Title: Hypertension Self-management: The use of Telemedicine as an Intervention Tool Hayden Bosworth, Ph.D. Center for Health Services Research in Primary Care, Durham VA Medical Center Departments of Medicine, Psychiatry and School of Nursing Duke
1Hypertension Self-management The use of
Telemedicine as an Intervention ToolHayden
Bosworth, Ph.D. Center for Health Services
Research in Primary Care, Durham VA Medical
CenterDepartments of Medicine, Psychiatry and
School of NursingDuke University Medical Center
2Outline
- Prevalence and Impact of Hypertension
- Chronic Disease Self-management Barriers and
Facilitators - Translation Studies
- Veterans Study to Improve The Control of
Hypertension - (V-STITCH)
- Hypertension Intervention Telemedicine Study
(HINTS) - Take Home Messages
- Future Directions
3Prevalence of Hypertension
- 1 in 3 adult Americans
- 65 million Americans (JAMA 2003)
- 45 million prehypertensive
- 8 million veterans (37) (Med Care Res Rev
2003) - Lifetime risk for normotensive 55 year old
90 (JAMA 2003)
4Hypertension Treatment Facts
- Life Style Matters
- Weight Loss (any means)
- DASH Diet
- Low Na Diet
- Exercise
- Limited Alcohol
- Medications Work
- Nothing Better Than Thiazide Diuretics
- Most Patients Require gt 2 medications
5Goal of Hypertension Self-management
6Hypertension as a Model for Self-management
- Complex, long-term, chronic disease
- Requires initiation and maintenance of multiple
behaviors - Requires provider/patient communication
7Significance of Self-management Adherence
- gt80 of adults took at least 1 medication in the
last week 25 took at least five - Cost of medication non-adherence gt100
billion/year - 50 of patients non-adherent with medication
- Rates of non-adherence higher in lifestyle
recommendations - 50 of treatment failures are due to
unrecognized patient non-adherence
8Traditional Paradigms Fail
- clinical trial information alone does not result
in adequate BP control - Specialist-based care not solution
- Primary care clinic based management is not
sufficient - Frequent contact with doctors in clinics does not
lead to BP control
9Disease Management Hypertension Evidence
- Cochrane review (2006)
- 59 trials
- Reduces SBP (8-10 mm Hg))
- Reduces DBP (4-7 mm Hg)
- Improves all cause mortality
- Self-monitoring alone (17 trials)
- Reduces DBP by 2 mm Hg
10Health Decision Model
Provider Characteristics
Patient Characteristics
Policy
Communication Style
Perceived Risks
Cognition
Medication Regimen
Literacy
Coping Stress
Treatment Guidelines Adherence
Intensity of Therapy
Side Effects
Comorbidities
Medical Environment
Depression Mental Health
Social Environment
TREATMENT ADHERENCE
Bosworth HB, Olsen MK, Oddone EZ. (2006). Am
Heart J 149795-803.l Bosworth HB Oddone EZ.
(2002). J Nat Med Ass. 94 236-248
BLOOD PRESSURE CONTROL
11Patient Characteristics Relatedto Self-management
- Risk Perceptions / Knowledge
- Cognition
- Memory
- Inductive Reasoning
- Verbal Comprehension
- Literacy / Numeracy
- Coping / Stress
- Avoidance
- Daily hassle
- Stigma
12Patient Characteristics Relatedto Self-management
- Comorbidities
- Medication Side Effects
- Depression/mental health
13Social Characteristics Relatedto Self-management
- Social Network
- Social Support
- Tangible/instrumental
- Emotional
- Culture
14Medical Environment Related to Self-management
- Access and Barriers
- Insurance (i.e., co-payments, deductibles)
- Transportation
- Organization and staffing
15Provider Characteristics Related to
Self-management
- Evidence-based Guideline Compliance
- Medication Complexity
- Medication Intensity
- Provider Communication
16Provider Factors Clinical Inertia
- Failure of providers to initiate or intensify
therapy when indicated - Reasons
- Overestimation of care provided
- Soft reasons to avoid intensification
- Lack of education, training or practice
organization - Lack of belief of efficacy
Phillips, et al. Ann Intern Med 2001
17Issues in Patient-Provider Communication
- Poor patient-physician communication is common
- Physicians do gt60 of talking during a visit
- Instrumental and biomedically focused
- Rarely address psychosocial issues
- 50 of the time physicians do not name the
medicine or give dosing instructions - Many patients reluctant to express
- Expectations or medication preferences
- Misunderstandings about the regimen
- Poor patient-provider communication may
contribute to health disparities in minority
populations
18- How do you translate this information into an
intervention?
