Supporting self-management for people with hypertension: a meta-review of quantitative and qualitative systematic reviews

Evaluation of a Question Prompt List About Cardiovascular Disease Risk and Prevention After Hypertensive Pregnancy: A Pilot Study

INTRODUCTION

The aim of this study was to pilot test a question prompt list (QPL) about cardiovascular disease (CVD) risk reduction after hypertensive pregnancy (HDP).

METHODS

In a prospective cohort study of adult women who had HDP given the QPL before and surveyed after a physician visit, we assessed perceived person-centred care, self-efficacy for self-management, perceived self-management and QPL feasibility.

RESULTS

Twenty-three women participated: 57% of diverse ethno-cultural groups, 65% < 40 years of age and 48% immigrants. Most scored high for person-centred care (mean 4.1 ± 0.2/5); and moderately for self-efficacy (mean 7.4 ± 0.6/10) and self-management (mean 3.1 ± 0.3/5). Most appreciated QPL design and reported QPL benefits: helped them to prepare for the visit and know what to ask; increased confidence to ask questions, knowledge of the link between HDP and CVD and lifestyle behaviours to reduce CVD risk. Most reported that physicians were receptive to discussing QPL questions.

CONCLUSION

Women appreciated the QPL and knowledge about self-management was high but self-efficacy for or perceived self-management was moderate. It appears feasible to share a QPL with ethno-culturally diverse women who can share it with physicians to facilitate discussions about post-pregnancy HDP-related CVD risk.

PATIENT OR PUBLIC CONTRIBUTION

This study involved women who experienced HDP and engaged ethno-culturally diverse women with lived experience of HDP as study advisors in all stages of the research.

Self-management in young and middle-aged patients with hypertension: a systematic review and meta-synthesis of qualitative studies

BACKGROUND

There has been a sharp increase in the prevalence of hypertension in young and middle-aged people at high risk of the disease. Despite the fact that good self-management can be effective in controlling blood pressure, patients do not perform well in this area, resulting in poor blood pressure control. It is therefore particularly important to gain a thorough understanding of patients' attitudes to self-management and the factors that influence them. The aim of this study was to synthesise the qualitative research on attitudes, motivations and challenges of self-management in young and middle-aged hypertensive patients, to analyse the synthesised results using the COM-B model and to propose appropriate improvement actions.

METHODS

From the time of construction until May 2023, the system searched PubMed, Web of Science, ProQuest, Embase, MEDLINE, CINAHL, PsyCINFO and CNKI databases. The analyses were carried out using a thematic synthesis approach to summarise the key findings. The findings were then mapped and analysed using the COM-B model.

RESULTS

A total of 11 studies were included, involving 250 patients between the ages of 18 and 64. Four themes with ten sub-themes were identified: Poor disease recognition (low disease perception, fuzzy disease knowledge); Barriers to doctor-patient interactions (short communication time, unmet knowledge needs, incomplete guidance for disease management); Living in a hostile environment (heavy workload, lack of companionship, ignorance of families); Expectations for a healthy body (responsibility of family roles, witness the cruelty of illness). Analysis of the composite results based on the COM-B model showed that low disease perceptions, barriers to doctor-patient interactions and life circumstances with enemies on all sides were the main challenges faced by young and middle-aged hypertensive patients, whereas the expectation of a healthy body was a motivation to promote self-management of blood pressure in patients.

CONCLUSIONS

This study shows that family responsibilities are a particular motivator for self-management in young and middle-aged hypertensive patients. In response to the problems they face, we believe that meeting patients' knowledge needs, improving healthcare professionals' communication skills and valuing the role of community hospitals are effective ways to promote patient self-management. In the future, telemedicine, mobile healthcare and intelligent monitoring devices will provide a solution to reduce the burden on medical resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018100810.

Associations between daily home blood pressure measurements and self-reports of lifestyle and symptoms in primary care: the PERHIT study

OBJECTIVE

To explore in a primary care setting the associations between patients' daily self-measured blood pressure (BP) during eight weeks and concurrent self-reported values of wellbeing, lifestyle, symptoms, and medication intake. We also explore these associations for men and women separately.

DESIGN AND SETTING

The study is a secondary post-hoc analysis of the randomised controlled trial PERson-centeredness in Hypertension management using Information Technology (PERHIT). The trial was conducted in primary health care in four regions in Southern Sweden.

PATIENTS

Participants (n = 454) in the intervention group in the PERHIT-trial used an interactive web-based system for self-management of hypertension for eight consecutive weeks. Each evening, participants reported in the system their wellbeing, lifestyle, symptoms, and medication adherence as well as their self-measured BP and heart rate.

MAIN OUTCOME MEASURES

Association between self-reported BP and 10 self-report lifestyle-related variables.

RESULTS

Self-reported less stress and higher wellbeing were similarly associated with BP, with 1.0 mmHg lower systolic BP and 0.6/0.4 mmHg lower diastolic BP (p < 0.001). Adherence to medication had the greatest impact on BP levels (5.2/2.6 mmHg, p < 0.001). Restlessness and headache were also significantly associated with BP, but to a lesser extent. Physical activity was only significantly associated with BP levels for men, but not for women.

CONCLUSION

In hypertension management, it may be important to identify patients with high-stress levels and low wellbeing. The association between medication intake and BP was obvious, thus stressing the importance of medication adherence for patients with hypertension.

Update of the clinical guideline for hypertension diagnosis and treatment in Iran

BACKGROUND

This article introduces the updated version of the Iranian guideline for the diagnosis and treatment of hypertension in adults. The initial version of the national guideline was developed in 2011 and updated in 2014. Among the reasons necessitating the update of this guideline were the passage of time, the incompleteness of the scopes, the limitation of the target group, and more important is the request of the ministry of health in Iran.

METHOD

The members of the guideline updating group, after reviewing the original version and the new evidence, prepared 10 clinical questions regarding hypertension, and based on the evidence found from the latest scientific documents, provided recommendations or suggestions to answer these questions.

RESULT

According to the updated guideline, the threshold for office prehypertension diagnosis should be considered the systolic blood pressure (SBP) of 130-139 mmHg and/or the diastolic blood pressure (DBP) of 80-89 mmHg, and in adults under 75 years of age without comorbidities, the threshold for office hypertension diagnosis should be SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg. The goal of treatment in adults who lack comorbidities and risk factors is SBP < 140 mmHg and DBP < 90 mmHg. The first-line treatment recommended in people with prehypertension is lifestyle modification, while for those with hypertension, pharmacotherapy along with lifestyle modification. The threshold to start drug therapy is determined at SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg, and the first-line treatment is considered a drug or a combined pill of antihypertensive drugs, including ACEIs, ARBs, thiazide and thiazide-like agents, or CCBs. At the beginning of the pharmacotherapy, the Guideline Updating Group members suggested studying serum electrolytes, creatinine, lipid profile, fasting sugar, urinalysis, and an electrocardiogram. Regarding the visit intervals, monthly visits are suggested at the beginning of the treatment or in case of any change in the type or dosage of the drug until achieving the treatment goal, followed by every 3-to-6-month visits. Moreover, to reduce further complications, it was suggested that healthcare unit employees use telehealth strategies.

CONCLUSIONS

In this guideline, specific recommendations and suggestions have been presented for adults and subgroups like older people or those with cardiovascular disease, diabetes mellitus, chronic kidney disease, and COVID-19.

Effectiveness of medication self-management, self-monitoring and a lifestyle intervention on hypertension in poorly controlled patients: The MEDICHY randomized trial

Background

Uncontrolled hypertension is a common problem worldwide, despite the availability of many effective antihypertensive drugs and lifestyle interventions. We assessed the efficacy of a multi-component intervention in individuals with uncontrolled hypertension in a primary care setting.

Methods

This study was a randomized, multicenter, parallel, two-arm, single-blind controlled trial performed in primary healthcare centers in Mallorca (Spain). All participants were 35 to 75-years-old and had poorly controlled hypertension. Patients were randomly assigned in a 1:1 ratio to a control group (usual care) or an intervention group (self-monitoring of blood pressure, self-titration of hypertensive medications, dietary interventions, and physical activity interventions). The primary outcome was decrease in the mean SBP at 6 months relative to baseline.

