Fast track — ArticlesTelemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial
Introduction
Raised blood pressure remains a key risk factor for cardiovascular disease, the largest cause of morbidity and mortality worldwide, yet only about half of people on treatment for hypertension have their blood pressure controlled to current recommended levels.1, 2 This difficulty in achieving control is despite substantial advances in the evidence base for both lifestyle and pharmaceutical interventions.3, 4 Therefore, there is a potentially important role for novel interventions to lower blood pressure, especially in primary care, where management of hypertension mainly takes place.
One such approach is patient self-management, which has gained widespread use in other chronic conditions such as diabetes5 and anticoagulation control.6 Prerequisites for self-management are the ability and willingness of a patient to self-monitor. Several randomised controlled trials have shown that self-monitoring of blood pressure can lead to blood pressure control that is at least as good as office-monitored blood pressure; it can also result in slightly better control, perhaps as a result of better adherence to treatment.7, 8 Patient management with self-titration (ie, adjustment) of antihypertensive drugs has previously only been tested on a small scale in 31 individuals with chronic stable hypertension from primary and secondary care clinics:9 a bespoke drug titration schedule incorporating current drugs resulted in a lower daytime ambulatory mean arterial pressure of 2·9 mm Hg at 8 weeks compared with usual care.
Another new approach is telemonitoring, whereby readings made at home are relayed to a health-care professional who can take appropriate action. This strategy shows some promise in heart failure, where it is associated with lower rates of hospital admission and reduced mortality compared with usual care.10 A systematic review in 2007 found 14 studies that assessed telemonitoring for hypertension, of which only three were randomised controlled trials. These studies showed that home telemonitoring for hypertension can produce reliable and accurate data, and is well accepted by patients.11 In the setting of self-management, telemonitoring adds a safety net by which researchers and clinicians can be reassured that patients are not ignoring very high (or low) readings.
The Telemonitoring and Self-Management of Hypertension Trial (TASMINH2) assessed whether self-management of hypertension, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements could lead to substantial reductions of blood pressure sustained for 1 year.
Section snippets
Study design and participants
TASMINH2 was a prospective, randomised open trial with automated ascertainment of endpoint. The protocol of the trial has been published elsewhere.12 Potential participants were identified by their own family doctor by use of electronic searches of practice clinical record systems in 24 general practices in the West Midlands, UK, between March, 2007, and May, 2008.13
Patients were eligible for enrolment if they were aged 35–85 years, receiving treatment for hypertension with two or fewer
Results
Figure 1 shows the trial profile. 527 patients from 24 general practices (range 8–56 patients per practice) were randomly assigned to study group, of whom 480 (91%) attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome (complete cases). Two patients attended follow-up but had no data for blood pressure because of intolerance to measurement in one case and a machine error in the other. Table 1 shows baseline characteristics of the complete cases.
Discussion
This study shows that self-management of hypertension, consisting of regular self-measurements of blood pressure and a simple predetermined titration plan for antihypertensive drugs, is more effective in lowering systolic blood pressure than is usual care during 1 year. The absolute reduction in blood pressure (5·4/2·7 mm Hg) is equivalent to a reduction in risk of stroke of more than 20% and in coronary heart disease of more than 10%.3 Subgroup analyses were not powered a priori, but no clear
References (36)
- et al.
A randomized study comparing a patient-directed hypertension management strategy with usual office-based care
Am J Hypertens
(1997) - et al.
Systematic review of home telemonitoring for chronic diseases: the evidence base
J Am Med Inform Assoc
(2007) - et al.
Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension
Lancet
(1997) - et al.
Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control
Am Heart J
(2007) Quality and outcomes framework 2008/09. Online GP practice results database
- et al.
Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies
BMJ
(2009) - et al.
Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials
J Hypertens
(2006) - et al.
Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature
Diabetes Educ
(2007) Self-management of anticoagulation
Expert Rev Cardiovasc Ther
(2008)
Does self monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials
Ann Med
A systematic review of the effects of home blood pressure monitoring on medication adherence
J Clin Hypertens (Greenwich)
Home telemonitoring for congestive heart failure: a systematic review and meta-analysis
J Telemed Telecare
Protocol for a randomised controlled trial of telemonitoring and self-management in the control of hypertension: telemonitoring and self-management in hypertension. [ISRCTN17585681]
BMC Cardiovasc Disord
How representative of primary care are research active practices? Cross-sectional survey
Fam Pract
Validation of a short orientation-memory-concentration test of cognitive impairment
Am J Psychiatry
CG34 hypertension (persistently high blood pressure) in adults—NICE guideline
Quality and outcomes framework guidance
Cited by (460)
Routine Prenatal Care
2023, Obstetrics and Gynecology Clinics of North AmericaPostpartum remote home blood pressure monitoring: the new frontier
2023, AJOG Global ReportsMedication Adherence: Focus on Improvement
2023, Hypertension: A Companion to Braunwald's Heart DiseaseHome Monitoring of Blood Pressure
2023, Hypertension: A Companion to Braunwald's Heart DiseaseDigital redesign of hypertension management with practice and patient apps for blood pressure control (PIA study): A cluster-randomised controlled trial in general practices
2023, eClinicalMedicineCitation Excerpt :However, routine implementation remains a challenge with improvement shown by IT-supported strategies. In eight studies with ICT (information and communication technology)-supported hypertension management, BP was reduced significantly by −6.0 to −21.4 mmHg systolic and −2.3 to −9.4 mmHg diastolic after 6 months.6–13 The ICT systems studied differ in their degree of ICT support for the complex care processes of hypertension management.
Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application
2024, Journal of the American Heart Association