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Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation
Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

Background: A 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. Methods: One 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. Results: Mean 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. Conclusions: This 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.

Blood pressure, Digital intervention, Hypertension, Mixed methods, Normalisation Process Theory, Process evaluation
1748-5908
57
Morton, Kate
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Dennison, Laura
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Band, Rebecca
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Stuart, Beth
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Wilde, Laura
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Cheetham-Blake, Tara
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Heber, Elena D
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Slodkowska-Barabasz, Joanna
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Little, Paul
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McManus, Richard J.
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May, Carl
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Yardley, Lucy
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Bradbury, Katherine
87fce0b9-d9c5-42b4-b041-bffeb4430863
Morton, Kate
6fa41cd3-ba4d-476c-9020-b8ef93c7ade7
Dennison, Laura
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Band, Rebecca
be8901bb-bb1b-4131-8e19-c1d4a3bdfb8d
Stuart, Beth
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Wilde, Laura
7f30b00a-8c3c-455d-a8b0-4dbffe22c770
Cheetham-Blake, Tara
99ea7608-7d19-4e78-bd98-5ca3ca1c46f1
Heber, Elena D
fc1e8b94-40d5-44bc-ad3a-e045c4764dfd
Slodkowska-Barabasz, Joanna
18182048-55ee-474c-9790-1f5b81fa585c
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
McManus, Richard J.
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May, Carl
86bf173e-540c-4849-b760-94e85f93c2e3
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Bradbury, Katherine
87fce0b9-d9c5-42b4-b041-bffeb4430863

Morton, Kate, Dennison, Laura, Band, Rebecca, Stuart, Beth, Wilde, Laura, Cheetham-Blake, Tara, Heber, Elena D, Slodkowska-Barabasz, Joanna, Little, Paul, McManus, Richard J., May, Carl, Yardley, Lucy and Bradbury, Katherine (2021) Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation. Implementation Science, 16 (1), 57, [10.1186/s13012-021-01123-1]. (doi:10.1186/s13012-021-01123-1).

Record type: Article

Abstract

Background: A 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. Methods: One 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. Results: Mean 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. Conclusions: This 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.

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More information

Accepted/In Press date: 29 April 2021
Published date: 26 May 2021
Additional Information: Funding Information: The HOME BP intervention was developed using LifeGuide software, which was partly funded by the NIHR Southampton Biomedical Research Centre (BRC). Funding Information: This independent research was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-1211-20001). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.
Keywords: Blood pressure, Digital intervention, Hypertension, Mixed methods, Normalisation Process Theory, Process evaluation

Identifiers

Local EPrints ID: 449575
URI: http://eprints.soton.ac.uk/id/eprint/449575
ISSN: 1748-5908
PURE UUID: 071fbced-5adc-41e5-9797-ff863d51beae
ORCID for Kate Morton: ORCID iD orcid.org/0000-0002-6674-0314
ORCID for Laura Dennison: ORCID iD orcid.org/0000-0003-0122-6610
ORCID for Rebecca Band: ORCID iD orcid.org/0000-0001-5403-1708
ORCID for Beth Stuart: ORCID iD orcid.org/0000-0001-5432-7437
ORCID for Lucy Yardley: ORCID iD orcid.org/0000-0002-3853-883X
ORCID for Katherine Bradbury: ORCID iD orcid.org/0000-0001-5513-7571

Catalogue record

Date deposited: 08 Jun 2021 16:31
Last modified: 28 Apr 2022 02:11

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Contributors

Author: Kate Morton ORCID iD
Author: Laura Dennison ORCID iD
Author: Rebecca Band ORCID iD
Author: Beth Stuart ORCID iD
Author: Laura Wilde
Author: Tara Cheetham-Blake
Author: Elena D Heber
Author: Paul Little
Author: Richard J. McManus
Author: Carl May
Author: Lucy Yardley ORCID iD

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