Results

A total of 153 participants were randomized to an intervention group (77) or a control group (76). After 6 months, the intervention group had a significantly lower systolic blood pressure (135.1 mmHg [±14.8] vs. 142.7 mmHg [±15.0], adjusted mean difference: 8.7 mmHg [95% CI: 3.4, 13.9], p < 0.001) and a significantly lower diastolic blood pressure (83.5 mmHg [±8.8] vs. 87.00 mmHg [±9.0], adjusted mean difference: 5.4 [95% CI: 2.9, 7.8], p < 0.0001). The intervention group also had significantly more patients who achieved successful blood pressure control (<140/90 mmHg; 54.4% vs. 32.9%, p = 0.011).

Discussion

Self-monitoring of blood pressure in combination with self-management of hypertensive medications, diet, and physical activity in a primary care setting leads to significantly lower blood pressure in patients with poorly controlled hypertension.Clinical Trial Registration: ClinicalTrials.gov, identifier ISRCTN14433778.

Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension: A Secondary Analysis of the ADAMPA Randomized Clinical Trial

Importance

Patient empowerment through pharmacologic self-management is a common strategy for some chronic diseases such as diabetes, but it is rarely used for controlling blood pressure (BP). Several trials have shown its potential for reducing BP in the short term, but evidence in the longer term is scarce.

Objective

To evaluate the longer-term effectiveness of BP self-monitoring plus self-titration of antihypertensive medication vs usual care for patients with poorly controlled hypertension, with passive follow-up and primary-care nursing involvement.

Design, Setting, and Participants

The ADAMPA (Impact of Self-Monitoring of Blood Pressure and Self-Titration of Medication in the Control of Hypertension) study was a randomized, unblinded clinical trial with 2 parallel arms conducted in Valencia, Spain. Included participants were patients 40 years or older, with systolic BP (SBP) over 145 mm Hg and/or diastolic BP (DBP) over 90 mm Hg, recruited from July 21, 2017, to June 30, 2018 (study completion, August 25, 2020). Statistical analysis was conducted on an intention-to-treat basis from August 2022 to February 2024.

Interventions

Participants were randomized 1:1 to usual care vs an individualized, prearranged plan based on BP self-monitoring plus medication self-titration.

Main Outcomes and Measures

The main outome was the adjusted mean difference (AMD) in SBP between groups at 24 months of follow-up. Secondary outcomes were the AMD in DBP between groups at 24 months of follow-up, proportion of patients reaching the BP target (SBP <140 mm Hg and DBP <90 mm Hg), change in behaviors, quality of life, health service use, and adverse events.

Results

Among 312 patients included in main trial, data on BP measurements at 24 months were available for 219 patients (111 in the intervention group and 108 in the control group). The mean (SD) age was 64.3 (10.1) years, and 120 patients (54.8%) were female; the mean (SD) SBP was 155.6 (13.1) mm Hg, and the mean (SD) diastolic BP was 90.8 (7.7) mm Hg. The median follow-up was 23.8 months (IQR, 19.8-24.5 months). The AMD in SBP at the end of follow-up was -3.4 mm Hg (95% CI, -4.7 to -2.1 mm Hg; P < .001), and the AMD in DBP was -2.5 mm Hg (95% CI, -3.5 to -1.6 mm Hg; P < .001). Subgroup analysis for the main outcome showed consistent results. Sensitivity analyses confirmed the robustness of the main findings. No differences were observed between groups in behaviors, quality of life, use of health services, or adverse events.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, BP self-monitoring plus self-titration of antihypertensive medication based on an individualized prearranged plan used in primary care reduced BP in the longer term with passive follow-up compared with usual care, without increasing health care use or adverse events. These results suggest that simple, inexpensive, and easy-to-implement self-management interventions have the potential to improve the long-term control of hypertension in routine clinical practice.

Trial Registration

ClinicalTrials.gov Identifier: NCT03242785.

Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Background

Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs.

Methods

In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227.

Findings

We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%].

Interpretation

Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence.

Funding

None.

Mobile health technologies in the prevention and management of hypertension: A scoping review

Introduction

An estimated one billion people globally are currently suffering from hypertension. Prevention and management of hypertension are suboptimal especially in low- and middle-income countries leading to increased complications and deaths. With increased mobile phone coverage globally, this study aims to review mobile health technologies used for the prevention and management of hypertension.

