Telemonitoring at scale for hypertension in primary care: An implementation study.

Author summaryWhy was this study done? Although uncontrolled hypertension is the biggest remediable cause of stroke and myocardial infarction, and anti-hypertensive medications are effective, many patients have uncontrolled blood pressure (BP). Despite strong evidence that telemonitoring encourages medication use and is effective at lowering BP, clinicians have been slow to adopt it, in part due to poor integration with routine clinical processes. We wanted to see if an integrated telemonitoring system would be taken up by primary care clinicians at scale, what impact this would have on their workload, and if changes in BP would match those of randomised controlled trials. What did the researchers do and find? Based on our previous research with clinicians on the desirable attributes of a telemonitoring system, NHS Lothian developed an integrated system that provided regular summaries of patient home-monitored BP readings to their general practitioner, which were delivered alongside routine laboratory results. We observed the rollout of this system, interviewing patients and clinicians about their attitudes towards innovations to determine what worked and did not in terms increasing uptake. In a group of 8 practices, we collected routinely acquired data on BP, clinician appointments, and other resource use and compared these to the previous year. Resource use was compared with patients in these practices with high BP who did not use telemonitoring. We found that the intervention was popular in many but not all practices. Patients who used the system had fewer appointments in the year of the intervention compared with the previous year. BP fell in the intervention group, in line with findings of UK randomised controlled trials. What do these findings mean? The findings suggest that introducing telemonitoring to routine practice at scale is feasible. Although not definitive, the findings provide some reassurance that the intervention did not increase practice workload and that in routine practice the improvements in BP control were similar to those in controlled trials. However, the people who took part were not entirely typical of practice populations as a whole, being on average younger and slightly more affluent. The findings support plans to introduce telemonitoring more generally, but within an evaluative framework. Background While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care. Methods and findings This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants' views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56-70, range 22-89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6-10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy. Conclusions Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative.