Abstract
BackgroundA high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.MethodsOne hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.ResultsMean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.ConclusionsThis mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.Trial registration(ISRCTN13790648). Registered 14 May 2015.
Highlights
A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes
Quantitative data were collected from all 125 practitioners in the randomised controlled trial (RCT), except the baseline questionnaires which were completed by 124/125 (99%)
The mean Index of Multiple Deprivation (IMD) for General Practitioner (GP) Practices who were invited to interviews but did not participate was 7.8
Summary
A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A patient component sought to increase self-efficacy to self-monitor blood pressure and positive outcome expectancies about receiving medication increases when needed, and a practitioner component targeted self-efficacy to escalate medication based on patients’ home readings, in line with a plan created in advance with each patient [6,7,8,9] This personalised three-step medication plan was theorised to reduce the risk of clinical inertia arising at the time of medication escalation, based on procedures from non-digital interventions which successfully reduced blood pressure without adverse outcomes such as increased side-effects or patient anxiety or dissatisfaction [10, 11]. A qualitative process evaluation of patients’ experiences of using HOME BP showed that perceived benefits included reassurance that uncontrolled hypertension was being addressed, whilst worry about health and fitting self-monitoring into the day could be burdens for patients [13]
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