Methods

We conducted a literature search on electronic databases using identified keywords involving "hypertension", "mobile health technology" and their synonyms. Snowballing technique was also used. Papers were screened at two levels by independent reviewers. The targets were studies published in peer-reviewed journals reporting mobile health interventions for hypertension prevention and management. Only primary research studies published in English from January 2017 to April 2024 were included. Google Forms were used to extract the data along with other characteristics, and selected articles were categorised into: mobile application, web-based solutions, and Short Message Service (SMS) and other offline solutions.

Result

The search yielded 184 articles, and 44 studies were included in the review. Most (n = 26) were randomised control trials. Twenty-two studies (22) focused only on mobile applications solutions, 12 on SMS and other offline mHealth, 5 web-based solutions, and 5 combined more than one type of mobile health technology. The United States of America had the majority of studies (n = 17), with 6 studies from other American countries, 11 from Asia and nine from Europe, while only one from Africa. A total of 36 studies reported that mobile health technology significantly improved hypertension care through reduced blood pressure, improved adherence to follow-up visits and medications, and lifestyle changes. SMS and offline mHealth strategies have also demonstrated effectiveness in promoting self-management and reducing racial disparities in hypertension care.

Conclusion

Mobile health technology has the potential to play a significant role in the prevention and management of hypertension. However, there is a need for mobile health solutions for hypertension prevention and management in African countries and other developing countries. Integrating mHealth into primary healthcare delivery would also go a long way in strengthening patient care and reducing the burden on healthcare systems.

Impact of poor medication adherence on clinical outcomes and health resource utilization in patients with hypertension and/or dyslipidemia: systematic review

INTRODUCTION

We aimed to summarize evidence on the effect of poor medication adherence on clinical outcomes and health resource utilization (HRU) among patients with hypertension and/or dyslipidemia.

AREAS COVERED

A systematic review of studies reporting clinical outcomes and HRU for patients by status of adherence to antihypertensives and/or lipid-lowering medications was searched using Embase, MEDLINE, and MEDLINE In-Process and supplemented by manual searches of conference abstracts. In total, 45 studies were included, with most being retrospective observational studies (n = 36). Patients with poor adherence to antihypertensives and lipid-lowering medications compared with those with good adherence showed less reduction of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-c) after 6-12 months follow-up (∆ systolic BP: 1.2 vs. -4.5 mmHg; ∆LDL-c: -14.0 to -18.9 vs. -34.1 to -42.0 mg/dL). Poor adherence was also significantly associated with a higher risk of cardiovascular events (HR: 1.1-1.9) and mortality (HR: 1.4-1.8) in patients with hypertension and dyslipidemia and increased HRU (i.e. outpatient visits, risk of cardiovascular-related and all-cause hospitalization, annual inpatient days, total health-care costs).

EXPERT OPINION

Poor adherence is associated with poor clinical outcomes and increased HRU, highlighting the need to enhance medication adherence in patients with hypertension and/or dyslipidemia.

Prevalence, awareness, treatment and control of high blood pressure in a cohort in Northern Andean Peru

BACKGROUND

Gaps exist along the high blood pressure (HBP) diagnosis-treatment-control pathway in high, low and middle-income countries.

OBJECTIVE

To determine the prevalence of HBP and to describe the levels of awareness, control and treatment of HBP in the rural Peruvian Andes.

METHODS

This cross-sectional study is embedded into a multigenerational cohort. We analysed data of all adult participants aged ≥ 30 years (n = 2752) who answered a baseline health and lifestyle questionnaire and underwent a physical examination, which included three blood pressure readings. HBP was defined as measured systolic or diastolic blood pressure (BP) ≥140 and/or 90 mm Hg and/or self-reported physician-diagnosed hypertension and/or self-reported antihypertensive intake. The determinants of the prevalence of HBP, unawareness of HBP and uncontrolled HBP were assessed using mixed-effect logistic regressions.

RESULTS

HBP was present in 18.9% of the participants. Of those with measured HBP, 72.2% were unaware of their HBP. Among those with a diagnosed or medically treated hypertension, 58.4% had uncontrolled HBP. The prevalence of HBP was higher in women (OR: 1.12, CI: 1.02-1.24), increased with age (OR: 1.01, CI: 1.01-1.01) and the presence of family history of hypertension (OR: 1.15, CI: 1.08-1.24), and decreased with healthier lifestyle score (OR: 0.93, CI: 0.91-0.95). Unawareness of HBP was lower among women (OR: 0.56, CI: 0.38-0.83), higher among participants living over 3000 m Above Sea Level (OR: 1.15, CI: 1.03-1.27) and decreased with age (OR: 0.99, CI: 0.98-0.99).

