Hypertension 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

Thank Morris et al

Outline

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

Prevalence 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)

Hypertension 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 > 2 medications

Low fat, high fruits/vegetables, and fiber

Goal of Hypertension

Self-management  

Small changes – great impacts

Hypertension as a Model for Self-management
        - Complex, long-term, chronic disease
        - Requires initiation and maintenance of multiple behaviors
        - Requires provider/patient communication

Significance of Self-management Adherence
        - >80% of adults took at least 1 medication in the last week; 25% took at least five 
        - Cost of medication non-adherence >$100 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

Traditional 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

Disease 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

Health Decision Model

Social  Environment 

TREATMENT  ADHERENCE 

Provider Characteristics

Communication 

Style

Medical Environment

Bosworth HB, Olsen MK, Oddone EZ. 

(2006). Am Heart J 149:795-803.l

Bosworth HB & Oddone EZ. (2002).  

J Nat Med Ass. 94; 236-248

Literacy

Perceived

 Risks

Patient Characteristics

Coping &  Stress

Side Effects

Comorbidities

Depression

Mental Health

Cognition

Medication Regimen

Treatment Guidelines Adherence

Intensity of Therapy

BLOOD  PRESSURE  CONTROL 

Policy

Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. 

HAS study led to development of a model to explain treatment adherence

EMPHASIZE THAT BOTH PATIENT/PROVIDER

Patient Characteristics Relatedto Self-management

Risk Perceptions / Knowledge

Cognition 

Memory

Inductive Reasoning

Verbal Comprehension

Literacy / Numeracy

Coping / Stress 

Avoidance

Daily hassle

Stigma

Avoidance

Discrimination

Daily hassle stress

Multiple studies have shown that patients recall and comprehend as little as 50% of what is told to them by health care providers

Patient Characteristics Relatedto Self-management

Comorbidities

Medication Side Effects

Depression/mental health

Avoidance

Discrimination

Daily hassle stress

Multiple studies have shown that patients recall and comprehend as little as 50% of what is told to them by health care providers

Social Characteristics Relatedto Self-management

Social Network

Social Support

Tangible/instrumental

Emotional

Culture

Medical Environment Related to Self-management

Access and Barriers

Insurance (i.e., co-payments, deductibles)

Transportation

Organization and staffing

Provider Characteristics Related to Self-management

Evidence-based Guideline Compliance

Medication Complexity

Medication Intensity

Provider Communication

40% veterans BP > 160/90 mm/hg despite M = 6 hypertension-related visits per year

Provider 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

Issues in Patient-Provider Communication
        - Poor patient-physician communication is common

Physicians do >60% 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

        - How do you translate this information into an intervention? 

Veterans Study to Improve TheControl of HypertensionVA Health Services ResearchInvestigator Initiated Award, 2001-06

The V-STITCH Study

The 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

The V-STITCH Study Design

Providers Randomly

Assigned (clusters)

R 1

Provider

Intervention

Provider 

Reminder

Patient

Intervention

N = 150

Patient

Usual Care

N = 151

Patient

Intervention

N = 144

Patient

Usual Care

N = 143

R 2

R 2

Provider clustering.

Patient Intervention

Patient Intervention

Hypertension Knowledge

African American

Diabetes

Family history

Literacy

Memory

Patient’s Relationship with Primary Care Provider

Social Support

Side Effects

Lifestyle Factors (smoking, alcohol, exercise, diet, stress)

Missed Appointments

Pill Refill

Tailored Behavioral Delivered via Telephone

Ex. Nurse inform overweight individuals that losing even a few pounds can have an effect on reducing one’s BP. 

In addition, when risk information is conveyed, proportions (e.g., stop smoking results in a reduction of 5 out of 10 people having a stroke”) as opposed to percentages  (“if you stop smoking, you have 50% chance of reducing your risk of having a stroke”) will be used.  The former presentation method is considered more “person oriented” as opposed to the latter, which is considered more mathematical and more difficult to understand by patients 

Patient Intervention

Frequency of Nurse-base calls
| 1st & 13th months  | Physician Interaction, Memory, Literacy, Side effects                                     |
|------------------------|-------------------------------------------------------------------------------------------|
| 3rd & 15th months  | Hypertension knowledge, Memory, Literacy, Side effects, Missed appointments, Pill refills |
| 5th & 17th months  | Lifestyle, Memory, Literacy, Side effects, Missed appointments, Pill refills              |
| 7th & 19th months  | Social Support, Memory, Literacy, Side effects, Missed appointments, Pill Refills         |
| 9th & 21st months  | Physician Interaction, Memory, Literacy, Side effects, Missed appointments, Pill Refills  |
| 11th & 23rd months | Memory, Literacy, Side effects, Missed appointments, Pill Refills                         |
| Any month              | Patient initiated                                                                         |

3 time patterns:	Set time – physician interaction, hypertension knowledge, lifestyle, social 				support;

			Baseline – memory, literacy;

			Activated when problem – side effects, missed appointment.

