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Table 6 Modifications made to HOME BP based on focus group feedback

From: Understanding how primary care practitioners perceive an online intervention for the management of hypertension

  Focus group feedback Changes made to HOME BP
1 Concerns that patients monitoring their blood pressure at home might contact the practice more, because of concern about their readings. TASMINH2 [6] did not find that patients monitoring their blood pressure at home consulted more frequently than those in usual care. This information was added to the Prescriber’s and Supporter’s guides to reassure practitioners that this is unlikely to be the case.
2 Concerns about the accuracy of home blood pressure readings, particularly very high readings. An explanation was added which described the procedures employed to ensure that patients’ readings would be accurate. This includes patients completing a week of practicing monitoring their blood pressure before beginning to monitor it for real. Patients can email their practice readings to their Supporter for feedback. They can also meet with their Supporter if they experience problems with home monitoring, or have concerns about their readings. It was also explained that few patients in the TASMINH2 study got very high readings [6], indicating that this is unlikely to be a regular occurrence.
3 Concerns about choosing 3 drugs in advance. This concern was based on:
1- Not knowing which drugs to pick and a concern that there might not be enough drugs to choose from.
2- Concerns about interactions between drugs in combined medication regimes.
1- To address the first concern we added explanation that medication changes could include increases in drug doses, not just adding further drugs. We also included a scenario of a complex patient taking 3 drugs, showing 3 possible medication changes which could be suggested for the patient in the first instance and a further 3 which could be used if the first 3 were unsuitable.
2- To address the second concern we showed Prescribers evidence of the safety and efficacy of this approach. We presented the findings of the TASMIN-SR study [7], which found that patients with co-morbidities who were already taking multiple drugs did not have more side effects (but did significantly reduce their blood pressure) compared to those receiving usual care when they monitored their blood pressure at home and implemented pre-agreed medication changes when blood pressure remained raised.
The Prescriber’s guide also reminded prescribers to check the patients’ notes to ensure a pre-agreed medication change was still appropriate.
5 Two GPs wanted the baseline medication review to be longer, others disagreed. The information was updated to suggest that some practitioners might find it helpful to use a double appointment for medication reviews for their first patient in the intervention group, to allow time to get used to the study procedures, but that after this a single appointment should suffice.
6 Nurses at the first focus group were concerned that they need to give patients advice, as patients would expect this. Information was added to reassure Supporters that the CARE approach (without giving advice) has been used successfully in previous studies. Quotes from patients and practitioners were shown, which demonstrated the acceptability of this approach.
7 Nurses at the first focus group were also concerned that they wouldn’t know how to congratulate patients who demonstrated a lack of adherence, or reassure patients about their concerns. Detailed examples of how to congratulate and reassure patients were added to model this approach.
8 Most Supporters wanted to be able to view the patient website This was made available to Supporters, with an explanation that it was not necessary to memorise this information, since their role would be to provide support using the CARE model, not specific advice.
9 A few nurses noted that a lack of time might be a barrier to providing support. Patients are offered two, optional, ten minute appointments during the 12 month study. It is likely that not all patients will choose to attend these appointments (this has been the case in our other web-based interventions, e.g.[14]). Nevertheless, some practices may find this time commitment too great. However, we decided to keep these support appointments as similar interventions have larger effects if human support is provided. The majority of support for patients is provided by email, with emails that are pre-written and only need to be tailored briefly to the patient, meaning this support should be very quick and easy to deliver.