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Has the time come for self-management of blood pressure and antihypertensive medications by patients?

Omboni, Stefano

doi: 10.1097/HJH.0000000000001797

Clinical Research Unit, Italian Institute of Telemedicine, Solbiate Arno, Varese, Italy

Correspondence to Stefano Omboni, MD, Clinical Research Unit, Italian Institute of Telemedicine, Via Colombera, 29, 21048 Solbiate Arno, Varese, Italy. Tel: +39 0331 984176; e-mail:

In their article, Schwartz et al. [1] evaluated adherence to self-management interventions based on home blood pressure (BP) monitoring and an individualized self-titration algorithm in a high-risk population of hypertensive patients with cardiovascular comorbidities recruited in a primary care setting and followed up for 1 year. In the 166 patients who properly completed the self-monitoring and self-management program SBP dropped by 20 mmHg as compared with the 12 mmHg BP reduction of the 38 patients who did not. Patients who completed the self-management program were prescribed more medications (3.6) at 1 year compared with the patients who stopped self-monitoring completely (2.3). Every patient who completed the self-management period implemented nearly three medication changes, which were responsible of an increased frequency of contacts with healthcare professionals and a lower achieved SBP. The authors concluded that the proposed self-monitoring and self-management program can be effective in improving BP control, provided that careful training about the procedure and monitoring of patient's fidelity is ensured.

The self-management algorithm in the TASMIN-R study was based on a color-coded chart, which helped the patients interpret the reading. The patients were asked to contact their surgery for advice or to make a management decision, including medication self-titration based on an individualized self-management plan, depending on the level of BP and the persistence over time of raised BP values. Given the complexity of the study protocol, before commencing the study, all the patients were offered training sessions on how to follow the self-monitoring protocol and how to interpret the color code and implement a medication change. Of the 276 patients randomized to the intervention, 51 (18.4%) did not complete the training session, and all of them except one did so because of their own choice. An additional 15 patients at the start of the study and nine during the study were switched to self-monitoring alone because they were unable to properly self-manage their treatment, totaling the number of patients with self-monitoring ± self-managing at 12 months to 182 and those who completed self-management to 166 (60.1% of the randomized patients). This high rate of patients not complying with the study protocol was larger than that observed in a similar study of the same group (TASMINH2) performed in younger patients with fewer comorbidities (39.9% of randomized patients did not complete the TASMIN-SR study vs. 28.5% for the TASMINH2 study) [2]. The complexity and the challenging aspects of the self-management algorithm implemented in the TASMIN-R study may have facilitated patients’ withdrawals. The low rate of persistence with the study procedures in the TASMIN-R study also suggests that simpler approaches based on more user-friendly tools, with automatic decision-making algorithms under the supervision of a trained case manager (e.g. a nurse or a doctor), should be preferred [3]. The introduction of mobile health solutions and dedicated applications for home telemonitoring of hypertensive patients may help in this regard [4,5].

In the TASMIN-R study, patients had to record their BP values on a paper sheet and send a copy of their readings each month to the research team. They were also asked to bring the BP monitor to the clinic during follow-up visits, in order to allow download of BP readings from the device memory. Electronic BP readings and paper records were compared and scored for accuracy of reporting. 89.6% of submitted readings were accurate compared with corresponding values downloaded from the BP-monitoring device, with a mean error rate per patient of 5.2%. Patient's awareness of the device memory did not significantly improve the accuracy of reported readings. Misreporting and selective reporting was more common at increased age (>65 years) and affected subsequent management for a very small percentage of months (2.2%). The discrepancy between stored and reported BP values did not significantly affect the mean BP achieved at study end, making such an approach reliable and useful, provided that attention is paid to adequate training and tight monitoring of patients, particularly those at advanced age. As a matter of fact, the nonoptimal performance of the proposed hypertension management model in older individuals should not be undervalued. This is because the majority of patients recruited in the TASMIN-R study were aged 65 years or older (although an age ≥35 years was the eligibility criteria) and because hypertension is a quite common condition in the elderly, being associated with an increased risk of BP-related complications and mortality [6]. Future studies evaluating the efficacy and feasibility of self-monitoring and self-management of hypertension should include also younger high-risk patients, although we acknowledge that the proportion of such patients is lesser at younger ages.

Interestingly, the level of accuracy of BP measured by patients at home in the TASMIN-R study was better than that of early studies based on self-BP monitoring with no remote case management [7–9]. In these studies, the precision of BP readings ranged between 68 and 76%, under-reporting between 2 and 35% and over-reporting between 7 and 9%. The use of BP telemonitoring tools with store-and-forward technology should reduce this error as suggested by few studies [10,11] and thus this solution should be preferred, particularly in high-risk and older patients.

In the 181 participants who continued to self-monitor or self-manage their hypertensive condition throughout the study, the proportion of months with BP on target increased from 6.6% during the first 6 months to 19.2% during the second 6 months. This proportion is disappointedly low and suggests that the proposed approach might not be ideal to achieve adequate BP control in high-risk aged hypertensive patients. It is likely that this finding might be the result of the choice of a too low home BP target (<120/75 mmHg) rather than depending on the inappropriateness of the self-management model.

Thus, in conclusion, the results of the TASMIN-SR study encourage the use of self-management and self-monitoring of BP in high-risk hypertensive patients in primary care. Although fidelity with the procedure is associated with a consistent BP drop, the need of training and constant supervision suggest that the proposed algorithm could better be implemented in automated management systems based on BP telemonitoring and remote case management by trained healthcare professionals.

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Conflicts of interest

There are no conflicts of interest.

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