Patient Intervention

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 (>97%) – 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.

Mode of Administration

Ex. Nurse inform overweight individuals that losing even a few pounds can have an effect on reducing one’s BP. 

In addition, when risk information is conveyed, proportions (e.g., stop smoking results in a reduction of 5 out of 10 people having a stroke”) as opposed to percentages  (“if you stop smoking, you have 50% chance of reducing your risk of having a stroke”) will be used.  The former presentation method is considered more “person oriented” as opposed to the latter, which is considered more mathematical and more difficult to understand by patients 

Provider Intervention

Automated Treatment for Hypertension:EvideNce-based 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 

ATHENA: BP - Prescription Graphs

The BP- Prescription Graphs Tab is very useful because it allows you to view the patient’s BP control over time and relate it to current prescriptions. The yellow line will always reflect the patient’s target (140/90 or 130/85). In a glance you can notice this patient’s systolic BP has been high in the last two measurements. All BP’s included in CPRS vital signs field are included. The medications will be displayed with doses and any gaps in the lines reflect actual gaps in prescription fills.

Control group patients receive minimum pop-up window – list drugs and last BP.

Provider Control Group

Displayed patient's most recent BP

Displayed patient’s current antihypertensive drug regimen

Provided opportunity to update BP  

Offered no advisories or recommendations for medication management

Simply a reminder for hypertension

Primary 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

CLUSTERING !

Patient Identification 

816 

Contacted either by Telephone or In-person

588 Enrolled 
        -  76% participation rate

190            Refused

38 Excluded
        -  Hospitalized last 3 months  
        -  Dementia diagnosis
        -  Resident in nursing home 
        -  Severely impaired hearing              or speech 

4017 

ICD code for Hypertension 

Hypertensive Medication

Enrolled  Durham VA
        -  85% 24 month retention rate

Patient Characteristics (N=588)

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%

Mostly men

Patient Characteristics

Taking BP meds for > 5 years		64%

Close relative with hypertension		65%

No exercise					44%

Smoke						30%

Diabetic						40%

BP in control at Baseline:			42%

	< 130 / 85 mm/Hg diabetic

	< 140 / 90 mm/Hg non-diabetic 

	Mean Systolic BP 138.4 (SD=18)

	Mean Diastolic BP 75.5  (SD=11)

Mention BP control based upon JNC 6 because that is when the study started.

Primary Outcome

Blood pressure control at every primary care provider clinic visit over 24 months

time in weeks

bp control

0

10

20

30

40

50

60

no

yes

patient 1

time in weeks

bp control

0

10

20

30

40

50

60

no

yes

patient 2

time in weeks

bp control

0

10

20

30

40

50

60

no

yes

patient 3

time in weeks

bp control

0

10

20

30

40

50

60

no

yes

patient 4

Blood pressure obtained at any primary care clinic visit over the 24 months

Standard VA Clinic Protocol, RN measured with IVAC/Alaris oscillometric  devices 

Time in Months

BP Control

0.2

0.3

0.4

0.5

0.6

0.7

0

6

12

18

24

Blood Pressure Control Rates

Primary Analysis

Reminder

 N=143

Behavioral

 N=144

Decision 

Support

 N=151

Combined

 N=150

Time Effect: P=.01

Group*Time Effect: P=.11

Footnote: Expected baseline to 24-month improvement for the combined group was 21% (p-value = 0.005); improvement for the tailored behavior only group was 20% (p-value = 0.003); improvement for the usual care control group was 17% (p-value=0.01).  There was no change in BP control for the medication management group (p-value = 0.97). 

Nurse Behavioral Intervention vs. None

Secondary Analysis

Time in Months

BP Control

0.40

0.50

0.60

0.70

0

6

12

18

24

RN Behavioral

N=294

No RN

N=294

P=0.03

Compliance with Nurse Telephone Intervention
        - Patients completing all 12 scheduled study calls:	 85%
        - Average length of call:	

				3 minutes  (SD 2.5 min)

Primary Care VisitsDuring Study (24 Months)
| Mean             | SD  |
|------------------|-----|
| Usual Care       | 7.7 | 4.7 |
| Behavior only    | 7.3 | 3.6 |
| Decision Support | 7.4 | 3.6 |
| Combined         | 7.1 | 3.5 |

7.7 (SD=4.7; median=7.0); was 7.4 (SD=3.6; median=7.0); and combined was 7.1 (SD=3.5; median=7.0) 

Two-Year Outpatient Costs
| Cost Category                   | Total cost | Average cost per Subject |
|---------------------------------|------------|--------------------------|
| Behavioral intervention (n=294) | $2,863,775 | $9,741                   |
| Non-Behavioral(N=294)           | $2,822,215 | $9,599                   |

< 130 / 85 mm/Hg diabetic;  < 140 / 90 mm/Hg non-diabetic.

