Telehealth for patients at high risk of cardiovascular disease: pragmatic randomised controlled trial.

OBJECTIVE:  To assess whether non-clinical staff can effectively manage people at high risk of cardiovascular disease using digital health technologies. DESIGN:  Pragmatic, multicentre, randomised controlled trial. SETTING:  42 general practices in three areas of England. PARTICIPANTS:  Between 3 December 2012 and 23 July 2013 we recruited 641 adults aged 40 to 74 years with a 10 year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor (systolic blood pressure ≥140 mm Hg, body mass index ≥30, current smoker), and access to a telephone, the internet, and email. Participants were individually allocated to intervention (n=325) or control (n=316) groups using automated randomisation stratified by site, minimised by practice and baseline risk score. INTERVENTIONS:  Intervention was the Healthlines service (alongside usual care), comprising regular telephone calls from trained lay health advisors following scripts generated by interactive software. Advisors facilitated self management by supporting participants to use online resources to reduce risk factors, and sought to optimise drug use, improve treatment adherence, and encourage healthier lifestyles. The control group comprised usual care alone. MAIN OUTCOME MEASURES:  The primary outcome was the proportion of participants responding to treatment, defined as maintaining or reducing their cardiovascular risk after 12 months. Outcomes were collected six and 12 months after randomisation and analysed masked. Participants were not masked. RESULTS:  50% (148/295) of participants in the intervention group responded to treatment compared with 43% (124/291) in the control group (adjusted odds ratio 1.3, 95% confidence interval 1.0 to 1.9; number needed to treat=13); a difference possibly due to chance (P=0.08). The intervention was associated with reductions in blood pressure (difference in mean systolic -2.7 mm Hg (95% confidence interval -4.7 to -0.6 mm Hg), mean diastolic -2.8 (-4.0 to -1.6 mm Hg); weight -1.0 kg (-1.8 to -0.3 kg), and body mass index -0.4 ( -0.6 to -0.1) but not cholesterol -0.1 (-0.2 to 0.0), smoking status (adjusted odds ratio 0.4, 0.2 to 1.0), or overall cardiovascular risk as a continuous measure (-0.4, -1.2 to 0.3)). The intervention was associated with improvements in diet, physical activity, drug adherence, and satisfaction with access to care, treatment received, and care coordination. One serious related adverse event occurred, when a participant was admitted to hospital with low blood pressure. CONCLUSIONS:  This evidence based telehealth approach was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk. The Healthlines service was, however, associated with improvements in some risk behaviours, and in perceptions of support and access to care.Trial registration Current Controlled Trials ISRCTN 27508731.

The characteristics and motivations of online health information seekers: cross-sectional survey and qualitative interview study.

BACKGROUND: Most households in the United Kingdom have Internet access, and health-related Internet use is increasing. The National Health Service (NHS) Direct website is the major UK provider of online health information. OBJECTIVE: Our objective was to identify the characteristics and motivations of online health information seekers accessing the NHS Direct website, and to examine the benefits and challenges of the health Internet. METHODS: We undertook an online questionnaire survey, offered to users of the NHS Direct website. A subsample of survey respondents participated in in-depth, semistructured, qualitative interviews by telephone or instant messaging/email. Questionnaire results were analyzed using chi-square statistics. Thematic coding with constant comparison was used for interview transcript analysis. RESULTS: In total 792 respondents completed some or all of the survey: 71.2% (534/750 with data available) were aged under 45 years, 67.4% (511/758) were female, and 37.7% (286/759) had university-level qualifications. They sought information for themselves (545/781, 69.8%), someone else (172/781, 22.0%), or both (64/781, 8.2%). Women were more likely than men to seek help for someone else or both themselves and someone else (168/509 vs 61/242, χ(2) (2) = 6.35, P = .04). Prior consultation with a health professional was reported by 44.9% (346/770), although this was less common in younger age groups (<36 years) (χ(2) (1) = 24.22, P < .001). Participants aged 16 to 75 years (n = 26, 20 female, 6 male) were recruited for interview by telephone (n = 23) and instant messaging/email (n = 3). Four major interview themes were identified: motivations for seeking help online; benefits of seeking help in this way and some of the challenges faced; strategies employed in navigating online health information provision and determining what information to use and to trust; and specific comments regarding the NHS Direct website service. Within the motivation category, four concepts emerged: the desire for reassurance; the desire for a second opinion to challenge other information; the desire for greater understanding to supplement other information; and perceived external barriers to accessing information through traditional sources. The benefits clustered around three theme areas: convenience, coverage, and anonymity. Various challenges were discussed but no prominent theme emerged. Navigating online health information and determining what to trust was regarded as a "common sense" activity, and brand recognition was important. Specific comments about NHS Direct included the perception that the online service was integrated with traditional service provision. CONCLUSIONS: This study supports a model of evolutionary rather than revolutionary change in online health information use. Given increasing resource constraints, the health care community needs to seek ways of promoting efficient and appropriate health service use, and should aim to harness the potential benefits of the Internet, informed by an understanding of how and why people go online for health.