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 - PowerPoint PPT Presentation

1 / 68
About This Presentation
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

Description:

Physician Interaction, Memory, Literacy, Side effects, Missed appointments, Pill Refills ... Patient Identification. 816. Contacted either by Telephone or In ... – PowerPoint PPT presentation

Number of Views:297
Avg rating:3.0/5.0

less

Transcript and Presenter's Notes

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


1
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
2
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

3
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)

4
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 gt 2 medications

5
Goal of Hypertension Self-management
6
Hypertension as a Model for Self-management
  • Complex, long-term, chronic disease
  • Requires initiation and maintenance of multiple
    behaviors
  • Requires provider/patient communication

7
Significance 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

8
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

9
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

10
Health 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
11
Patient Characteristics Relatedto Self-management
  • Risk Perceptions / Knowledge
  • Cognition
  • Memory
  • Inductive Reasoning
  • Verbal Comprehension
  • Literacy / Numeracy
  • Coping / Stress
  • Avoidance
  • Daily hassle
  • Stigma

12
Patient Characteristics Relatedto Self-management
  • Comorbidities
  • Medication Side Effects
  • Depression/mental health

13
Social Characteristics Relatedto Self-management
  • Social Network
  • Social Support
  • Tangible/instrumental
  • Emotional
  • Culture

14
Medical Environment Related to Self-management
  • Access and Barriers
  • Insurance (i.e., co-payments, deductibles)
  • Transportation
  • Organization and staffing

15
Provider Characteristics Related to
Self-management
  • Evidence-based Guideline Compliance
  • Medication Complexity
  • Medication Intensity
  • Provider Communication

16
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
17
Issues 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?

19
Veterans Study to Improve TheControl of
HypertensionVA Health Services
ResearchInvestigator Initiated Award, 2001-06
The V-STITCH Study
20
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

21
The V-STITCH Study Design
22
Patient Intervention
23
Patient 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

24
Patient Intervention
Frequency of Nurse-base calls
25
Patient 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
  • Provider Intervention

27
Automated 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

28
ATHENA BP - Prescription Graphs
29
Provider 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

30
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

31
Patient Identification
32
Patient 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

33
Patient 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)

34
Primary 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
35
Blood 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
36
Nurse 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
37
Compliance with Nurse Telephone Intervention
  • Patients completing all 12 scheduled study
    calls 85
  • Average length of call
  • 3 minutes (SD 2.5 min)

38
Primary Care VisitsDuring Study (24 Months)
 
39
Two-Year Outpatient Costs
 
40
Average Behavioral Intervention Costs Per
Patient over 24 months
 
41
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

42
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

43
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

44
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?

45
Hypertension Intervention Telemedicine
Study(HINTS)
Department of Veterans Affairs, Grant IIR 04-426
(2005-2008) Established Investigator Award,
American Heart Association (2006-2011)
46
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

47
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

48
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

49
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

50
HINTS Study Telemedicine
51
Baseline Patient Characteristics
  • 546 subjects enrolled
  • Minority 51
  • Low Literate 38
  • Diabetic 44
  • Males 98

52
Summary 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

53
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

54
Home Readings Console View
55
RNMD Dialogue for Medication Change
56
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

57
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

58
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)

59
Recommendations
  • Educational Interventions
  • Knowledge alone will not change behavior
  • Establish what is known before offering new
    knowledge
  • Use concrete examples

60
Recommendations
  • Ways of Presenting Written Information
  • Instructions should be clear and structured
  • Picture charts, color-coded medication schedules
    and large print

61
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

62
Recommendations
  • 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

63
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.

64
Recommendations
  • Effective, collaborative provider-patient
    communication should be the foundation of all
    clinical interventions designed to improve
    patient self-management.

65
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

66
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
67
Relevant 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.

68
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 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.
Write a Comment
User Comments (0)
About PowerShow.com