19Veterans Study to Improve TheControl of
HypertensionVA Health Services
ResearchInvestigator Initiated Award, 2001-06
The V-STITCH Study
20The V-STITCH Study
- A randomized controlled trial testing two
interventions designed to improve BP control - Patient Intervention Self-Management
- Provider Intervention Decision Support
- Durham VAMC General Medicine Clinics
- Patients with hypertension on medications
- 24 month intervention and follow-up
21The V-STITCH Study Design
22Patient Intervention
23Patient Intervention
Tailored Behavioral Delivered via Telephone
- Hypertension Knowledge
- African American
- Diabetes
- Family history
- Literacy
- Memory
- Patients Relationship with Primary Care Provider
- Social Support
- Side Effects
- Lifestyle Factors (smoking, alcohol, exercise,
diet, stress) - Missed Appointments
- Pill Refill
24Patient Intervention
Frequency of Nurse-base calls
25Patient Intervention
Mode of Administration
- Use of Telephone
- Telephone contact has been shown to be effective
in changing patient behavior (Am J Hypertens
1996, Am J Prev Med 2002) - Allow reaching more patients
- Tend to be more acceptable and convenient than
in-person interventions. - Most U.S. homes have phones (gt97) useful tool
to deliver an intervention (U.S. Bureau of
Census, 2003) - May enhance the interventions cost-effectiveness,
due to reduced intervention costs and reduced
visit rates.
26 27Automated Treatment for HypertensionEvideNce-bas
ed Advice (ATHENA)
- Displayed at point-of-care
- Summarized the hypertension-relevant information
from clinical record - Individualized for the patient
- Educated as well as reminded
- Displayed reasons / explanations
- Provided continuous quality improvement -
quarterly
28ATHENA BP - Prescription Graphs
29Provider Control Group
- Displayed patient's most recent BP
- Displayed patients current antihypertensive drug
regimen - Provided opportunity to update BP
- Offered no advisories or recommendations for
medication management - Simply a reminder for hypertension
30Primary Care Providers
- 24 Attending Physicians
- 6 Physician Assistants
- 2 Registered Nurse Practioners
- 17 intervention providers received full decision
support tailored to specific patient - 15 control providers received display with most
recent BP
31Patient Identification
32Patient Characteristics (N588)
- Male 98
- Mean age 63 years (21-87)
- Married 68
- Live alone 22
- White 57
- African American 40
- High school or less 51
- Inadequate income 23
33Patient Characteristics
- Taking BP meds for gt 5 years 64
- Close relative with hypertension 65
- No exercise 44
- Smoke 30
- Diabetic 40
- BP in control at Baseline 42
- lt 130 / 85 mm/Hg diabetic
- lt 140 / 90 mm/Hg non-diabetic
- Mean Systolic BP 138.4 (SD18)
- Mean Diastolic BP 75.5 (SD11)
34Primary Outcome
- Blood pressure control at every primary care
provider clinic visit over 24 months
patient 1
patient 2
yes
yes
bp control
bp control
no
no
0
10
20
30
40
50
60
0
10
20
30
40
50
60
time in weeks
time in weeks
patient 3
patient 4
yes
yes
bp control
bp control
no
no
0
10
20
30
40
50
60
0
10
20
30
40
50
60
time in weeks
time in weeks
35Blood Pressure Control Rates Primary Analysis
Behavioral N144
0.7
Combined N150
0.6
Reminder N143
0.5
BP Control
0.4
Decision Support N151
0.3
GroupTime Effect P.11
Time Effect P.01
0.2
0
6
12
18
24
Time in Months
36Nurse Behavioral Intervention vs. None Secondary
Analysis
0.70
RN Behavioral N294
0.60
P0.03
BP Control
No RN N294
0.50
0.40
0
6
12
18
24
Time in Months
37Compliance with Nurse Telephone Intervention
- Patients completing all 12 scheduled study
calls 85 - Average length of call
- 3 minutes (SD 2.5 min)
38Primary Care VisitsDuring Study (24 Months)
39Two-Year Outpatient Costs
40Average Behavioral Intervention Costs Per
Patient over 24 months
41Provider Intervention Results
- ATHENA displayed at 68 of visits (929/1370)
- Among displayed, providers interacted with
intervention 57 of time (38.5 overall) - 54 BP control when provider interacted versus
45 when provider did not interact
42Provider Intervention Results
- Most common reasons for disregarding
recommendations - 68 inadequate BP control due to med
non-adherence - 68 concern that an inaccurate BP reading was
used to generate recommendations - 46 insufficient time
43Summary
- Brief telephone intervention improved BP control
by 21 at 24 months - 12.6 improvement compared to the non-behavioral
group - No increase in clinic utilization
- Cost effective
- Computer Decision Support did not significantly
improve BP control rates at 24 months
44Next Study
- How can we overcome provider inertia with a
stronger medication management intervention? - Focus intensive interventions on those at greater
risk (i.e., out of control) - Can we monitor and treat blood pressure outside
of clinic?
