Implementing Evidence for practice. Hypertension

Implementing Evidence for Practice
Student’s Name
Institutional Affiliation
Implementing Evidence for Practice
Introduction
Hypertension is a disorder characterized by higher than normal blood pressure, and it is one of the leading causes of other diseases such as stroke and various cardiovascular diseases (Lee & Park, 2016). When left uncontrolled, the condition can be fatal (Lee & Park, 2016). Unfortunately, although the disease affects many people around the world, only a few individuals have their blood pressure controlled (Lee & Park, 2016; Monahan et al., 2019). The rate of hypertension control has improved in the past few decades, but the number of people living with uncontrolled hypertension is still high (Monahan et al., 2019). Consequently, a significant number of people suffering from the disorder are at higher risk of developing other ailments such as stroke, kidney failure, and cardiovascular diseases.
Current blood pressure control methods are physical exercise, diet control, and medication, and these interventions can be implemented alone or in combination (Monahan et al., 2019). Hypertension monitoring can be done either in hospitals or at home. In homes, it can be done either through self-monitoring of blood pressure (BP) or through telemonitoring arrangements (Logan et al., 2012; Parati et al., 2018; Sivakumaran & Earle, 2014). Telemonitoring involves health care professionals using information technologies to monitor the state of a patient at a distance without necessarily meeting them, and hypertension is one of the conditions monitored using this method, where professionals use various information technologies to evaluate the levels of blood pressure of a patient and take necessary actions (Duan et al., 2017). The method has been proven cost-effective because the expenses associated with patient travel, time off work, and inpatient services are significantly reduced (Duan et al., 2017). Also, because hypertension is more prevalent in the elderly population who often lack the physical capacity to travel to hospital appointments, this section of the population benefits in particular from telemonitoring (Logan et al., 2012; Sivakumaran & Earle, 2014). Also, the telemonitoring of patients in ambulances enable emergency crews to be better prepared and initiate treatment quickly (Logan et al., 2012). However, the telemonitoring technique has limitations due to the high cost of installing the system and the need for physician licensing (Logan et al., 2012). The other blood pressure control approach is self-monitoring, where the patients or their caregivers are educated on ways to control their blood pressure at home. Similar to telemonitoring, self-monitoring cuts the costs of travel and inpatient services such as bed fees (Duan et al., 2017).
The current study examines these two approaches to hypertension control to determine their effectiveness compared with the usual nursing care and how they can be incorporated into nursing practice. The study examines various scholarly studies related to hypertension control away from clinical settings. Six scholarly articles are comprehensively analysed, and the evidence contained in these studies is used to explain the most appropriate processes for blood pressure monitoring that can be applied in nursing practice.
Clinical Question
The current study will use the PICOT approach to critically analyze the two procedures used to control high blood pressure. PICOT is an abbreviation of Population, Intervention, Comparison, Outcome, and Time. The PICOT question for the current study is: In patients living with hypertension (P), how effective is telemonitoring and self-monitoring (I) compared with usual nursing care (C) in controlling blood pressure (O)?
Scholarly Articles Search Method
To critically analyze the above PICOT question, a comprehensive literature search was carried out using various medical databases such as PubMed, Cochrane, EMBASE, Medline, and CINAHL. Some of the terms used to search for various articles include hypertension control, blood pressure control, telemonitoring hypertension, and BP self-control. The search was limited to articles less than five years old. The other criteria used include all selected articles to be peer-reviewed, published in English, and studies with only adult populations as the participants. The databases contained several studies related to hypertension among adults. Initially, 40 articles were identified, and each of their abstracts was evaluated to determine their relevance to the PICOT question. The mentioned databases were selected as they contain tens of thousands of peer-reviewed articles with thousands of health topics. The articles from the selected health databases are written by renowned authors with sufficient knowledge on various health topics, meaning that they contain reliable and adequate evidence. The first 40 articles were further scrutinized, and the four terms used initially were reduced to two, telemonitoring hypertension and BP self-monitoring. After a thorough search, six articles that were most relevant to the study were selected for further analysis. For the six articles chosen, they all contained patients suffering from hypertension requiring control of blood pressure. The relevance of evidence was determined using randomized controlled trials (RCT), and studies were arranged according to the strength of evidence. Three studies were found to be the most relevant to the PICOT question, but the other additional three with some relevant information about the current topic were also selected. All of the articles selected are well elaborated in appendix 1.
Appraisal of Selected Articles
The selected articles have relevant information regarding the control of hypertension among adults. Most of the articles present two methods of hypertension control, which include telemonitoring and self-control, either applied alone or in combination. Although there are some differences, the information contained in the articles revolves around the control of hypertension away from the hospital, either through self-control or telemonitoring approaches. Some articles offer a comparison between home-based monitoring and the usual care. The objective of this study is to identify which method of hypertension control is more effective between clinical and home-based approaches. After determining the most effective method, the current paper describes how it can be used by nurses to improve hypertension control among patients. As indicated earlier, the number of people living with uncontrolled hypertension is still higher, and health care providers should devise ways of combating this issue. One of the methods that can help care providers is using evidence-based practice in clinical practices.
