 1 of the programme (see published paper included in 'Supporting material' section). This is likely to be due to improved implementation of NICE hypertension guidelines from attainment of greater numbers of BP readings, more frequent changes in antihypertensive medications, more appropriate timing of BP recordings, increased awareness among patients of their BP values and the significance of the same and/or an increased sense of control among patients.
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
Careful selection and counselling of patients is required at recruitment onto such a programme to ensure that they understand and agree with the nature and frequency of the processes involved and that they are physically and cognitively able to operate the simple equipment is essential to promote success with a programme such as this.
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.