Managing hypertension in urban underserved subjects using telemedicine—A clinical trial

doi:10.1016/j.ahj.2013.01.004

American Heart Journal

Volume 165, Issue 4, April 2013, Pages 615-621

https://doi.org/10.1016/j.ahj.2013.01.004 Get rights and content

Background

We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension.

Methods

A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months.

Results

Average age was 59.6 years, average body mass index was 33.7 kg/m², 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: −13.9 mm Hg, T: −18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: −19 ± 20 mm Hg, C: −12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes.

Conclusion

In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

Section snippets

Methods

We conducted a randomized, controlled trial to test the hypothesis that self-monitoring of BP and an Internet- and telephone-based communication system will allow more patients to reach goal BP compared with usual care. We studied an urban population comprised mainly of African Americans with a high incidence of both hypertension and diabetes. Subjects were recruited from Temple University Medical Center in Philadelphia, Pennsylvania, and Christiana Health Care Center in Wilmington, Delaware,

Results

The study was conducted over a 4-year period. We recruited 241 subjects, of which 206 completed the 6-month study. Figure shows a flow diagram of the recruiting process. After screening, 241 patients were randomized into 121 controls and 120 telemedicine subjects. Table I shows the demographic characteristics of the subjects. African American subjects represented about 80% of the study population. Sixty-five percent were female, more than 50% had family incomes at or near the poverty level, and

Discussion

We tested a telephone- and Internet- based hypertension self-monitoring intervention for BP control in an urban underserved population. Although more than 50% of subjects in the telemedicine group achieved the goal BP of <140 mm Hg, the control group demonstrated a similar proportion of patients reaching the goal BP. Although the primary end point was not achieved because of improved BP in the control group, the magnitude of the BP change was greater in the telemedicine group. This finding

Summary

In asymptomatic hypertensive individuals, engagement with a health care system was successful in reducing BP. Telemedicine appears to have little advantage, except in nondiabetic patients who showed a substantial improvement in BP control compared with control subjects. The increased number of antihypertensive medications noted in the telemedicine subjects suggests that physician reminders are an important part of hypertension management. The observation that BP was also reduced in the control,

Conclusion

In a community of low-income, underserved urban subjects with a high incidence of hypertension, we demonstrated that minimal engagement with a system of care resulted in a significant reduction of BP. Internet- and telephone-based communications coupled with self-measured BP and physician reminders showed a distinct advantage over usual care in asymptomatic nondiabetic subjects.

References (33)

H.B. Bosworth et al.
Racial differences in two self-management hypertension interventions
Am J Med
(2011)
R.H. Friedman et al.
Telecommunications system for monitoring and counseling patients with hypertension: impact on medication adherence and BP control
Am J Hypertens
(1996)
R.J. McManus et al.
Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial
Lancet
(2010)
A.A. Bove et al.
Reducing cardiovascular disease risk in medically underserved urban and rural communities
Am Heart J
(2011)
H. Kramer et al.
Racial/Ethnic differences in hypertension and hypertension treatment and control in the Multi-Ethnic Study of Atherosclerosis (MESA)
Am J Hypertens
(2004)
V.L. Roger et al.
Heart disease and stroke statistics—2011 update: a report from the American Heart Association
Circulation
(2011)
R.F. Gillum et al.
Coronary heart disease risk factors and attributable risks in African-American women and men: NHANES I epidemiologic follow-up study
Am J Public Health
(1998)
R. Cooper et al.
Trends and disparities in coronary heart disease, stroke, and other CVDs in the United States: findings of the national conference on CVD prevention
Circulation
(2000)
R. Cooper et al.
Slowdown in the decline of stroke mortality in the United States, 1978-1986
Stroke
(1990)
C. Sempos et al.
Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States
Am J Public Health
(1988)

M.D. Wong et al.

Contribution of major disease to disparities in mortality

N Engl J Med

(2002)

M.A. Rogers et al.

Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial

Ann Intern Med

(2001)

S. Ewald et al.

Relationship between the frequency of BP self-measurement and BP reduction with antihypertensive therapy: results of the OLMETEL (OLMEsartan TELemonitoring BP) study

Clin Drug Investig

(2006)

C.L. Neumann et al.

BP telemonitoring is useful to achieve BP control in inadequately treated patients with arterial hypertension

J Hum Hypertens

(2011)

A.G. Logan et al.

Effect of home BP telemonitoring with self-care support on uncontrolled systolic hypertension in diabetics

Hypertension

(2012)

E.H. Wagner et al.

