Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503.
Pare, Guy, Mirou Jaana, and Claude Sicotte. “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.” J Am Med Inform Assoc 14, no. 3 (May 1, 2007): 269-277
Little, Paul, Jane Barnett, Lucy Barnsley, Jean Marjoram, Alex Fitzgerald-Barron, and David Mant. “Comparison of acceptability of and preferences for different methods of measuring blood pressure in primary care.” BMJ 325, no. 7358 (August 3, 2002): 258-259.
Not pictured: Port, Kristjan, Kairit Palm, and Margus Viigimaa. “Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.” J Telemed Telecare 11, no. suppl_1 (July 1, 2005): 34-36.
There’s a potentially serious gap in the Connectivity for Californians initiative that we are addressing. Here’s a quote that illustrates it:
It is very clear from the interview data that patients have their own ideas, and spend a lot more time thinking about their BP than is apparent in the average 10-min consultation in general practice.
The gap is patient involvement in the design and planning of this initiative, or any healthcare initiative for that matter. Patients have many more ideas about what the problems are to be solved than can be gleaned even from articles like this – the articles simply show that the ideas are out there. Fortunately, we are committing ourselves to have a patient representative involved from the beginning, and that is coming together before any work is started.
The quote above is from the first paper by Rickerby, et. al (click on the images to the right to review any of the papers yourself), which described a qualitative study to look at a small number of patients’ attitudes toward monitoring their own blood pressure, in a practice that routinely recommends this.
The question (#1)
The reason I have reviewed these particular papers is because of the commonly posed question to me over the past several months, in the form of, “Ted, will/are patients really motivated to check their own blood pressure?” with the implication that they are not and they won’t. It’s a fair question that deserves an informed response. Several of the readers on this blog have given me some information from their own lives. These papers add to that knowledge.
The answer (#1)
They are and they will.
The question (#2)
This came up during reading of the papers. Does patient engagement come from having knowledge? Or does knowledge come from being engaged? This came up because patients in the first study who did not have knowledge about why they should monitor their blood pressure or how to do it seemed less engaged.
The answer (#2)
Unclear, with the implication being about whether to work to engage patients with more knowledge or use knowledge as a means test for engagement. I think regardless of the answer, there’s no reason not to provide information to patients. That answer is good enough in this case.
Read on for more conclusions….
In the qualitative piece (structured interviews of 17 patients), patients were generally satisfied that home monitoring is “acceptable and convenient.” There was a wish among patients to minimize medication use, and an information gap presented throughout about how to monitor, and whether or not home measurements were as good as the doctor’s. There is also a hint in this paper, echoed in one of the others, and in my own experience in Informatics, that patients understand the value of their doctor’s time (in addition to their own, of course):
Even though it’s the doctors job because of course, and different things in the medical centres I would have thought maybe just saving time for more serious things and other people.
It’s important to note here that the recommendation for monitoring is not every day; it’s twice a day for 7 days, once a quarter. Patients should not monitor more than twice a day, and they should not monitor throughout the day. The goal is for an average in the morning, and in the evening. The monitor should stay at home.
The second article (Pare, et. al) is a more systematic review of all forms of telemonitoring, and again, self-monitoring for hypertension is favorable in 14 studies revewed:
In general, patients were very receptive of telemonitoring as a patient management approach and showed a very positive attitude toward it.
The third and fourth articles are even more definitive on this topic. In quantitative measurement, patients prefer home monitoring over any other way to measure blood pressure, including self-measurement in the doctor’s office, ambulatory blood pressure monitoring (where you wear an automated cuff for 24 hours, even while sleeping), having a nurse do it, having the doctor do it.
One dimension that was interesting was the question about whether the patient “felt unsure of what to do” for the various methods. Uncertainty actually was increased around the doctor doing it rather than the patient.
Few patients regarded measurement by a doctor as the most acceptable method.
Conclusions, and challenges to assumptions
The Pare paper raises a very interesting question in the comments I have received – what is the acceptability of home monitoring to health care providers, and by extension health care leaders? Could it be that they/we are projecting some of our own beliefs and values onto our patients in thinking that they are uninterested in being engaged in the management of their chronic conditions? Could it also be related to the idea that we’ve grown up in a system that stresses physician acquisition of clinical data? We seem to have let that go with blood sugar measurement – but only partially. The physician still orders the hemoglobin A1c.
I think work in hypertension is a great place to involve patients from the beginning, and to establish where the locus of control should be in health care. Right now in hypertension, the locus of control is external to the patient, in the hands of the health system. From the patient perspective, though, how can this make sense, if the potential damage caused by hypertension is happening outside of the doctor’s office, the best place to measure it is outside the doctor’s office, and the most simple and effective interventions happen outside the doctor’s office.
Just something to think about. For my part, I don’t have to bring this message forward, I will involve patients who will bring this message forward. Our goal is to move the locus of control to one that is internal to the patient. How does that sound?
Comments welcomed, of course.