Self-management of Hypertension

Self-monitoring Underused

Medscape: What is the main message from the TASMIN-SR results, and what are the implications for general practitioners in the treatment of hypertension?

Prof McManus: We have shown that people with a history of coronary heart disease, diabetes, stroke, or chronic kidney disease who are willing to self-monitor their BP and adjust their own medication can, by working in partnership with their providers, achieve significantly better BP control compared with usual care. We know from a survey we did that about 1 in 3 people in the United Kingdom with hypertension are currently self-monitoring BP,^[24] and we have some unpublished data suggesting that this figure may be nearer 40%. It strikes me that this is a potential population that is probably being underused at the moment. I have always been surprised—given that in asthma, diabetes, or even anticoagulation, it would be commonplace for people to self-titrate their medications—that until our previous study^[15] and the one we have just published,^[17] very little was published in the international literature about self-titrating in hypertension. Obviously there are some limitations. For instance, if you are asking patients to adjust doses of angiotensin-converting enzyme (ACE) inhibitors or similar kinds of drugs, you have to be willing to do blood tests, but we have shown that these difficulties can be overcome without enormous amounts of time.

We also know, from work related to our survey, that about half of the people who self-monitor currently never tell their family physician that they are doing it, so it would be useful for family physicians, when discussing hypertension with a patient, to ask whether they are self-monitoring. We found that a number of the physicians were quite surprised about some of the patients who were able to self-manage, and they may also be surprised at some of the patients who already measure their own BP, which then would give them the opportunity to talk about whether self-titration would be appropriate.

Medscape: In separate comments to Medscape's heartwire,^[25] the authors of the JAMA editorial suggested that healthcare providers might be more likely to support a home-management approach if there were financial incentives for doing so, whereas office visits for BP measurement "are a way to get reimbursed for healthcare easily without too many resources spent in a commercial medical care system."

Prof McManus: Those sorts of arguments may apply in the US healthcare system, where a fee for service is paid, but in the United Kingdom, it is mostly done on a capitation basis, and so there is less of an issue about needing to bill.

Medscape: Do you think that self-management of BP could be interpreted as clinicians passing the buck a bit in an area that can sometimes be complex?

Prof McManus: The other side of the issue is that healthcare does involve the patient, so involving patients in their own care is a good thing. There is a lot of evidence, in terms of such theoretical concepts as self-efficacy, that people do better if they are more involved and confident about what they should be doing for their own care. We hope that it won't require a lot of extra work, but if patients can get their BPs down, it will allow the clinician to concentrate on other problems. I see it as part of a partnership rather than dumping it on the patient.

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