Finding common ground: patient-centeredness and evidence-based chronic illness care

J Altern Complement Med

(2005)

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Digital health interventions are effective for hypertension self-management, but a comparison of the effectiveness and implementation of the different modes of interventions is not currently available. This study aimed to compare the effectiveness of SMS, smartphone application, and website interventions on improving blood pressure in adults with hypertension, and to report on their reach, uptake, and feasibility.
In this systematic review and meta-analysis we searched CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid MEDLINE, and APA PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) published in English from Jan 1, 2009, that examined the effectiveness of digital health interventions on reducing blood pressure in adults with hypertension. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint was change in the mean of systolic blood pressure. Risk of bias was assessed with Cochrane Risk of Bias 2. Data on systolic and diastolic blood pressure reduction were synthesised in a meta-analysis, and data on reach, uptake and feasibility were summarised narratively. Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to evaluate the level of evidence. The study was registered with PROSPERO CRD42021247845.
Of the 3235 records identified, 29 RCTs from 13 regions (n=7592 participants) were included in the systematic review, and 28 of these RCTs (n=7092 participants) were included in the meta-analysis. 11 studies used SMS as the primary mode of delivery of the digital health intervention, 13 used smartphone applications, and five used websites. Overall, digital health intervention group participants had a –3·62 mm Hg (95% CI –5·22 to –2·02) greater reduction in systolic blood pressure, and a –2·45 mm Hg (–3·83 to –1·07) greater reduction in diastolic blood pressure, compared with control group participants. No statistically significant differences between the three different modes of delivery were observed for both the systolic (p=0·73) and the diastolic blood pressure (p=0·80) outcomes. Smartphone application interventions had a statistically significant reduction in diastolic blood pressure (–2·45 mm Hg [–4·15 to –0·74]); however, there were no statistically significant reductions for SMS interventions (–1·80 mm Hg [–4·60 to 1·00]) or website interventions (–3·43 mm Hg [–7·24 to 0·38]). Due to the considerable heterogeneity between included studies and the high risk of bias in some, the level of evidence was assigned a low overall score. Interventions were more effective among people with greater severity of hypertension at baseline. SMS interventions reported higher reach and smartphone application studies reported higher uptake, but differences were not statistically significant.
SMS, smartphone application, and website interventions were associated with statistically and clinically significant systolic and diastolic blood pressure reductions, compared with usual care, regardless of the mode of delivery of the intervention. This conclusion is tempered by the considerable heterogeneity of included studies and the high risk of bias in most. Future studies need to describe in detail the mediators and moderators of the effectiveness and implementation of these interventions, to both further improve their effectiveness as well as increase their reach, uptake, and feasibility.
European Union's Horizon 2020 Research and Innovation Programme.
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The COVID-19 pandemic crisis, among so many social, economic and health problems, also brought new opportunities. The potential of telemedicine to improve health outcomes had already been recognised in the last decades, but the pandemic crisis has accelerated the digital revolution. In 2020, a rapid increase in the use of remote consultations occurred due to the need to reduce attendance and overcrowding in outpatient clinics. However, the benefit of their use extends beyond the pandemic crisis, as an important tool to improve both the efficiency and capacity of future healthcare systems. This article reviews the literature regarding telemedicine and teleconsultation standards and recommendations, collects opinions of Portuguese experts in respiratory medicine and provides guidance in teleconsultation practices for Pulmonologists.
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Self-care interventions improved quality of life in heart failure compared with control conditions (Supplemental Fig. 4); but the overall effect size was small (g = 0.20 (95%CI = 0.11–0.28), z = 6.53, p < 0.001). Twenty-six self-care trials in hypertension involving 8753 patients were included (Blom et al., 2014; Bennett et al., 2018; Kuhmmer et al., 2016; Bennett et al., 2010; Augustovski et al., 2018; Dusek et al., 2008; Green et al., 2008; McManus et al., 2018; Bennett et al., 2012; Bove et al., 2013; Takada et al., 2018; Piette et al., 2012; Daniali et al., 2017; Nolan et al., 2018; Bosworth et al., 2009; Margolius et al., 2012; Feldman et al., 2016; Brennan et al., 2010; Kim et al., 2014; Okada et al., 2018; McManus et al., 2010; Chan et al., 2018; McManus et al., 2014; Xue et al., 2008; Hinderliter et al., 2014; Perl et al., 2016). Overall, self-care interventions improved systolic blood pressure compared with control conditions (Supplemental Fig. 5); the overall effect size was small-to-moderate (g = 0.34 (95%CI = 0.24–0.44), z = 14.23, p < 0.001).
To characterize and explain variation in the comparative effectiveness of self-care interventions on relevant outcomes of chronic illness compared with controls.
Meta-analysis and meta-regression.
Data extraction was framed within the context of a previously-published scoping review of randomized trials designed to enhance self-care in type 2 diabetes mellitus, heart failure, hypertension, asthma, coronary artery disease, and chronic obstructive pulmonary disease (published between 2008 and 2019). Data were pooled using random-effects meta-analyses. Meta-regression was used to test the effect of potential moderators on trial effectiveness.
145 trials involving 36,853 participants were included. Overall, the effect size of self-care interventions on improving outcomes was small (Hedges' g = 0.29 (95% CI = 0.25–0.33), p < 0.001) with statistically significant heterogeneity across trials (Q = 514.85, p < 0.001, I² = 72.0%). A majority of trials (n = 83, 57.2%) were rated as having a high risk of bias. There was no statistically significant difference in trial effectiveness based on the use of theory, specific components of self-care addressed, the number of modes of delivery, the number of behavioral change techniques, specific modes of delivery, specific behavioral change techniques, intervention duration, total number of hours of intervention, or either participant age or gender.
Self-care interventions are modestly effective in improving outcomes. Poor trial quality limits the strength of conclusions in this area of science. There is much to be done to enhance the design, conduct and reporting of self-care trials in order to gain more insight into the effectiveness of self-care interventions.
New review highlights poor trial design as major impediment to understanding the contribution of self -care to outcomes in chronic illness.
The effects of a smartphone-enhanced nurse-facilitated self-care intervention for Chinese hypertensive patients: A randomised controlled trial
2022, International Journal of Nursing Studies
