Towards Integrated Care for the Elderly: Exploring the Acceptability of Telemonitoring for Hypertension and Type 2 Diabetes Management

Study Design

We conducted a concurrent triangulation mixed-methods study from March 2022 to June 2023. The study was nested within a larger parent study investigating the clinical effectiveness and cost structure of telemonitoring in patients with AH and T2D [423].

Ethic and Consent

The study was approved by the Medical Ethics Committee of the Republic of Slovenia (0120-219/2019/4) and was registered in the ISRCTN registry (https://doi.org/10.1186/ISRCTN31471852). The study aligned with the Declaration of Helsinki. Before participation, patients were informed about the aims of the study and signed an informed consent form.

Study Setting

The study took place in three primary healthcare centres (PHCs) in Slovenia, each representing different development contexts. PHC Ljubljana, serving about 300,000 residents, reflected an urban profile with a gross domestic product (GDP) of 108% of the EU mean in 2021. In contrast, PHC Trebnje and PHC Slovenj Gradec, catering to around 50,000 residents in Eastern Slovenia, exemplified rural settings with a GDP of 74% of the EU mean in 2021 [24].

Sampling Strategy

The original randomised controlled study [4] was conducted over two periods: round 1 from March 2021 to April 2022 and round 2 from May 2022 to June 2023. During this time, a total of 128 patients were randomly assigned to either the telemonitoring group (n = 64) or the standard care group (n = 64). The necessity for two rounds arose due to limited telemonitoring equipment availability. Following a 12-month follow-up period, 55 out of 64 patients (85.9%) completed the telemonitoring intervention. Reasons for early dropout included difficulties in using the telemonitoring equipment correctly (n = 7), psychological burden (n = 1), and the death of a spouse (n = 1).

Inclusion criteria were: (a) age ≥65 years, (b) comorbidity of AH and T2D for at least one year, (c) ability to use telemonitoring equipment. Exclusion criteria were: (a) T2D requiring insulin treatment at inclusion, (b) type 1 diabetes, (c) cognitive impairment, and (d) inability to use telemonitoring devices for various reasons.

For this mixed-methods study, we initially recruited patients from round 1 who were assigned to the telemonitoring intervention (n = 30). All 30 patients agreed to participate in the quantitative acceptability survey, while one declined to participate in the semi-structured interviews (29/30). After the first round, we achieved data saturation in the qualitative segment. Nevertheless, to underpin the reliability of our quantitative findings, we extended our quantitative analysis to encompass participants from round 2 as well, culminating in a total of 55 participants.

Integrated Care Model

In Slovenia, a team made up of a general practitioner (GP) and a registered nurse provides integrated care for patients with AH and T2D at the primary care level [347]. This team conducts annual check-ups on patients, with the physician conducting physical examinations, requesting laboratory tests, assessing disease control, and determining if adjustments to treatment are necessary. The registered nurse, on the other hand, screens patients for complications related to AH and T2D, evaluates their psychosocial status, educates them on non-pharmacological measures, and refers them to health promotion activities at the health education centre. Standard protocols for diagnosis and treatment, health education, and guidelines for collaboration among various healthcare providers are used to ensure coordinated care for patients. Although the implementation of ICP in Slovenia is high, improvements are still needed in the aspects related to self-management and structured collaboration [3].

Telemonitoring Intervention

To improve self-management support and structured collaboration within primary care units in Slovenia, we introduced a telemonitoring intervention alongside standard care [4]. Participants were equipped with a telemonitoring package comprising a smartphone and monitors for BP and BG, which they used over a 12-month period. These devices transmitted data to a mobile application via Bluetooth, serving as a central hub, which then transferred the measurement results to the telemedicine cloud platform using a 4G or 5G mobile standard. Upon enrolment, participants underwent a one-hour training session led by a registered nurse. This one-on-one session covered the telemonitoring regimen and provided instructions on how to use the telemonitoring equipment.

Under the supervision of a GP, the telemedicine centre monitored recorded values and facilitated communication between other GPs and enrolled patients on weekdays. Throughout the 12-month period, participants measured their BP twice weekly and their BG once monthly. The transmitted values were colour-coded to indicate their status: green for normal, yellow for slightly off-target, and red for significantly deviated values. A green status indicated no changes were necessary, while yellow prompted adjustments to the measurement protocol, such as a 7-day BP profile with morning and evening measurements for AH or a one-day BG profile with six measurements for T2D. In cases of red status, immediate teleconsultation with a GP or further examination was required.

Patients were managed according to recent guidelines [25], aiming for home BP <135/85 mmHg, fasting BG <7 mmol/l and postprandial BG <10 mmol/l, with treatment goals adjusted for the elderly.

Data Collection

Theoretical framework

The semi-structured interviews and acceptability tool were informed by the TFA [14]. The TFA describes acceptability as a multi-faceted construct consisting of the seven domains explained in Figure 1, which we adapted to measure retrospective acceptability of the telemonitoring and estimate its role in the integrated care model.

Figure 1

Data Analysis

Data triangulation

After completing both analyses, we applied a convergence model of data triangulation to our data [29]. This model involves gathering and examining quantitative and qualitative data on a phenomenon separately and then combining the results through comparison in the interpretation phase (Figure 2). The aim was to validate the results, improve reliability, and gain a more comprehensive understanding of telemonitoring in terms of its acceptability, the components of the ICP it supported, and the barriers to its further scale-up within the integrated care model.

Figure 2

Participant characteristics

The study included 55 participants in the quantitative survey and 29 in the qualitative study, representing urban and rural regions of Slovenia with different demographic characteristics (Table 1). Despite challenges in managing their cardiometabolic risk factors, which were comparable to the Slovenian population of older people with T2D [2], participants showed high adherence in monitoring BP and BG levels, spending an average of 14–15 hours per year on monitoring.

Qualitative Results

During the qualitative analysis, we delineated seven overarching themes and twenty-one subthemes, as detailed in Table 2. These themes are structured in alignment with the TFA, while the subthemes are arranged based on their emergence sequence during the analysis process. Additionally, we assessed the influence of each subtheme on acceptability, indicating whether it had a positive influence (⊕) by facilitating acceptability or a negative influence (⊖) by impeding it, according to the views of participants.

Quantitative Results

The overall acceptability of telemonitoring was high (4.4 out of 5) in the quantitative survey, with favourably ratings in all seven TFA domains (Table 3). However, the overall acceptability was higher in urban regions compared to the rural regions (4.5 vs. 4.3). Participants in rural regions perceived initial training and participation effort as significantly more burdensome than their urban counterparts. They found that telemonitoring was in lower agreement with their beliefs and values and had a lower understanding of the objectives of telemonitoring. On the other hand, they felt that after 12 months of telemonitoring they had gained more knowledge and understanding of their disease than the participants from the urban regions.

Principal Findings and Comparison with the Existing Literature

The results of the study showed that older people with AH and T2D found telemonitoring to be highly acceptable in all seven TFA domains and provided examples of how telemonitoring supported the ICP elements. However, there were discrepancies between the measured acceptability through the quantitative acceptability tool and the barriers identified through the qualitative content analysis.

Telemonitoring systems are generally well accepted by patients with chronic diseases, such as heart failure [15], chronic obstructive pulmonary disease [16], AH [17], and T2D [1819]. However, previous studies relied on proxies of acceptability such as satisfaction [15161819], perceived benefits [18], or intention to use in the future [161719], making a direct comparison with TFA difficult. Furthermore, high acceptability does not necessarily guarantee an effective intervention [13], and there are other factors that influence scalability and sustainability of the intervention [1213].

Patients mentioned several facilitating factors that influenced acceptability and supported the ICP components. A positive patient-doctor relationship, perceived benefits, and previous positive experiences with self-management or the use of modern technologies were important motivating factors at the start of the intervention. Throughout the telemonitoring process, good family support, successful adjustment to their environment and beliefs, reassurance from normal clinical parameters, and regular feedback from the telemedicine centre emerged as important motivating factors for patients. Most of these factors were also identified in previous studies and should be reinforced during telemonitoring [121516171819].

On the other hand, patients described factors that might hinder these processes, such as technical difficulties, negative attitudes towards measurement routines, anxiety, taking measurements during holidays, and additional burden on family members. Personal beliefs and financial resources were also found to be potential barriers in previous studies [121920]. Additionally, some studies have pointed to the risk of focusing solely on monitoring health parameters rather than the overall health of patients [30].

Participants in rural regions perceived initial training and participation effort as significantly more burdensome than their urban counterparts. They found that telemonitoring was in lower agreement with their beliefs and values and had a lower understanding of the objectives of telemonitoring. On the other hand, they felt that after 12 months of telemonitoring they had gained more knowledge and understanding of their disease than participants from the urban region. This discrepancy could be explained by the Diffusion of Innovation Theory [31], which suggests that the adoption of new health technologies requires changes in healthcare organisations, and that adoption is slower in rural areas because there are fewer early adopters, less support from healthcare leaders, and limitations in technological infrastructure than in urban areas [32].

Ultimately, patients described several ways in which telemonitoring supported the self-management, education, treatment, and identification components of the ICP [138]. Regular self-monitoring and timely feedback from medical staff facilitated the education process, and patients learned how non-pharmacological measures improve glycaemic control and were motivated to achieve better health outcomes [33]. However, this approach was less effective in controlling BP, where levels of BP were less stable, and patients were more reliant on treatment modification and stress management [17]. In terms of early identification and treatment, patients were provided with monitors and clinical protocols that allowed them to detect deterioration in their health earlier than usual and adjust their AH/T2D treatment without having to see their doctor [12].

Implications for Research and Practice

Despite good overall acceptability, our study identified several scale-up barriers in the areas of screening, technical support, integration of telemonitoring into patient homes, education, and follow-up programmes that need to be addressed before scaling up telemonitoring in integrated care models for older patients.

Strengths and Limitations

The strength of this study lies in its mixed methods approach to investigating the acceptability of telemonitoring, embedded in a larger randomised controlled trial, and in diverse population from different centres and regions. In addition, telemonitoring was also examined from the perspective of how it supports the integrated care elements in older people with AH and T2D. However, the small sample size and inclusion of only motivated participants may limit the generalisability of the findings. Although the initial response rate to participate in the intervention was high (128/160, 80%), potentially mitigating the impact of this limitation. In addition, we did not return the transcripts to participants for comments or corrections, which could limit the validity of the interviews. However, we attempted to limit this limitation using the convergence model of data triangulation. Finally, we only considered the views of older participants, who have rarely been studied before, whereas views of the healthcare workers involved in the telemonitoring process could also be beneficial.