AIM: Interventions uninspiring in telemedicine BP study
Researchers found overall moderate effects of three blood pressure control interventions tested on more than 1,500 patients from May 2006 to July 2009, according to study findings published online July 11 in the Archives of Internal Medicine.
In an accompanying commentary, William B. White, MD, and Nancy M. Petry, PhD, wrote that the findings should be of interest to primary care practitioners, and certain aspects of nurse telemedicine intervention could be implemented into primary care practices. They called the findings “disappointing, however, because despite a large effort, results were not sustained after an 18 month period."
In a four-arm randomized trial, Hayden B. Bosworth, PhD, of health services research and development at Durham Veterans Affairs Medical Center, N.C., and colleagues, placed eligible patients into one of three telephone-based intervention groups. They consisted of nurse-administered behavioral management, nurse- and physician-administered medication management or a combination of both. There were 1,551 eligible patients in the study, of which 593 were randomized and 48 percent were African American.
Patients were eligible for the study if they had been diagnosed with hypertension and were using a blood pressure-lowering medication, according to the study. Excluded patients were those with kidney disorders, organ transplants, cancer or dementia; as well as those without a telephone or who resided in a nursing home.
The study consisted of interventional phone calls which were triggered at home by blood pressure values transmitted via telemedicine. At the time of a call, investigators would encourage behavioral management—which included 11 behavior modules focused on improving hypertension—or medication management—which consisted of a medication change based on decision support software. Some patients underwent a combination of both the interventions; and all patients, in addition to a control group, were also administered usual care practices.
Researchers evaluated the results at six, 12 and 18 months. At 12 months, improvement in blood pressure control was significant in the behavioral management group as well as the medication group, but less so for the combined group. At 18 months, however, only the combined intervention group showed evidence of improved blood pressure control. “However, the difference was not statistically significant,” the authors wrote.
“Each intervention demonstrated improvements in blood pressure control or systolic blood pressure at 12 months; none of these improvements were sustained at 18 months and did not result in lower medical care costs. However, among those individuals with poor baseline blood pressure control, the combined intervention significantly decreased systolic blood pressure and diastolic blood pressure at 12 and 18 months,” Bosworth et al concluded.
In the accompanying commentary, White and Petry noted that the most successful results occurred in individuals who underwent both the behavioral and medication interventions, sustaining a 10 percent improvement from baseline at 12 months. More impressive, wrote the researchers, were results associated with the nurse-telemedicine interventions in those with inadequate control of blood pressure prior to entering the program. However, White and Petry noted that patients were included based on one-year of inadequate blood pressure control.
However, the results were unimpressive, considering the effort involved.
“Collectively, a large effort was made by the nurse clinicians to improve blood pressure control rates, and while this type of intervention was effective in a previous 24-month study of the same investigative group, results were not sustained after 12 months in the present trial,” White and Petry concluded. “The cost of the combined intervention was estimated at $1,153 for 18 months, an amount that could be justified if a large enough proportion of patients achieved enough improvement in blood pressure control to ultimately lead to a reduction in strokes, congestive heart failure, and other cardiovascular events in patients with uncontrolled hypertension.”
In an accompanying commentary, William B. White, MD, and Nancy M. Petry, PhD, wrote that the findings should be of interest to primary care practitioners, and certain aspects of nurse telemedicine intervention could be implemented into primary care practices. They called the findings “disappointing, however, because despite a large effort, results were not sustained after an 18 month period."
In a four-arm randomized trial, Hayden B. Bosworth, PhD, of health services research and development at Durham Veterans Affairs Medical Center, N.C., and colleagues, placed eligible patients into one of three telephone-based intervention groups. They consisted of nurse-administered behavioral management, nurse- and physician-administered medication management or a combination of both. There were 1,551 eligible patients in the study, of which 593 were randomized and 48 percent were African American.
Patients were eligible for the study if they had been diagnosed with hypertension and were using a blood pressure-lowering medication, according to the study. Excluded patients were those with kidney disorders, organ transplants, cancer or dementia; as well as those without a telephone or who resided in a nursing home.
The study consisted of interventional phone calls which were triggered at home by blood pressure values transmitted via telemedicine. At the time of a call, investigators would encourage behavioral management—which included 11 behavior modules focused on improving hypertension—or medication management—which consisted of a medication change based on decision support software. Some patients underwent a combination of both the interventions; and all patients, in addition to a control group, were also administered usual care practices.
Researchers evaluated the results at six, 12 and 18 months. At 12 months, improvement in blood pressure control was significant in the behavioral management group as well as the medication group, but less so for the combined group. At 18 months, however, only the combined intervention group showed evidence of improved blood pressure control. “However, the difference was not statistically significant,” the authors wrote.
“Each intervention demonstrated improvements in blood pressure control or systolic blood pressure at 12 months; none of these improvements were sustained at 18 months and did not result in lower medical care costs. However, among those individuals with poor baseline blood pressure control, the combined intervention significantly decreased systolic blood pressure and diastolic blood pressure at 12 and 18 months,” Bosworth et al concluded.
In the accompanying commentary, White and Petry noted that the most successful results occurred in individuals who underwent both the behavioral and medication interventions, sustaining a 10 percent improvement from baseline at 12 months. More impressive, wrote the researchers, were results associated with the nurse-telemedicine interventions in those with inadequate control of blood pressure prior to entering the program. However, White and Petry noted that patients were included based on one-year of inadequate blood pressure control.
However, the results were unimpressive, considering the effort involved.
“Collectively, a large effort was made by the nurse clinicians to improve blood pressure control rates, and while this type of intervention was effective in a previous 24-month study of the same investigative group, results were not sustained after 12 months in the present trial,” White and Petry concluded. “The cost of the combined intervention was estimated at $1,153 for 18 months, an amount that could be justified if a large enough proportion of patients achieved enough improvement in blood pressure control to ultimately lead to a reduction in strokes, congestive heart failure, and other cardiovascular events in patients with uncontrolled hypertension.”