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Self monitor blood pressure

NIHR Signal Patients, in theory, might prefer GP-led care to self-management for high blood pressure

Published on 19 November 2019

doi: 10.3310/signal-000840

Patients offered the pros and cons of different monitoring options appear reluctant to self-manage high blood pressure, and prefer frequent monitoring by a GP, pharmacist or via telehealth (where readings are sent to health professionals and medicines managed remotely). The small online survey, completed by 167 patients, was used to explore how patients might feel about moving away from GP-led care to other care models not currently routinely offered in the UK.

Perhaps surprisingly, patients, in general, preferred GP management and were less comfortable with the idea of self-management. Respondents were also more likely to engage with the options offered if they were told that controlling blood pressure could have a large effect on their risk of a future heart attack or stroke. Those recruited were predominantly white and well-educated and preferred monitoring every one to three months rather than every six months or annually.

Although the sample size of this NIHR-funded survey was small, it produced statistically significant results regarding a preference for GP-led care over self-management.

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Why was this study needed?

Around one in four adults in the UK have high blood pressure, which is a major modifiable risk factor for early death or disability from heart disease or stroke. High blood pressure accounts for around 12% of GP visits, and treating it, and the associated conditions, cost the NHS around £2 billion per year.

While GPs are responsible for making adjustments to medication, patients are becoming more comfortable with measuring their own blood pressure at home and discussing the results in the surgery. This experimental study attempted to understand how patients would feel about moving medication titration away from GPs and either making changes themselves according to a prearranged agreement with the GP, or by the pharmacist or through telehealth.

The Department of Health is keen to promote patient choice. This is the first survey of its kind that has attempted to assess patient preferences for different ways of managing hypertension.

What did this study do?

An online survey was completed by 167 patients registered at GP practices in the UK in June 2016. This was a discrete choice experiment that asked patients how likely they would be to choose one of four different models of care (GP-led, pharmacist-led, telehealth and self-management) given a set of typical characteristics of each model. The characteristics were things like the frequency of blood pressure measurement, reduction in 5-year cardiovascular risk, and costs to the NHS.

Respondents’ average age was 61.4 years, and 45% were women. The majority (82%) had been diagnosed with hypertension in the last five years and took an average of two medications for it.

The choices or preferences are therefore hypothetical, and as three of the models of care are not routinely available in the UK, participant choices may not represent their preferences when faced with a choice for real.

What did it find?

  • GP management was preferred to all other options. Although the differences in patient preferences for GP management, telehealth or pharmacist-led were not statistically significant from each other, GP management was significantly preferred to self-management.
  • Monthly to three-monthly blood pressure measurements were preferred to six-monthly or annual measurement.
  • Patients preferred models of care that were likely to be more effective in reducing cardiovascular risk. From a baseline of 25.7% of patients engaging with GP management, if they knew it would reduce the 5-year cardiovascular risk by 10% rather than 5%, then 21.5% more patients were likely to take up this model (95% confidence interval [CI), 11.5 to 31.6). If it were to reduce the risk by 25%, then 34% more patients would engage. Similar increases were found for the other models of care.
  • Overall, increases in costs were likely to deter uptake. Respondents said that they were comfortable with the cost [to the NHS] of £374.74, £398.98 and £673.45 for a 10%, 15% and 25% reduction in 5-year cardiovascular disease risk, respectively. They were willing [for the NHS] to pay £247.90 for monthly BP measurement over annual.

What does current guidance say on this issue?

NICE 2019 guidelines state that diagnosis, monitoring and treatment of hypertension should take place in the clinic, but also support home-monitoring of blood pressure, where patients are willing and motivated to do so.

If patients want to self-monitor, they should be given training and advice on how to use home blood pressure monitors. They should also be given instruction on what to do if they are not achieving their target blood pressure.

What are the implications?

These results indicate that while patients are wary of self-management, they may be open to change if some contact with healthcare professionals is maintained.

When introducing new models of care, explaining any potential benefit may encourage uptake. Other studies have found that self-monitoring of blood pressure can help reduce patient cardiovascular risk, as well as benefitting those who experience ‘white coat effect’ in clinical settings.

Larger and different types of studies will be useful in this area. Not all patients want the same thing, and minority and less well-educated groups are less likely to respond to survey requests.

Citation and Funding

Fletcher B, Hinton L, McManus R and Rivero-Arias O. Patient preferences for management of high blood pressure in the UK: a discrete choice experiment. Br J Gen Pract. 2019;8(12).

This project was funded by the NIHR School of Primary Care (project number NIHR-SPCR-2013-S18).

Bibliography

McManus RJ, Mant J, Franssen M et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391:949-59.

NHS website. High blood pressure (hypertension). Diagnosis. London. Department of Health and Social Care; updated 2019.

NICE. Hypertension in adults: diagnosis and management. NG136. London. National Institute for Health and Care Excellence; 2019.

Why was this study needed?

Around one in four adults in the UK have high blood pressure, which is a major modifiable risk factor for early death or disability from heart disease or stroke. High blood pressure accounts for around 12% of GP visits, and treating it, and the associated conditions, cost the NHS around £2 billion per year.

While GPs are responsible for making adjustments to medication, patients are becoming more comfortable with measuring their own blood pressure at home and discussing the results in the surgery. This experimental study attempted to understand how patients would feel about moving medication titration away from GPs and either making changes themselves according to a prearranged agreement with the GP, or by the pharmacist or through telehealth.

The Department of Health is keen to promote patient choice. This is the first survey of its kind that has attempted to assess patient preferences for different ways of managing hypertension.

What did this study do?

