The Use of Telemedicine to Improve
p
Access and Quality of Care in the
Veterans Health
Administration:
C
Case
St
Studies
di
Hypertension Intervention Nurse
Telemedicine Study (HINTS)
Hayden Bosworth, PhD
Center for Health Services Research in Primary Care
Departments of Medicine
Medicine, Psychiatry and School of Nursing
Duke University Medical Center
Background

Hypertension affects 65 million US adults
and another 45 million have
“prehypertension”

8.5 million veterans with hypertension

Only a third of all U.S. hypertensive
patients have their BP under adequate
control
t l

IInterventions
t
ti
delivered
d li
d in
i patients’
ti t ’ homes
h
may improve control
Case for Home Telemedicine

Offers Potential for:
–
–
–

improving hypertension outcomes
averting visits and improving BP control
overcoming clinical inertia
Provides alternative way to integrate
home BP monitoring into primary care
Hypertension
yp
Intervention Nurse
Telemedicine Study (HINTS)

591 primary care veterans with poor BP control

4 arms (usual care, selfself-management, medication
management, combined selfself-mgt & medication mgt)

Intervention arm patients

–
received tele
tele--monitoring equipment
–
transmitted home BPs to study through phone line
–
activated intervention when mean BP above goal for
preceding 2 weeks
Intervention Administration: by nurse via telephone
by for 18 months
HINTS Study: Design
Four Group Design
Usual Care
 PCP drive management,
g
, no special
p
program
p g
Tailored Self Management Phone Intervention
 Home BP monitoring
g evaluated by
y nurse
 Tailored self mgt modules administered by nurse
Medication Management
g
Phone Intervention
 Home BP monitoring evaluated by nurse
 HTN decision support for medication recommendations
 Medication management implemented by study MD/RN
Tailored Self Mgt & Medication Mgt Phone Intervention
 Home BP monitoring evaluated by nurse
 Tailored self mgt modules & medication mgt administered
by nurse
HINTS Study: Telemedicine
RN:MD Dialogue
g for Medication
Change
Patient Flow
1893 Potentially Eligible
Subjects Mailed Letters
ICD
C code ffor Hypertension
Hypertensive Medication
Avgas BP >140/90 year prior
Enrolled Durham VAMC
342
1551
Completed Screening Phone
Call
591
Randomized
(38% participation
rate)
Not Contacted or
Unable to Contact
688 Refused
252 Ineligible
17 Excluded (arm size)
1 Withdrew prior to
randomization
d i ti
2 rand, but not eligible
Patient Flow (continued)
Patients Randomly
Assigned
(n=591)
Self Mgt +
Medication Mgt
(n=148)
87% 18 month
th
retention
Self Management
(n=147)
Medication Mgt
(n=149)
Usuall care
U
(n=147)
92% 18 month
h
retention
85%
8
% 18 month
h
retention
88% 18 month
retention
B
Baseline
li Characteristics
Ch
t i ti (N=591)
Mean age (range)
64 (30
(30--89)
Married
66%
Male
92%
White
49%
African American
48%
Not high school graduate 13%
Low literacy
y level ((< 9th ggrade)) 38%
Inadequate income
18%
Blood Pressure Control
Systolic Blood Pressure
Systolic Blood Pressure
Health Care Use and Costs

Utilization
– No significant between group difference
over 18 months in the number of :
• primary care visits (median 4)
• specialty care visits (median 5-6)
• Proportion of patients hospitalized (range, 13.4%
to 19.7%)

Costs
– No significant between group difference in
median VA medical cost (median costs in
each arm ranged from $6871 to $8612)
Health Care Use and Costs
over 18 Months
Intervention Self
Med
Self Mgt &
arm
management management Med Mgt
Usual
care
Intervention
cost
$162 899 $163,516
$162,899
$163 516 $162,282
$162 282 n/a
Per patient
$1101
$1097
$1104
n/a
Descriptives of Telephone Interactions
Total
Intervention
n=444
SelfManagement
n=147
Medication
Management
n=149
Number of Patients
Who Generated Alerts)
Combined
(Self Management &
Medication
Management)
n=148
Number of Alerts
Activated
435
144
146
145
1944 (389)
723 (131)
659 (133)
562 (125)
Safety
289 (79)
102 (28)
125 (35)
62 (16)
Praise
240 (165)
74 (53)
77 (50)
89 (62)
Technical
Alerts
Activated
2282 (414)
804 (133)
768 (141)
710 (140)
Introductory
Phone Call
Nurse Alerts
Activated
Intervention
Summary

Medication management combined
with a telephone tailored self
management
g
intervention resulted in
modest improvements in BP control
and systolic BP
Acknowledgements
Hypertension Intervention Nurse Telemedicine Study (HINTS)
VA H
Health
lhS
Services
i
Research
R
h Grant
G
IIR 04-426
04 426 (2005
(2005-2008)
2008)
Career Scientist Award 08-027 (2008-2013)
Benjamin Powers, MD, MHS
Maren K Olsen PhD
Felicia McCant MSSW
Janet Grubber MSPH
Pamela Gentry RN
Cynthia Rose RN
Mary K. Goldstein MD, MS
Eugene Z. Oddone, MD, MHz