The most relevant source of the six articles chosen is the study by McManus et al. (2018), titled “Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomized controlled trial.” The study attempts to draw a line between self-monitoring either inclusive or without telemonitoring and the usual care. Thus, the study was divided into through sub-studies, each with distinct characteristics. 1183 patients aged above 35 years participated in the study and were divided into three groups in a ratio of 1:1:1. Each of the individuals taking part in this study had a blood pressure that exceeded 140/90 mmHg. The first group (395) was assigned self-monitoring, the second, telemonitoring (393), and the third group, the usual care (394). Randomization was done through a secure web system, and both the investigators and participants were unmasked to the group assignment. The investigators measured systolic blood pressure (SBP) in the twelfth month after the start of the study. The study established that in the 12th month, the individuals in self-monitoring groups recorded a lower SBP compared to the usual care group. The findings also indicated that there was no significant difference between self-monitoring and telemonitoring. It is evident that the application of self- and telemonitoring when used by clinicians to administer hypertension drugs in patients suffering from uncontrolled blood pressure can reduce the blood pressure significantly than the administration guided by clinical standards.
One of the weaknesses of the study includes the fact that investigators did not maintain uniformity among the participants in terms of exercise and dieting (Booth et al., 2017). Some practices, such as proper diet and physical exercise, are known to reduce blood pressure, whereas others, such as alcohol and smoking, complicates the problem. It would be crucial if the researchers ensured that all participants were put under similar conditions to ensure that the results obtained were only as a result of antihypertensive medication and no other factors (Booth et al., 2017)
However, the study did not have several notable weaknesses because the selection of the sample was not biased. At first, 2383 people were evaluated for suitability from 142 general practices across the United Kingdom. Of this number, 1201 were eliminated, with 1196 failing to meet eligibility criteria and five withdrawing from the study. Most of the people excluded either did not have the required blood pressure of greater than 140/90 mm Hg, had orthostatic hypertension, or lacked stable dose of antihypertension drugs. Thus, every person who participated in the study met the inclusion criteria. Measuring blood pressure before conducting the actual study was essential to ensure that the results obtained were not biased as a result of some people not meeting the inclusion criteria. The number of males and females participating in the study did not differ significantly, which eliminated the chance of gender bias. The result indicates that 95% confidence interval for participants in the self-monitoring group was between -5.8 to -1.2, which is equivalent to the p-value of 0.0029, whereas that of telemonitoring group was -7.0 to -1.2 or a p-value of less than 0.0001. The results for these two groups are, therefore statistically significant because the p-values are less than 0.05. On the other hand, for the usual care group, the p-value was 0.1119, which indicates that the result was not statistically significant, meaning that it is not the best method for controlling blood pressure compared to the first two. Consequently, the study had reliable results that can be used by clinicians in the control of hypertension among the patients.
Another study by Margolis et al. (2018), “Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults with Uncontrolled Hypertension,” was conducted to determine the most effective method in controlling hypertension between the usual care and telemonitoring with pharmacist management. The study involved 420 participants who had uncontrolled high blood pressure. Patients were either assigned telemonitoring with pharmacist management or the usual care. The measurements were done four times in the 6th, 12th, 18th, and the last one done after 54 months, both for systolic and diastolic blood pressures. All patients participating in the study had a systolic blood pressure of above 148 mm Hg. For the 228 patients who were assigned telemonitoring with pharmacist management, their BP was much lower than the 222 who were in the usual care group for the first 18 months, but this trend was not maintained up to the 54th month.
The study had some drawbacks, such as approximately 28% of the original participants failed to complete the study for the entire study period; 54 months. Similar proportions of the cohort in telemonitoring group and the usual care group did not attend the 54-month follow-up for the entirety. Similar to the previous study by McManus et al. (2018), the researcher did not put into consideration other factors contributing to the reduction of high blood pressure, such as physical exercise and adjustment of dieting behaviour. The sample size was small for a presentation of the entire population. Usually, a small sample reduces the reliability of the results due to the high variability that could result in bias (Faber & Fonseca, 2014; Nayak, 2010; Jamali et al., 2017). In any study, variability is determined by the standard deviation of the sample. A smaller sample leads to a larger standard deviation, which results in less accurate results. Sampling errors may have negative effects on the interpretation and precision of the results, which can, in turn, harm a particular population of people or living organisms being studied (Button et al., 2013; Lin, 2018).