For hypertensive patients, self-care is of the utmost importance in disease management and health maintenance. However, due to inadequate motivation and self-efficacy in performing self-care behaviours, satisfactory self-care is difficult to initiate and maintain. Smartphone-based interventions with support from nurses may be an alternative way to improve self-care behaviours and blood pressure control. Therefore, a randomised controlled trial was conducted to test the effects of a smartphone-enhanced nurse-facilitated self-care intervention for hypertensive people.
To examine the effects of a smartphone-enhanced nurse-facilitated self-care intervention on improving blood pressure control, anthropometric parameters, and self-care amongst Chinese hypertensive patients from two community health service centres.
This study was a single-blinded, two-arm randomised controlled trial with a repeated-measures design.
Participants were recruited from two community health service centres in China from March 2018 to June 2018.
A total of 210 patients with hypertension were randomly allocated to either the intervention or control group (n = 105 per group).
Participants in the intervention group received six individual weekly education and consultation sessions provided by a nurse in the first 6 weeks and a researcher-developed smartphone application for 12 weeks. The sessions consisted of health education, individual self-care planning, daily records of physical health status and lifestyle behaviour, and an automated weekly health report. Data on systolic blood pressure, diastolic blood pressure, body weight, waist circumference, and self-care (behaviour, motivation, and self-efficacy) were collected at baseline, the 6th week, and 12th week after joining the study. A generalised estimating equation model was used to analyse the outcome.
A total of 191 patients (91%) completed outcome measurements at the three time points. Compared with the control group at the 6th and 12th week follow-ups, the intervention group exhibited significant reductions in systolic blood pressure (T1: β = − 7.29, T2: β = − 11.07), diastolic blood pressure (T1: β = − 4.80, T2: β = − 7.50), body weight, body mass index, and waist circumference, and a significant improvement in self-care (behaviour, motivation, and self-efficacy). At the 12th week follow-up, the proportion of participants with BP < 140/90 mmHg in the intervention group (31%) was significantly higher than that in the control group (9%, p = 0.003).
The smartphone-enhanced nurse-facilitated self-care intervention could improve blood pressure, anthropometric parameters, and self-care amongst Chinese hypertensive people in two communities. Its long-term effects amongst diverse hypertensive patient populations can be examined in a future study.
The smartphone-enhanced nurse-facilitated self-care intervention improved BP control and self-care, which is an effective alternative to hypertension management.
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Increasingly, health professionals and patients have begun to be involved in eHealth interventions to assist in the self-management of hypertension. Therefore, this study was aimed at comparing the effect of different types of eHealth interventions (phone calls, blood pressure telemonitoring, emails, web-site, smartphone-app, short message service (SMS) and more than two eHealth interventions) on reducing systolic and diastolic blood pressure, increasing adherence to medication treatment, improving physical activity compliance, controlling blood pressure, and improving quality of life (QoL).
A systematic search in MEDLINE (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted to identify experimental studies addressing the effect of eHealth interventions on the self-management of hypertension. Comparative evaluation of the eHealth interventions effect were performed by conducting a standard pairwise meta-analysis and a network meta-analysis for direct and indirect comparisons between eHealth interventions and control/non-intervention.
Fifty-one studies were included in the analysis showing a moderate effect size for more than two types of eHealth interventions (-0.46; 95%CI: -0.64, -0.27, p < 0.001 and -0.29; 95%CI: -0.46, -0.13, p < 0.001), phone calls (-0.37; 95%CI: -0.57, -0.17, p < 0.001 and -0.29; 95%CI: -0.52, -0.07, p = 0.011) and smartphone-app (-0.26; 95%CI: -0.50, -0.01, p = 0.040 and -0.40; 95%CI: -0.70, -0.10, p = 0.010) on reducing both systolic and diastolic blood pressure, respectively. Additionally, i) smartphone-app improved medication adherence by 45%; ii) more than two types of eHealth interventions and emails improved physical activity compliance by 18% and 57% respectively; ii) more than two types of eHealth interventions, phone calls, blood pressure telemonitoring, website and SMS improved blood pressure control between 16% and 30%; and iv) blood pressure telemonitoring showed a week effect on QoL
Our study reported eHealth to be a suitable intervention for the self-management of hypertension. Considering our results and the population's accessibility to eHealth devices, eHealth could be a useful and largely scalable tool for the self-management of hypertension.
PROSPERO CRD42020187468.
Rapid review: Identification of digital health interventions in atherosclerotic-related cardiovascular disease populations to address racial, ethnic, and socioeconomic health disparities
2020, Cardiovascular Digital Health Journal
Citation Excerpt :
Patient-reported outcomes included improvement in diet quality (+3.5 points, P < .03) and total energy expenditure (+80 kcal/day, P < .03) in hypertensive urban black populations with low SES in an RCT.43 However, nonsignificant changes in health outcomes were observed for medication adherence in this same trial,43 quality of life in a separate RCT,46 and hospital admissions in a pre-post study51 following telemedicine interventions; BP control had mixed results in racial and ethnic minorities in separate RCTs.24,43 The impact of telemedicine on healthcare utilization (HCU) in the form of technology protocol adherence and use of services had mixed effects on disparate populations.
Disparities in cardiovascular disease (CVD) and associated health and healthcare delivery outcomes have been partially attributed to differential risk factors, and to prevention and treatment inequities within racial and ethnic (including language) minority groups and low socioeconomic status (SES) populations in urban and rural settings. Digital health interventions (DHIs) show promise in promoting equitable access to high-quality care, optimal utilization, and improved outcomes; however, their potential role and impact has not been fully explored. The role of DHIs to mitigate drivers of the health disparities listed above in populations disproportionately affected by atherosclerotic-related CVD was systematically reviewed using published literature (January 2008–July 2020) from multiple databases. Study design, type and description of the technology, health disparities information, type of CVD, outcomes, and notable barriers and innovations associated with the technology utilized were abstracted. Study quality was assessed using the Oxford Levels of Evidence. Included studies described digital health technologies in a disparity population with CVD and reported outcomes. DHIs significantly improved health (eg, clinical, intermediate, and patient-reported) and healthcare delivery (eg, access, quality, and utilization of care) outcomes in populations disproportionately affected by CVD in 24 of 38 included studies identified from 2104 citations. Hypertension control was the most frequently improved clinical outcome. Telemedicine, mobile health, and clinical decision support systems were the most common types of DHIs identified. DHIs improved CVD-related health and healthcare delivery outcomes in racial/ethnic groups and low SES populations in both rural and urban geographies globally.