Average Behavioral Intervention Costs Per Patient over 24 months
| Cost Category            | Patients Overseen by Nurse |
|--------------------------|----------------------------|
| Number of Patients       | 1120                       | 840 | 560 |
| Direct Costs/per patient | $70($61-81)                | $94($82-$109) | $141($123-$163) |
| Average min/per patient  | 15                         | 20 | 30 |

< 130 / 85 mm/Hg diabetic;  < 140 / 90 mm/Hg non-diabetic.

Provider 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

For the 929 visits in which the provider intervention was displayed, providers interacted with the intervention 56.8% of the time (n=528) (across all patient visits, providers interacted with the provider intervention for 528 of the 1370 visits 38.5%).  The most common form of interaction with the intervention was updating patients’ BP and subsequently considering a medication recommendation.  Across all visits where the provider intervention was displayed and the provider interacted with the intervention, the BP control rates were 54.2% and 45.1% when the provider intervention was displayed, but the provider did not interact with the intervention. 

Provider 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

For the 929 visits in which the provider intervention was displayed, providers interacted with the intervention 56.8% of the time (n=528) (across all patient visits, providers interacted with the provider intervention for 528 of the 1370 visits 38.5%).  The most common form of interaction with the intervention was updating patients’ BP and subsequently considering a medication recommendation.  Across all visits where the provider intervention was displayed and the provider interacted with the intervention, the BP control rates were 54.2% and 45.1% when the provider intervention was displayed, but the provider did not interact with the intervention. 

Summary

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

At 12 months 8% - overall, nurse intervention 

Demographic Factors

Education

Income

Psychosocial Factors

Social support				Risk Perception

Participatory Decision making		Literacy

Memory					Knowledge

Clinical Factors

Diabetes					 Parental history

Use of home BP monitor		 Exercise

Length of being hypertensive		 Smoking

Number of hypertensive meds

Number of side effects and specific side effects

Next 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? 

Among displayed, providers interacted with intervention 57% of time (38.5% overall)

(54% control when provider interacted versus 45% when provider did not interact)

Hypertension Intervention Telemedicine Study(HINTS)

Department of Veterans Affairs, 

Grant IIR 04-426 (2005-2008)

Established Investigator Award, 

American Heart Association (2006-2011)

Hypertension 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

Enrolled 230 thus far

HINTS 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

Interventions activated when home BP poorly controlled

Bp values 5 points lower

Non-diabetic 135/85

Diabetic 130/85

Why 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

Case 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

Define telemedicine – home BP values transmitted to central location

HINTS Study:  Telemedicine

Interventions activated when home BP poorly controlled

Baseline Patient Characteristics

546 subjects enrolled

Minority				51%

Low Literate			38%

Diabetic				44%

Males				98%

**Make sure you have explained the safety alerts.

result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

Summary of Intervention

Safety alert activated 

	(2 values within 12 hours >175 systolic, >105 diastolic, pulse <40 or >110) 

	144 times, 51 unique pts

Intervention activated 	

	687 times, 241 unique pts

Praise alert activated		

	74 times, 68 unique pts

**Make sure you have explained the safety alerts.

result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

Summary 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

**Make sure you have explained the safety alerts.

result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

Home Readings: Console View

RN:MD Dialogue for Medication Change

Outcomes

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

Self-efficacy found to significantly increase intervention group whereas decrease in usual care.

Summary 

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

Recommendations 
        -  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)

Recommendations 

Educational Interventions 
        -  Knowledge alone will not change behavior 
        -  Establish what is known before offering new knowledge  
        -  Use concrete examples

Recommendations 

Ways of Presenting Written Information
        -  Instructions should be clear and structured
        -  Picture charts, color-coded medication schedules and large print 

Recommendations 

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

Recommendations 

Clinical Issues
        -  Key validated question “Have you missed any pills in the past week?” 
        -  Sensitivity > 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  

Recommendations 

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.

Recommendations
        - Effective, collaborative provider-patient communication should be the foundation of all clinical interventions designed to improve patient self-management.

Future 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

Acknowledgements

	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

Relevant Publications
        - Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention Nurse Telemedicine 

Study (HINTS). Am Heart J 2007;153(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 2005;26:155-68.

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 2004;11(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 2004;11(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 2000:300-4.

6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in guideline-based decision 

support for hypertension management: ATHENA DSS. Proc AMIA Symp 2001:214-8.

Relevant 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 2006:494-8.

8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. J Clin Outcomes Management 2004;11(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 2006;119(1):70.

11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of 

blood pressure control. Journal of the National Medical Association 2002;94:236-248.

12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone intervention for 

blood pressure control. Patient Educ Couns 2005;57(1):5-14.

13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control by tailored 

feedback to patients and clinicians. Am Heart J 2005;149(5):795-803.