45Hypertension Intervention Telemedicine
Study(HINTS)
Department of Veterans Affairs, Grant IIR 04-426
(2005-2008) Established Investigator Award,
American Heart Association (2006-2011)
46Hypertension Intervention Nurse Telemedicine
Study (HINTS)
- 600 primary care veterans with poor BP control
- Home BP tele-monitoring used to activate
interventions - Nurse-administered via telephone for 18 months
47HINTS Study Design
- Four Group Design
- Usual Care
- PCP drive management, no special program
- Tailored Behavioral Phone Intervention
- Home BP monitoring evaluated by nurse
- Tailored behavioral modules
- Medication Management (ATHENA) Phone Intervention
- Home BP monitoring evaluated by nurse
- Medication management implemented by study MD/RN
- Combined Intervention
- Home BP monitoring evaluated by nurse
- Medication management/tailored behavioral modules
48Why BP Monitors as Interventions?
- Improve BP control
- Self-monitoring programs are used in clinical
practice to assist PCP in treating their patients - Encourage patients to monitor their disease
- Provide objective information to motivate
patients to control their health condition
49Case for Telemedicine
- Effective use of home BP monitoring improve
hypertension outcomes - Treating at home may avert visits and result in
better BP control - Alternative way to integrate home BP monitoring
into primary care
50HINTS Study Telemedicine
51Baseline Patient Characteristics
- 546 subjects enrolled
- Minority 51
- Low Literate 38
- Diabetic 44
- Males 98
52Summary of Intervention
- Safety alert activated
- (2 values within 12 hours gt175 systolic, gt105
diastolic, pulse lt40 or gt110) - 144 times, 51 unique pts
- Intervention activated
- 687 times, 241 unique pts
- Praise alert activated
- 74 times, 68 unique pts
53Summary of Intervention
- Technicals activated
- 634 times, 220 unique pts
- 7 Did not understand how to set up or use
equipment - 66 nonadherence
- 27 technical problems with equipment
-
54Home Readings Console View
55RNMD Dialogue for Medication Change
56Outcomes
- BP control
- 0, 6, 12, 18 months
- Health-related quality of life (SF-12)
- Hypertension knowledge
- Adherence to hypertension regimen
- Cost-effectiveness of both interventions
57Summary
- Need to consider
- Alternative methods of implementing interventions
- Telemedicine not panacea for all
- Cost of implementing interventions
- Methods of reimbursement
- Not just initiating, but maintaining multiple
health behaviors - Both patient/provider and possibly system
58Recommendations
-
- Self-management adherence-enhancing strategies
need to occur - Introduction of treatment
- Later in the course (remediation)
- Maintenance (less attention)
-
- Strategies include
- Social Support
- Educational Interventions (written and/or verbal
- instructions delivered individually, group,
- telephone, or audiovisually)
- Behavioral Strategies (self-monitoring, positive
reinforcement, goal setting, cueing, chaining)
59Recommendations
- Educational Interventions
- Knowledge alone will not change behavior
- Establish what is known before offering new
knowledge - Use concrete examples
60Recommendations
- Ways of Presenting Written Information
- Instructions should be clear and structured
- Picture charts, color-coded medication schedules
and large print
61Recommendations
- Behavioral Interventions
- Strategies include
- Developing prompts and reminder systems
- Identifying a potential relapse into old
behavior - Setting appropriate and realistic goals
- Simplifying regimens to once or twice daily
- Use opportunities to model behavior
- Reinforce positive behaviors
62Recommendations
- Clinical Issues
- Key validated question Have you missed any
pills in the past week? - Sensitivity gt 50 of those with low adherence
- Specificity of 87
- Common misperceptions should be anticipated and
avoided - i.e., medication can be stopped when the
prescription runs out or symptoms are guides to
when to take the medication
63Recommendations
- Clinical Issues (continued)
-
- Missing appointments is correlated with lower
adherence rates - first sign of dropping out of
care entirely, the most severe form of
nonadherence. - Telephone or appointment reminders provide
relatively easy method to overcome nonadherence.