CONCLUSIONS

Unawareness of HBP was high, few HTN patients received treatment and BP remained high in the presence of antihypertensive treatment.

Efficacy of an mHealth App to Support Patients' Self-Management of Hypertension: Randomized Controlled Trial

BACKGROUND

Hypertension is a significant global disease burden. Mobile health (mHealth) offers a promising means to provide patients with hypertension with easy access to health care services. Yet, its efficacy needs to be validated, especially in lower-income areas with a high-salt diet.

OBJECTIVE

This study aims to assess the efficacy of an mHealth app-based intervention in supporting patients' self-management of hypertension.

METHODS

A 2-arm randomized controlled trial was conducted among 297 patients with hypertension at the General Hospital of Ningxia Medical University, Ningxia Hui Autonomous Region, China. Participants selected via convenience sampling were randomly allocated into intervention and control groups. Intervention group participants were trained and asked to use an mHealth app named Blood Pressure Assistant for 6 months. They could use the app to record and upload vital signs, access educational materials, and receive self-management reminders and feedback from health care providers based on the analysis of the uploaded data. Control group participants received usual care. Blood pressure (BP) and 2 questionnaire surveys about hypertension knowledge and lifestyle behavior were used to assess all participants at baseline and 6 months. Data analysis was performed with SPSS software using 2-tailed t tests and a chi-square test.

RESULTS

There were no significant differences in baseline characteristics and medication use between the 2 groups (all P>.05). After 6 months, although both groups show a significant pre-post improvement (P<.001 each), the BP control rate (ie, the proportion of patients with a systolic BP of <140 mm Hg and diastolic BP of <90 mm Hg) in the intervention group was better than that in the control group (100/111, 90.1% vs 75/115, 65.2%; P<.001). The mean systolic and diastolic BP were significantly reduced by 25.83 (SD 8.99) and 14.28 (SD 3.74) mm Hg in the intervention group (P<.001) and by 21.83 (SD 6.86) and 8.87 (SD 4.22) mm Hg in the control group (P<.001), respectively. The differences in systolic and diastolic BP between the 2 groups were significant (P<.001 and P=.01, respectively). Hypertension knowledge significantly improved only in the intervention group in both pre-post and intergroup comparisons (both P<.001). However, only intragroup improvement was observed for lifestyle behaviors in the intervention group (P<.001), including medication adherence (P<.001), healthy diet (P=.02), low salt intake (P<.001), and physical exercises (P=.02), and no significant difference was observed in the control group or on intergroup comparisons.

CONCLUSIONS

This research shows that the mHealth app-based intervention has the potential to improve patient health knowledge and support self-management among them toward a healthier lifestyle, including medication adherence, low-salt diets, and physical exercises, thereby achieving optimal BP control. Further research is still needed to verify the specific effects of these interventions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900026437; https://www.chictr.org.cn/showproj.html?proj=38801.

Translation and evaluation of psychometric properties of the Persian version of the Hypertension Self-Care Activity Level Effects (H-SCALE)

BACKGROUND & OBJECTIVES

Hypertension is a major cause of cardiovascular disease and premature death worldwide. Managing hypertension through self-care practices is considered one of the most effective strategies. However, to accurately assess the self-care status of individuals with hypertension, a valid and reliable tool is necessary. This study aimed to evaluate the psychometric properties of the Persian version of the Hypertension Self-Care Activity Level Effects Questionnaire.

METHODS

Present methodological study was conducted on 218 patients with hypertension visiting the Clinic of Qom educational and medical centers. Subjects were selected with convenience sampling. Data were collected using the H-SCALE, and a demographic questionnaire. The translation was done from the recommended backward-forward method according to the WHO protocol. After that, face and content validity were applied, along with construct validity involving a comparison of known groups and confirmatory factor analysis. To test reliability, Cronbach's alpha was used. Data analysis was performed by SPSS and smart-PLS software.

