Home based telemedicine intervention for patients with uncontrolled hypertension: a real life - non-randomized study
Control of blood pressure is frequently inadequate in spite of availability of several classes of well tolerated and effective antihypertensive drugs. The aim of the study was to evaluate the effectiveness of a Home-Based Telemedicine service in patients with uncontrolled hypertension.
The paper describes how a telemedicine service was trialled and concludes that a telemedicine service, consisting of structured physician-directed, nurse-managed telephone support added to remote telemonitoring is feasible,reliable and has a positive effect on blood pressure control and that this type of approach could decrease the number of hypertensive patients that are currently being treated but who are still uncontrolled.
The paper reports that systematic reviews have shown that in patients with hypertension, home blood pressure monitoring compared to a simple check at GPs offices may play an important role in improving control of systolic and diastolic blood pressure and treatment adjustment. Published papers increasingly show the central and crucial role of properly trained nursing staff in coordinating all the health care professionals involved in the home management program, including providing advice to patients on life style changes,diet, exercise and smoking habits.
The service consisted of a structured physician-directed,nurse-managed telephone support added to a BP tele-monitoring. The staff included hypertension specialists,cardiologists and trained nurses. The structured telephone support included the following:
- Scheduled telephone appointments: these were done approximately every 15 days. During these contacts,the nurse carried out a standardized interview on general clinical condition of the patients. The patient was also counseled on weight management and physical activity, smoking cessation, dietary changes and stress management.The patients were asked information about their prescribed drugs and whether they took them. If drug compliance was poor, the nurseoffered strategies to improve patient’s compliance.
- Unscheduled appointments: these were initiated by the patient when they experienced signs and symptoms or had questions about their therapy. The patient had the opportunity to contact the nurse at any time of the day through the service centre and report any clinical problems.
The authors report that in comparison with the previous studies, the educational programme run by the nurses is fundamental; the physicians are immediately made aware when BP values are outside the range. This leads to re-evaluation of drug compliance or drug therapy. The continuous monitoring of patients followed by appropriate intervention is a critical attribute of the programme. The authors suggest that this is is probably the reason why in the HBT group there was a higher number of patients (70%) in whom the drug therapy was modified compared to those in the UC group(23%). The authors suggest that the complete optimization of the treatment probably requires a longer period with more frequent nurse-patient contacts. The authors conclude that In this respect, telemedicine could be an excellent addition which could reduce the number of office visits.
Moreover, when the patients realize that their adherence is constantly and carefully checked, they acquire a feeling of greater control and consequently higher compliance which contributes to positive effects that can be observed in the first few weeks. Through telemedicine, symptoms of hypertension or hypotension, malaise, or requests for comfort or simple communications needs can be relayed in real time leading to greater patient satisfaction.
The authors conclude that the importance of self BP measurement is an educational goal for the patient. This goal cannot be achievedby a single office visit. Furthermore, because of the issues with cost containment, repeated office visits are discouraged. In addition, the Telemedicine approach whichcombines nurse support plus remote monitoring, re-duces the problem of“white coat syndrome”. An effective monitoring programme for a period of 2–4months associated with a structured physician-nurse approach can lead to beneficial overall effect for patients with uncontrolled hypertension. Telemedicine services provide an additional value to standard of care with only a small cost addition. In view of the results obtained (greater significant reduction in the HBT group vs. the SC group), it would be crucial to plan randomized studies with a longer home follow-up to confirm these findings and to verify the efficacy of Telemedicine intervention in the reduction of acute cardiovascular events, which are known to increase by 30%for every 10 mmHg increase in BP.