64Recommendations
- Effective, collaborative provider-patient
communication should be the foundation of all
clinical interventions designed to improve
patient self-management.
65Future Directions Conclusions
- Examining tailoring of intervention mode to needs
and intensity of intervention (Stepped level
care) - Disseminating and sustaining interventions in the
community - Expanding behavioral interventions to multiple
chronic diseases - Translating evidence into practice
66Acknowledgements
Research Team Alice Neary Melinda Orr Maren
Olsen Mike Harrelson Felicia McCant Kelly
Deal Pam Gentry Laura Svetkey Mary
Goldstein Rowena Dolor Tara Dudley Laurie
Marbrey Martha Adams Shelby Reed Santanu
Datta Laurie Leeson Anthony Goodin Gwen
McKoy Courtney Van Houtven Ben Powers Cindy
Rose Sharon Hooker Tina Hong David Simel Janet
Grubber
67Relevant Publications
- Bosworth HB, Olsen MK, McCant F, et al.
Hypertension Intervention Nurse Telemedicine - Study (HINTS). Am Heart J 2007153(6)918-24.
- 2. Bosworth HB, Olsen MK, Goldstein MK, et al.
The veterans' study to improve the control - of hypertension (V-STITCH) design and
methodology. Contemp Clin Trials 200526155-68. - 3. Chan AS, Coleman RW, Martins SB, et al.
Evaluating provider adherence in a trial of a - guideline-based decision support system for
hypertension. Medinfo 200411(Pt 1)125-9. - 4. Goldstein MK, Coleman RW, Tu SW, et al.
Translating research into practice - organizational issues in implementing automated
decision support for hypertension in - three medical centers. J Am Med Inform Assoc
200411(5)368-76. - 5. Goldstein MK, Hoffman BB, Coleman RW, et al.
Implementing clinical practice guidelines - while taking account of changing evidence. Proc
AMIA Symp 2000300-4. - 6. Goldstein MK, Hoffman BB, Coleman RW, et al.
Patient safety in guideline-based decision - support for hypertension management ATHENA DSS.
Proc AMIA Symp 2001214-8.
68Relevant Publications
7. Lin ND, Martins SB, Chan AS, et al.
Identifying barriers to hypertension guideline
adherence using clinician feedback at the point
of care. AMIA Annu Symp Proc 2006494-8. 8.
Bosworth HB, Oddone EZ. Telemedicine and
Hypertension. J Clin Outcomes Management
200411(8)517-522. 9. Bosworth HB, Oddone EZ,
Weinberger M. Patient treatment adherence
Concepts interventions, and measurement. Mahwah,
NJ Lawrence Erlbaum Associates, 2006. 10.
Bosworth HB, Dudley T, Olsen MK, et al. Racial
differences in blood pressure control potential
explanatory factors. Am J Med 2006119(1)70. 11.
Bosworth HB, Oddone EZ. A model of psychosocial
and cultural antecedents of blood pressure
control. Journal of the National Medical
Association 200294236-248. 12. Bosworth HB,
Olsen MK, Gentry P, et al. Nurse administered
telephone intervention for blood pressure
control. Patient Educ Couns 200557(1)5-14. 13.
Bosworth HB, Olsen MK, Oddone EZ. Improving blood
pressure control by tailored feedback to
patients and clinicians. Am Heart J
2005149(5)795-803.