RESULTS

The factor loadings of the self-care behaviors questionnaire were significant in all constructs, and were higher than 0.5 except for three items. The known-groups method showed that the self-care score of patients with controlled blood pressure was significantly higher than those with uncontrolled blood pressure. The extent of average variance extracted (AVE) of the majority of the constructs in the questionnaire was greater than 0.5 and, the composite reliability was greater than the AVE, indicating a good convergent validity. The divergent validity of the questionnaire was confirmed using the Fornell-Larcker criterion and the heterotrait-monotrait ratio (HTMT). Cronbach's alpha coefficient, combined reliability, and communalities index were optimal.

CONCLUSION

According to research findings, the Persian version of the questionnaire has good validity and reliability that can be used as a tool to measure the level of self-care of hypertension by health care providers.

Web-based interventions to improve blood pressure control in patients with hypertension: a protocol for a systematic review

INTRODUCTION

Hypertension is the major cause of cardiovascular disease and mortality in the world. Blood pressure control (BPC) is recognised as a key measure in the management of hypertension. Several studies have been conducted assessing the impact of specific web-based interventions in improving BPC. Our systematic review intends to identify all the available web-based interventions and determine if and which are more effective than usual care in improving BPC.

METHODS AND ANALYSIS

We will include randomised control trials completed until April 2023 including patients diagnosed with hypertension comparing the effect of receiving usual care versus web-based interventions in BPC. No language restriction will be applied. We will start with an extensive electronic database search, in the Cochrane Central Register of Controlled Trials, PubMed, Embase, Scopus, EU Clinical Trials Register, Pan-African Clinical Trials Registry and ClinicalTrials.gov. Eligibility criteria will be applied blindly and independently by two researchers to the title and abstract of the references, in the first stage, and to the full version of the ones selected. All divergences will be solved by a third researcher. We will conduct a narrative description and meta-analysis (if adequate) of the results of the included studies, structured according to the type of intervention, characteristics of the population and outcome measurement. We will extract features of the web-based interventions, selecting the ones with the best outcomes regarding BPC, to later propose an ideal web-based intervention to improve BPC in hypertensive patients and/or guide future research on this topic. The risk of bias will be assessed using Cochrane's RoB2 Tool.

ETHICS AND DISSEMINATION

Ethical approval is not required since this is a protocol for a systematic review. The findings of this study will be disseminated through peer-reviewed publications and national or international conference presentations. Updates of the review will be conducted, as necessary.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020184166.

Identification of the Most Suitable Mobile Apps to Support Dietary Approaches to Stop Hypertension (DASH) Diet Self-Management: Systematic Search of App Stores and Content Analysis

Smartphone apps might provide an opportunity to support the Dietary Approaches to Stop Hypertension (DASH) diet, a healthy diet designed to help lower blood pressure. This study evaluated DASH diet self-management apps based on their quality, likely effectiveness, and data privacy/security to identify the most suitable app(s). A systematic search and content analysis were conducted of all DASH diet apps available in Google Play and the Apple App Store in the UK in November 2022. Apps were included if they provided DASH diet tracking. A previous systematic literature review found some commercial apps not found in the app store search, and these were also included in this review. Three reviewers used the App Quality Evaluation Tool (AQEL) to assess each app's quality across seven domains: knowledge acquisition, skill development, behaviour change, purpose, functionality, and appropriateness for adults with hypertension. Domains with a score of 8 or higher were considered high-quality. Two reviewers assessed the apps' data privacy and security and then coded Behaviour change techniques (BCTs) linked to the Theoretical Domain Framework (TDF) underpinning the likely effectiveness of the apps. Seven DASH diet apps were assessed, showing the limited availability of apps supporting DASH diet self-management. The AQEL assessment showed that three apps scored higher than eight in most of the AQEL domains. Nineteen BCTs were used across the apps, linked to nine TDF action mechanisms that may support DASH diet self-management behaviours. Four apps met standards for privacy and security. All seven apps with self-monitoring functionality had sufficient theoretical basis to demonstrate likely effectiveness. However, most had significant quality and data security shortcomings. Only two apps, NOOM and DASH To TEN, were found to have both adequate quality and security and were thus deemed suitable to support DASH diet self-management.

Effect of education based on the Common-Sense Model of Self-Regulation on blood pressure and self-management of hypertensive patients: A clinical trial study

Objective

This study aimed to determine the impact of training based on the Common-Sense Model of Self-Regulation (CSM) on blood pressure and self-management of patients with hypertension.

