Project objectives

Self-monitoring reduces clinic blood pressure compared to usual care. A recent individual patient data analyses suggest that larger reductions can be achieved where self-monitoring is combined with more intensive co-interventions. However, the same analysis also showed that self-monitoring may not be as effective in patients with co-morbid conditions such as myocardial infarction or stroke.

Brief summary

Aims & objectives

To establish whether self-monitoring is effective at controlling blood pressure in the co and multi-morbid population.

Research design

This is an individual patient data analyses of studies examining the efficacy of self-monitoring for patients with hypertension. The presented analyses will examine the efficacy of self-monitoring of blood pressure in all multi-morbid patients enrolled to previous trials.

Methods

This was an individual patient data analysis of the efficacy of self-monitoring of blood pressure in hypertensive patients with multimorbidity. Individual patient data from 14 randomised trials comparing blood pressure self-monitoring to usual care for 12 months were collated. Data from all studies were pooled in a two-stage individual patient data meta-analysis using logistic regression to estimate the relative risk of blood pressure control at 12 month follow-up with self-monitoring.

Key findings, Results

Individual patient data were available for total of 6,086 patients. Self-monitoring was associated with an increased likelihood of blood pressure control at follow-up compared to usual care in patients with 1 to 3 co-morbidities (RR 1.36, 95%CI 1.13-1.64 [1 morbidity]; 1.54 95%CI 1.18-2.02 [3 co-morbidities]), but there was no evidence of benefit in those with 4 or more co-morbidities (RR 1.11, 95%CI 0.55-1.57). In patients with diabetes, stroke, CHD, CKD or obesity, self-monitoring was only associated an increased likelihood of with blood pressure control when combined with higher intensity co-interventions (diabetic patients: RR 1.06 95%CI 0.71-1.56 [low intensity intervention] vs. 1.48 95%CI 1.12-1.95 [high intensity intervention]).

Expected impact

Conclusions

These data suggest that self-monitoring of blood pressure results in better blood pressure control in patients with multi-morbidity, except in those individuals with 4 or more co-morbid conditions.  Self-monitoring appears to be effective in specific co-morbid conditions such as diabetes and stroke, but only when combined with more intensive co-interventions such as self-management, education or lifestyle counselling.

Plain English summary

Background

It is common for individuals to have more than one chronic condition requiring management in Primary Care with estimates suggesting up to 1 in 2 patients may suffer from so called ‘multimorbidity’. However, strategies to manage such patients are scarce and there is little evidence for interventions to improve outcomes in this population. What little evidence exists suggests that self-management and a focus on managing specific risk factors may improve outcomes.

One of the most common co-morbid conditions is high blood pressure (hypertension), there is an increasing body of evidence, which suggests that self-monitoring can improve the management of hypertension. Previous studies have enrolled patients with multi-morbid conditions. None however, have been powered to examine the effectiveness of self-monitoring in multi-morbid sub-groups.

Aim

To establish whether self-monitoring of blood pressure is effective at controlling blood pressure in this population and provide evidence to inform future studies examining the wider use of self-monitoring and self-management strategies to improve the control of multiple risk factors in patients with multi-morbidity.

Method

Using individual patient data from 14 previous clinical trials, this study examined the effectiveness of self-monitoring of blood pressure in patients with increasing numbers of co-morbid conditions.

Results 

Individual patient data were available for total of 6,086 patients. Self-monitoring was associated with an increased likelihood of blood pressure control at follow-up compared to usual care in patients with 1 to 3 co-morbidities, but there was no evidence of benefit in those with 4 or more co-morbidities. In patients with diabetes, stroke, coronary heart disease, chronic kidney disease or obesity, self-monitoring was only associated an increased likelihood of with blood pressure control when combined with higher intensity co-interventions (those with additional support).

Conclusions 

These data suggest that self-monitoring of blood pressure results in better blood pressure control in patients with multi-morbidity, except in those individuals with 4 or more co-morbid conditions.  Self-monitoring appears to be effective in specific co-morbid conditions such as diabetes and stroke, but only when combined with more intensive co-interventions such as self-management, education or lifestyle counselling.

Dissemination

Articles

We plan to publish this work in a peer reviewed scientific journal

Presentations

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. Katherine L. Tucker, James P. Sheppard, Richard Stevens, Hayden B. Bosworth, Alfred Bove, Emma P. Bray, Kenneth Earle, Johnson George, Marshall Godwin, Beverly B. Green, Paul Hebert, F. D. Richard Hobbs, Ilkka Kantola, Sally M. Kerry, Alfonso Leiva, David J. Magid, Jonathan Mant, Karen L. Margolis, Brian McKinstry, Mary Ann McLaughlin, Stefano Omboni, Olugbenga Ogedegbe, Gianfranco Parati, Nashat Qamar, Bahman P. Tabaei, Juha Varis, Willem J. Verberk, Bonnie J. Wakefield, Richard J. McManus.  

This work was presented at the Society of Academic Primary Care and British Hypertension Society Scientific Meetings in 2016 (http://www.nature.com/jhh/journal/v30/n10/pdf/jhh201660a.pdf [page 368])

Public involvement

We plan to communicate our findings to relevant patients / group to help us investigate the best way to progress work in this area. 

Impact

Analyses from this work are still being finalised and will be published in due course. This work addresses an important question around the applicability of self-monitoring of blood pressure to different patient groups, including those with multiple morbidities as well as those with specific disease conditions. The findings of this research will inform guidance around the uptake and implementation of self-monitoring of blood pressure in routine clinical care, and may result in an increase in the number of patients using self-monitoring to assist the management of their blood pressure in Primary Care.

Project website: https://www.spcr.nihr.ac.uk/projects/blood-pressure-self-monitoring-individual-patient-meta-analysis-of-registered-trials-sub-group-analyses-in-a-multi-morbid-population

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 267)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.