Self-Monitoring & Management of Hypertension
“Working at the top of our license” is a common phrase in use today. The concept is fairly straightforward: focus one’s time and energy on problems that require the highest order skills honed through training and experience. Delegate other matters to team members that may be better suited to approaching them. Of work that we are currently doing, what can we delegate to patients? What is reasonable to ask patients to do on their own, with guardrails and guidance?
I’ve shared examples in this forum already of patient self-management. Insulin self-management is a good example in use today, where patients adjust meal-time insulin based on their carbohydrate intake, exercise plans for the day, and personal correction factors. In Sweden, patients quite literally have the keys to dialysis centers, connecting themselves to machines in what is called ‘empowered dialysis.’[1] I first heard about this back in 2011 through the Institute for Healthcare Improvement when Christian Farman was highlighted at the National Forum.
Christian was diagnosed with renal failure at the age of 25. After failed kidney transplants, he ended back up on hemodialysis, and asked if he could learn to dialyze himself. The Swedish hospital where he was receiving care worked with him, and soon thereafter he was connecting himself and managing the sessions. He found he had less side effects. This has progressed now to other at-home hemodialysis solutions where patients can be in control.
“You have to help me treat myself. I need to have control in my life.” — Christian Farman
What else can we help the patient take control over?
One of several that we are exploring at Froedtert & MCW is around hypertension self-titration. We are partnering directly with patients, our pharmacists, and our physicians in this work. I’ll describe our current thinking about the programs, and I invite you to comment or engage with us directly if you are interested in joining the design of this body of work.
For hypertension, we are looking at providing self-management programs for patients, whereby they can titrate antihypertensive medications within parameters to achieve their target. In what we are calling the “Get to Goal” program, the aim is to help patients get to their goal blood pressure faster. By leveraging our digital health services, we can provide monitoring services and provide a layer of additional support.
Self-titration for blood pressure is not new. In 2012, Watson, Grant, and colleagues at the MGH created a web-based program to help guide patients, providing a protocol for self-titration of medication and finding the program feasible.[2,3]. McManus et al later published in JAMA results of the TASMIN-SR trial that showed patient self-monitoring and self-titration resulted in mean blood pressures lower by 10 mmHg than usual care, without any statistical differences in side effects. Cost analyses performed on the 2010 TASMINH 2[4] study showed that self-titration and management “represents a cost-effective use of healthcare resources.”[5]
In our approach, we are combining self-titration with our digital health platform so that our pharmacy and virtual care team colleagues can support patients in getting to the goal. Patients enrolling in the program can be loaned a blood pressure cuff for the duration of the program, if needed, and will record readings through an app. We are working with our early partner patients and the virtual care team to define the workflows, but the goal is to enable doctors to have the important conversations with patients about goal setting for hypertension, and then enable patients, supported by our virtual care team, to get there.
1. Is “Empowered” Self-Dialysis the Key to Better Outcomes? -NEJM Catalyst. In: NEJM Catalyst [Internet]. 15 Mar 2018 [cited 13 Jun 2019]. Available: https://catalyst.nejm.org/empowered-self-dialysis-better-outcomes/
2. Watson AJ, Singh K, Myint-U K, Grant RW, Jethwani K, Murachver E, et al. Evaluating a web-based self-management program for employees with hypertension and prehypertension: a randomized clinical trial. Am Heart J. ahjonline.com; 2012;164: 625–631.
3. Grant RW, Pandiscio JC, Pajolek H, Woulfe A, Pelletier A, Kvedar J, et al. Implementation of a web-based tool for patient medication self-management: the Medication Self-titration Evaluation Programme (Med-STEP) for blood pressure control. Inform Prim Care. 2012;20: 57–67.
4. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet. 2010;376: 163–172.
5. Kaambwa B, Bryan S, Jowett S, Mant J, Bray EP, Hobbs FDR, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis. Eur J Prev Cardiol. 2014;21: 1517–1530.
