How Far Could This Go?
Medscape: You wrote that 20% of patients might be able to use self-monitoring and self-medication titration. Did you mean 20% of people at high risk for CV disease or 20% of everyone with hypertension?
Prof McManus: We didn't originally include that in our paper, but one of the reviewers requested it. We know that 30%-40% of people are self-monitoring, and this number is increasing all the time, so we don't see any reason why a good proportion of people who have their own monitor couldn't do this. It's not exactly rocket science.
Medscape: In TASMINH2, you used telemonitoring, sending the BP readings to the researcher team through a modem connected to the sphygmomanometer and plugged in to the patient's phone. Although you didn't use it in TASMIN-SR, would your ultimate aim be to use telemonitoring for home measurements?
Prof McManus: For TASMIN-SR, we reverted slightly, and the patients recorded their BPs on paper. It was a carbonized sheet, and they could send the top copy back to the physician. The physician could see what the patient's BP recordings were and agree regarding the next medication change, where appropriate, without needing to have the patient come in. We did it that way because everyone can cope with a piece of paper. But telemonitoring would need an appropriate system to be set up. We wanted to have a relatively simple intervention that anyone could do. The next randomized trial that we are just starting, the Telemonitoring and/or Self-Monitoring in Hypertension Trial (TASMINH4), is comparing usual care with doctor-adjusted medication based on self-monitored readings with or without telemonitoring. For the telemonitoring, BP readings will be transmitted to a secure, centralized database using a free SMS text message system, which again is slightly trailing-edge technology, but everyone nowadays has a phone that they can text on, so we are going to see whether this brings any added value.
Medscape: Do you think you might be able to come up with a structure that could be introduced for use on a wider scale—for example, throughout the National Health Service in the United Kingdom? Could it be introduced gradually or would it have to be a whole new system?
Prof McManus: It could definitely be done gradually. We have shown that self-monitoring is safe and effective for people who are prepared to self-monitor and self-titrate, both hypertensive patients and those in high-risk groups. We are now looking at the next group of patients who might be prepared to self-monitor but don't want to self-titrate. The nirvana would be a world where you are able to offer an intervention that involves self-monitoring, and then the patient chooses whether they want to get more involved and do the self-titration or want their healthcare provider to perform that component. That is a little ahead of the evidence. Arguably, you would want to do a big trial to see whether you could show an effect on CV events. That would be ideal, but there is a bit of a question about whether that would be ethical because we know that lowering BP is a good thing.
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Cite this: Self-management of Hypertension: Are Patients and Providers Ready to Partner? - Medscape - Nov 24, 2014.