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: This work was supported by a grant from the Agency for Healthcare Quality and Research.

: Clinical trial no. NCT00644267.

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Clinical InvestigationHypertensionManaging hypertension in urban underserved subjects using telemedicine—A clinical trial

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Summary

Conclusion

Am J Med

Am J Hypertens

Lancet

Am Heart J

Am J Hypertens

Heart disease and stroke statistics—2011 update: a report from the American Heart Association

Circulation

Coronary heart disease risk factors and attributable risks in African-American women and men: NHANES I epidemiologic follow-up study

Am J Public Health

Trends and disparities in coronary heart disease, stroke, and other CVDs in the United States: findings of the national conference on CVD prevention

Circulation

Slowdown in the decline of stroke mortality in the United States, 1978-1986

Stroke

Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States

Am J Public Health

Contribution of major disease to disparities in mortality

N Engl J Med

Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial

Ann Intern Med

Relationship between the frequency of BP self-measurement and BP reduction with antihypertensive therapy: results of the OLMETEL (OLMEsartan TELemonitoring BP) study

Clin Drug Investig

BP telemonitoring is useful to achieve BP control in inadequately treated patients with arterial hypertension

J Hum Hypertens

Effect of home BP telemonitoring with self-care support on uncontrolled systolic hypertension in diabetics

Hypertension

Finding common ground: patient-centeredness and evidence-based chronic illness care

J Altern Complement Med

Clinical Investigation
Hypertension
Managing hypertension in urban underserved subjects using telemedicine—A clinical trial