Healthcare practitioner views and experiences of patients self-monitoring blood pressure: a vignette study

Summary

This study has explored primary care practitioners’ experiences and practices in supporting blood pressure self-monitoring in the management of hypertension. The findings demonstrate how clinicians guide patients to make choices about purchasing healthcare technologies, and make clear the need for balance between maintaining professional impartiality and providing patients with guidance to ensure they purchase appropriate devices. Participants indicated pharmacies as reputable vendors of approved blood pressure monitors, and lists of approved devices as resources to which they refer their patients. On educating patients about their devices, several participants stated that they use email or SMS to refer patients to online materials, including videos on YouTube, when these originate from reputable sources. They also refer patients to healthcare assistants to learn how to use blood pressure monitors.

The findings highlight a recognition among primary care professionals of the anxiety patients may experience as a result of home monitoring, and a variety of approaches to mitigate it. These included use of ambulatory monitors to reduce outputs visible to patients that may cause them concern, or providing patients with guidance on monitoring frequency. Participants suggested they were aware of the need to be open with patients about how their self-generated data would be used. This openness was recognised as a way to encourage continued monitoring, and to communicate to patients that primary care professionals value the data that patients provide.

Cost was highlighted as a barrier to some patients purchasing monitors and suggestions were given for overcoming this barrier, for example, patients might borrow a monitor from friends or family, or use one owned by the surgery. The results demonstrate too the possibility of variations in patients’ attitudes to discussing monitoring and blood pressure medication with their primary care practitioner.

Strengths and limitations

The use of vignettes developed from interviews with people who self-monitor provided authenticity to the study materials. In contrast to traditional vignette methodology, this approach may reduce research participants’ sense that the research is contrived.¹⁸ The use of vignettes more generally provided a useful framework within which to promote discussion, as indicated by Keane and colleagues.¹⁴

The study is limited in that practitioners were all recruited from the same geographical region in one area of the UK. However, by conducting focus groups with a total of 21 primary care practitioners across both GP and PN roles, a wide variety of practices and experiences of managing patient use of blood pressure monitors at home have been elicited. Inclusion of healthcare assistants and practice managers in the focus groups may have shed more light on how self-monitoring fits within the wider structure of primary care. Use of vignettes may have led participant conversations, although it is considered this was necessary in order to stimulate discussion of the topics examined in the research.

The thematic analysis was limited in that it was principally completed by one researcher (JA); however, the analysis of one of the transcripts by three researchers, and the subsequent discussion of themes arising, ensured that themes were robust.

Comparison with existing literature

Smolen and colleagues’ conceptual model of providers’ approach to hypertension management details three particular provider actions for successful blood pressure management: relationship building; self-management tools; and patient education.⁹ The findings provide detail in the ways that these provider actions are currently undertaken, highlighting variation in practice occurring among surgeries. For example, the findings indicate that healthcare assistants are increasingly providing support for home monitoring, which GPs and PNs may not have time to provide. Healthcare assistants may be more likely to understand local patient culture and provide a sense of continuity of care,¹¹ which contributes to aspects of relationship building. Their role in supporting home monitoring could, therefore, bring benefits to patient care, beyond time-saving for GPs.

While prior research in this area has primarily focused on care occurring after a patient has obtained a home blood pressure monitor,⁸ the results show that there are important considerations to be made around whether and how patients obtain a monitor in the first place. Primary care professionals were found to advise patients differently on where to purchase a blood pressure monitor, including from pharmacies and online, and patients on low incomes were given other suggestions about how they might obtain a monitor. Thus, while Smolen and colleagues highlight the importance of self-management tools,⁹ the participants in the present study gave examples of how they guide patients to obtain these tools, taking account of differences across socioeconomic backgrounds.

While patients are known to turn to the internet to seek guidance for home monitoring of their own volition,⁴ the results demonstrate how primary care professionals advise patients to seek out online materials from sources, including YouTube, professional associations and NHS Choices (now referred to as the NHS website), and may send them direct links to online information. Thus, the study demonstrates the kinds of resources primary care professionals draw on and the way that these are disseminated to patients in the third part of Smolen et al’s conceptual model, patient education.

The findings also highlight how primary care professionals experience patient anxiety around self-monitoring, including through the use of ambulatory monitors. Anxiety around self-monitoring is recognised in guidance for patients with hypertension from the British Heart Foundation, which suggests that self-monitoring is 'not a good idea for everyone' and that 'some people feel more anxious when taking their own blood pressure',²⁰ although some research suggests that anxiety does not increase in those self-monitoring blood pressure.²¹ Here, the authors add that primary care professionals share guidelines on the frequency of monitoring and encourage patients to take a longer term view of blood pressure in order to mitigate patient concerns and worry.

Implications for research and practice

This article has explored the experience of blood pressure self-monitoring in primary care. It has been demonstrated how pharmacists are called on to supply and support the use of blood pressure monitors by patients with hypertension, supporting suggestions in the Topol Review that the role of the pharmacist will need to evolve to include the supply and support of multiple healthcare technologies as the use of these increases.²² The findings show too that clinicians are finding workarounds to enable patients to obtain blood pressure monitors in more deprived areas. The NHS Long Term Plan promises greater funding for poorer areas,²³ which could provide self-monitoring technologies to those who cannot afford them, without the need for such workarounds.

The results provide a view of how primary care practitioners currently manage the use of home blood pressure monitoring, and provide examples of practice that may be informative for those working in this area. In particular, a need to consider five aspects of patient self-monitoring of blood pressure (advising on purchase, supporting monitoring, mitigating potential anxiety, valuing patient data, and considering socioeconomic barriers) is highlighted. These findings are of particular importance since NICE guidance⁶ currently advocates that practitioners provide guidance and education to their patients on blood pressure monitoring, but lacks detail on how this should be conducted. The five aspects of managing self-monitoring that have been highlighted may also be useful when considering how primary care practitioners can best support self-monitoring by patients with conditions other than hypertension. The importance of the role of the healthcare assistant in helping patients to manage a self-monitoring practice is emphasised. It is also highlighted that there is a need to ensure patients are clear about how their data is used to encourage continued monitoring.

Further research is required to understand views of pharmacists and healthcare assistants on spending more of their time supporting patients with self-monitoring technologies, particularly as the number of self-monitoring technologies implemented in primary care for different conditions increases. Further work could also examine the potential of a standardised NHS care pathway for self-monitoring, which could include detail on how devices should be obtained, how their accuracy can be checked, target readings, when readings should be taken, and which healthcare professional should be consulted once readings are collated.