Regardless of the highlighted drawbacks, the study produced reliable results, and the probability of gender bias was reduced significantly because males and females who participated in the study were well-matched. The results indicate that the SBP decreased from 148 mm Hg to 126.7 in the 6th month, 125.7 at 12th month, 126.9 at 18th month, and 130.6 mm Hg at 54th month for telemonitoring group and to 136.9 at 6th month, 134.8 at 12th month, 133.0 at 18th month, and 132.6 mm Hg at the 54th month for the usual care group. The 95% confidence interval for the telemonitoring group and the usual group were -14.3 to -7.3 at 6th month, which translates to a p-value of less than 0.001, and was similar to the 12th month value. The p-value in the 18th month was slightly higher (0.004). The results were therefore statistically significant for both groups. Notably, although blood pressure reduced significantly in both cases, in the telemonitoring group, it was slightly lower compared to the usual care group, which suggests that the telemonitoring method is more effective in lowering blood pressure compared to the usual care monitoring.
In another study, “Cost-effectiveness of telemonitoring and self-monitoring of blood pressure for antihypertensive titration in primary care (TASMINH4)” by Monahan et al. (2019), the cost-effectiveness of self-care without telemonitoring and self-care with telemonitoring were compared with that of usual care among the patients with uncontrolled high blood pressure. 1182 patients were selected as the participants, and the inclusion criteria included a BP higher than 140/90 mm Hg, age of above 35 years, and willingness to self-monitor the blood pressure. The cohort was recruited from 138 general practices and was divided into three groups, self-monitoring, telemonitoring, and usual care in the ratio of 1:1:1. The objective of the study was to measure cost of reduction of systolic blood pressure among the patients in these three groups. Investigators used the Markov patient-level simulation to estimate the cost of each type of care. The BP values for all groups were measured in the 6th and 12th months. The costs of each type of intervention were estimated and recorded. The authors found that both the self-monitoring and telemonitoring were less costly as compared to the usual care. The cost of care was compared with the Ј20,000 per QALY threshold set by the United Kingdom National Institute of Health and Care Excellence.
Despite some few limitations, the study produced the strongest results because it was based on TASMINHA4, one of the best primary care trials for patients suffering from hypertension. The tool is one of the best models used by physicians in the titration of antihypertensive medication for self-care monitoring and telemonitoring. Moreover, participants were obtained from several primary care practices all over the United Kingdom, and thus, the results were less likely to be biased. The size of the sample was good, which reduced the chances of obtaining higher variability, further eliminating bias. In addition, the measurement of blood pressure for all patients participating in the study was done based on the standardized blood pressure ranges. While a different model would be needed to estimate specific costs of the three monitoring methods for various countries, the literature indicates that self-monitoring method either with or without telemonitoring is more cost-effective than usual care monitoring. Thus, since the study indicates that self-monitoring reduced the cost of controlling hypertension, the results are widely relevant. The costs obtained from the study are lower than in other developed countries. However, as the literature suggests, self-monitoring is less costly compared to the usual care, and the result obtained from this research can be applied in clinical practices internationally.
The study, “Telemonitoring is acceptable amongst community-dwelling elderly Australians with chronic conditions” by Halcomb et al. (2016), focused on determining the perceptions of elderly people about telemonitoring chronic diseases, including hypertension, diabetes, heart failure, asthma, and chronic obstructive pulmonary disease, among others. The study involved pre and post-test interventions, where the investigators administered surveys prior to and after the intervention. Researchers applied telemonitoring as an intervention method where participants with various chronic diseases were closely monitored at home, and important signs were sent to general practice nurses. The cohort consisted of 21 individuals aged above 65 years, who were selected by general practitioners. Various inclusion criteria were used, which include the presence of chronic disease and above 65 years old. The study used a telemonitoring technique called a Tunstall Mytelemedic monitor that has the main monitor and Bluetooth-enabled peripherals. The type of monitoring assigned to each patient was determined by their clinical conditions. Depending on the patient’s medical history, patients were assigned either cardiovascular disease, respiratory or hypertension algorithm. The algorithm used highlighted important signs and symptoms that would be measured as well as various questions on symptoms exhibited by each patient. Some of the variables used include pulse rate, blood pressure, blood glucose, oxygen saturation, temperature, and body weight, among others. The data collected from the monitoring was then stored in a server easily accessed by general practitioners and the investigators. The entire process of monitoring for each patient took a duration of six weeks. As indicated earlier, pre and post-test surveys were conducted during this research. A pre-test involved collection of important information about the participants’ health status, demographics, perceptions about telemonitoring, and computing experience. The post-test survey included questions about perception of telemonitoring and the ease of use of telemonitoring systems. The findings of the study indicate that the telemonitoring technique is acceptable among elderly individuals suffering from various chronic conditions, such as hypertension in Australia. Lack of computer and technology experience did not affect the acceptability of telemonitoring among this population. The results indicate that telemonitoring provided vital physiological information about patients to clinicians and had the potential to empower and educate patients on their health.
The key limitation of this study is the small size of the sample. Only 21 individuals participated in the study, and the number is too small to generalize the outcome of the study. Smaller sample results in high variability, which can produce highly biased results that most elderly individuals will accept telemonitoring method for the management of various health issues. With a larger sample, there is an increased likelihood of obtaining more accurate results.
Despite the sample flaws, the results indicate that although most participants declared that they experienced difficulties using telemonit...