An online survey was completed by 167 patients registered at GP practices in the UK in June 2016. This was a discrete choice experiment that asked patients how likely they would be to choose one of four different models of care (GP-led, pharmacist-led, telehealth and self-management) given a set of typical characteristics of each model. The characteristics were things like the frequency of blood pressure measurement, reduction in 5-year cardiovascular risk, and costs to the NHS.

Respondents’ average age was 61.4 years, and 45% were women. The majority (82%) had been diagnosed with hypertension in the last five years and took an average of two medications for it.

The choices or preferences are therefore hypothetical, and as three of the models of care are not routinely available in the UK, participant choices may not represent their preferences when faced with a choice for real.

What did it find?

  • GP management was preferred to all other options. Although the differences in patient preferences for GP management, telehealth or pharmacist-led were not statistically significant from each other, GP management was significantly preferred to self-management.
  • Monthly to three-monthly blood pressure measurements were preferred to six-monthly or annual measurement.
  • Patients preferred models of care that were likely to be more effective in reducing cardiovascular risk. From a baseline of 25.7% of patients engaging with GP management, if they knew it would reduce the 5-year cardiovascular risk by 10% rather than 5%, then 21.5% more patients were likely to take up this model (95% confidence interval [CI), 11.5 to 31.6). If it were to reduce the risk by 25%, then 34% more patients would engage. Similar increases were found for the other models of care.
  • Overall, increases in costs were likely to deter uptake. Respondents said that they were comfortable with the cost [to the NHS] of £374.74, £398.98 and £673.45 for a 10%, 15% and 25% reduction in 5-year cardiovascular disease risk, respectively. They were willing [for the NHS] to pay £247.90 for monthly BP measurement over annual.

What does current guidance say on this issue?

NICE 2019 guidelines state that diagnosis, monitoring and treatment of hypertension should take place in the clinic, but also support home-monitoring of blood pressure, where patients are willing and motivated to do so.

If patients want to self-monitor, they should be given training and advice on how to use home blood pressure monitors. They should also be given instruction on what to do if they are not achieving their target blood pressure.

What are the implications?

These results indicate that while patients are wary of self-management, they may be open to change if some contact with healthcare professionals is maintained.

When introducing new models of care, explaining any potential benefit may encourage uptake. Other studies have found that self-monitoring of blood pressure can help reduce patient cardiovascular risk, as well as benefitting those who experience ‘white coat effect’ in clinical settings.

Larger and different types of studies will be useful in this area. Not all patients want the same thing, and minority and less well-educated groups are less likely to respond to survey requests.

Citation and Funding

Fletcher B, Hinton L, McManus R and Rivero-Arias O. Patient preferences for management of high blood pressure in the UK: a discrete choice experiment. Br J Gen Pract. 2019;8(12).

This project was funded by the NIHR School of Primary Care (project number NIHR-SPCR-2013-S18).

Bibliography

McManus RJ, Mant J, Franssen M et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391:949-59.

NHS website. High blood pressure (hypertension). Diagnosis. London. Department of Health and Social Care; updated 2019.

NICE. Hypertension in adults: diagnosis and management. NG136. London. National Institute for Health and Care Excellence; 2019.

Patient preferences for management of high blood pressure in the UK: a discrete choice experiment

Published on 12 August 2019

Benjamin Fletcher, Lisa Hinton, Richard McManus and Oliver Rivero-Arias

British Journal of General Practice , 2019

Background With a variety of potentially effective hypertension management options, it is important to determine how patients value different models of care, and the relative importance of factors in their decision-making process. Aim To explore patient preferences for the management of hypertension in the UK. Design and setting Online survey of patients who have hypertension in the UK including an unlabelled discrete choice experiment (DCE). Method A DCE was developed to assess patient preferences for the management of hypertension based on four attributes: model of care, frequency of blood pressure (BP) measurement, reduction in 5-year cardiovascular risk, and costs to the NHS. A mixed logit model was used to estimate preferences, willingness-to-pay was modelled, and a scenario analysis was conducted to evaluate the impact of changes in attribute levels on the uptake of different models of care. Results One hundred and sixty-seven participants completed the DCE (aged 61.4 years, 45.0% female, 82.0% >5 years since diagnosis). All four attributes were significant in choice (P<0.05). Reduction in 5-year cardiovascular risk was the main driver of patient preference as evidenced in the scenario and willingness-to-pay analyses. GP management was significantly preferred over self-management. Patients preferred scenarios with more frequent BP measurement, and lower costs to the NHS. Conclusion Participants had similar preferences for GP management, pharmacist management, and telehealth, but a negative preference for self-management. When introducing new models of care for hypertension to patients, discussion of the potential benefits in terms of risk reduction should be prioritised to maximise uptake.

The models of care used in this discrete choice experiment were:

GP-led: patient makes a GP appointment. Blood pressure is measured, and any necessary adjustments made to medication are done by the GP.

Pharmacist-led: patient attends walk-in service at a local pharmacy. Blood pressure is measured by the pharmacist, who makes any adjustments to medication based on GP-agreed plan.

Telehealth: patient measures blood pressure at home using a device which automatically sends the results to their GP. The GP reviews the measurements to make any changes to medication.

Self-management: patient measures blood pressure at home, and makes medication changes in accordance with GP-agreed plan.

Expert commentary

Anti-hypertensive medicines only work if they are taken and so the most effective strategy to treat hypertension is likely to be that which patients prefer. This study assessed preferences for hypertension management in older British Caucasian patients.

That reduction in cardiovascular disease (CVD) risk was the main driver of patient preference highlights the importance of vascular risk discussion when initiating and reviewing hypertension treatment.

The preference in favour of GP rather than self-management may suggest limitations on the uptake of self-management strategies, although there was little preference between GP, pharmacist and telehealth models of healthcare.

Mark Glover, MRC Clinician Scientist, Faculty of Medicine and Health Sciences, University of Nottingham

The commentator declares no conflicting interests