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

Vicky Hammersley, Richard Parker, Mary Paterson, Janet Hanley, Hilary Pinnock, Paul Padfield, Andrew Stoddart, Hyeon Gyeong Park, Aziz Sheikh, Brian McKinstry

Abstract

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.

Introduction

Hypertension is common among people over the age of 50 years and is an important risk factor for cardiovascular disease [1]. Although effective management greatly reduces the risk of cardiovascular events, blood pressure (BP) remains uncontrolled in many people [2]. This is in part due to poor adherence to medication [3], but also reluctance on the part of clinicians to intensify therapy [4] and on the part of patients to accept intensified therapy [5].

Methods

This study is reported in accordance with the Standards for Reporting Implementation Studies (StaRI) [21]. This study was approved by the East of England–Cambridge South Research Ethics Committee (16/EE/0058). We describe the deployment and uptake of telemonitoring generally and then the evaluation of the impact of the implementation in 8 practices chosen to represent a range of size, deprivation, and earlier and later adopter of the technology.

Discussion

Summary of findings

This study shows that a telemonitoring system for BP monitoring using software to integrate it with normal primary care work patterns can be implemented at scale. BP control improved, in line with results found in RCTs of telemonitoring, probably mediated by an intensification in therapy [16,33–36]. This new model of care was associated with an observed reduction in the number of face-to-face appointments and consulting time. The well-recognised barriers to implementation of new technologies (lack of confidence in technology, workload fears, lack of time to learn and introduce new things, and scepticism that the implementation will improve patient care or efficiency) were overcome through engaging frontline clinicians in the development of the system, particularly local champions, and strong continuous support from a facilitator team. While it was relatively straightforward to persuade practices of the likely benefits of the intervention and to undertake training, they varied in translating that training into action. Some practices required several training sessions before they started regular recruitment, while some did not get started at all, usually citing lack of time. Others, however, recruited large numbers of patients to the project, and their success persuaded other practices to follow them. Patients liked the system, and relatively few discontinued; however, it is concerning that people with less well controlled BP were overrepresented among those who discontinued, and this requires further investigation.

Acknowledgments

We would like to thank the patients and practice staff who took part, and Grahame Cumming, Elizabeth Payne, Alison McAulay, Arek Makarenko, and Daniel Plenderleith of NHS Lothian. We acknowledge the support of NHS Research Scotland Primary Care Network and Lothian Safe Haven, particularly Allan Walker. Special thanks to Margaret Whoriskey and Michelle Brogan of Scottish Government Technology Enabled Care and Richard Forsyth of the British Heart Foundation.

Citation: Hammersley V, Parker R, Paterson M, Hanley J, Pinnock H, Padfield P, et al. (2020) Telemonitoring at scale for hypertension in primary care: An implementation study. PLoS Med 17(6): e1003124. https://doi.org/10.1371/journal.pmed.1003124

Academic Editor: Kazem Rahimi, University of Oxford, UNITED KINGDOM

Received: September 5, 2019; Accepted: May 22, 2020; Published: June 17, 2020

Copyright: © 2020 Hammersley et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Scale-up BP made use of several routine electronic health care data sources that are linked, de-identified, and held in the NHS Lothian safe haven, which is only accessible by approved individuals who have undertaken the necessary governance training. Therefore, raw participant-level data is not available for public sharing. Requests to access data should first be made to NHS Lothian Safe Haven (https://www.accord.scot/researcher-access-research-data-nrs-safe-haven/safe-haven-network) who will assist with further access for researchers who meet the criteria for access to confidential data.

Funding: BM, JH, RP, HP, PP,AS were supported by a grant the Chief Scientist Office of the Scottish Government CZH/4/1135. This funding source had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit the paper for publication. The authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: BM is supported by the Scottish Government in relation to their plans to scale up telemonitoring for hypertension across Scotland. MP is paid by the Scottish Government to give advice on implementing telemonitoring of blood pressure. BM and ASh are in receipt of funding for an unrelated hypertension telemonitoring study of people with stroke. ASh is a member of the Editorial Board of PLOS Medicine. ASt has received research funding for this study and another trial of Telehealth for Blood Pressure. HP has received fundng in the last 3 years from the European EIT Digital fund to develop an app for BP management. All other authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Abbreviations: BP, blood pressure; DDD, defined daily dose; GP, general practitioner; RCT, randomised controlled trial; SIMD, Scottish Index of Multiple Deprivation.