Methods

This randomized controlled trial study was conducted. Seventy-two hypertensive patients were referred to the Farshchian Hospital clinic in Hamadan from April 2021 to March 2022. Samples were selected and randomly assigned to the intervention group (n = 36) and control group (n = 36). The intervention group participated in a training program based on the CSM in five sessions of 30-45 min for one month. Phone follow-up was also done once every three days. The control group only received routine clinic education. The clinic's nurse measured the patients' blood pressure, and the participants completed the self-management questionnaire before and three months after the start of the study.

Results

A total of 68 participants completed the study. Results showed that before the intervention, there was no statistically significant difference in the mean scores of self-management and its dimensions, systolic, diastolic, and mean arterial pressure between intervention and control groups (P > 0.05). However, after the intervention, the mean of systolic blood pressure (116.21 ± 14.52 vs. 128.62 ± 16.88) mmHg, mean arterial pressure (88.03 ± 8.47 vs. 98.11 ± 11.69) mmHg and the scores of self-management and its dimensions among patients in the intervention group were decreased comparison with control group (P < 0.05).

Conclusions

Education based on the CSM improved self-management and blood pressure reduction in hypertensive patients, so nurses should use it as an effective educational model.

Experience-based design: Empowering individuals while they wait for interprofessional chronic pain care

OBJECTIVES

Chronic pain is highly prevalent and a leading cause of disability. Long wait times for interprofessional care provide an opportunity to introduce web-based interventions that improve psychosocial function and patients' readiness and ability to manage their condition. Here we describe the process of partnering with people with lived experience (PWLE) to develop an online self-management program enhanced by motivational interviewing. We also report the multiphase usability testing of the program.

METHODS

PWLE were included in all aspects of this project from program inception to content creation, module development, usability testing, and knowledge dissemination. Phase 1 included the development of the interactive, web-based modules. This process involved weekly meetings and asynchronous content creation with a core team of interprofessional pain experts, researchers, and PWLE. Phase 2 included usability testing by our PWLE and clinical expert advisory. Phase 3 included survey-based usability testing with a sample of 10 PWLE.

RESULTS

We created a chronic pain & motivational empowerment program includes a series of eight interactive educational web-based modules. Topics included: setting expectations, chronic pain explained, biopsychosocial factors, empowered management, self-awareness & compassion & acceptance, values, goal setting, and communication. The program is accompanied by a reflection journal and can be enhanced by one-on-one coaching sessions using a motivational interviewing approach. Phase two usability testing resulted in numerous content changes and the addition of accessibility features. Phase 3 usability testing with PWLE found the program highly accessible and easy to use.

CONCLUSIONS

The engagement of our PWLE team member and advisors made the online program more relevant, sensitive and helpful to the needs of people with pain.

PRACTICAL VALUE

This PWLE-centric project sets the foundation for future work to examine the feasibility and effectiveness of the program for supporting individuals with chronic pain self-manage.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with hypertension: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

FUNDING

European Union's Horizon 2020 Research and Innovation Programme.

PERson-centredness in Hypertension management using Information Technology: a randomized controlled trial in primary care

OBJECTIVES

To increase the proportion of individuals with hypertension obtaining a blood pressure (BP) of less than 140/90 mmHg by improving the management of hypertension in daily life from a person-centred perspective.

METHODS

In this unblinded randomized controlled trial, we tested an interactive web-based self-management system for hypertension. A total of 949 patients with hypertension from 31 primary healthcare centres (PHCCs) in Sweden were randomized 1 : 1 to either the intervention or usual care group. The intervention included daily measurement - via the participant's mobile phone - of BP and pulse and reports of well being, symptoms, lifestyle, medication intake and side effects for eight consecutive weeks. It also included reminders and optional motivational messages. The primary outcome was the proportion of participants obtaining BP of less than 140/90 mmHg at 8 weeks and 12 months. Significance was tested by Pearson's chi 2 -test.

RESULTS

A total of 862 patients completed the trial, 442 in the intervention group and 420 in the control group. The primary outcome (BP <140/90 mmHg) at 8 weeks was achieved by 48.8% in the intervention group and 39.9% in the control group ( P  = 0.006). At 12 months, 47.1% (intervention) and 41.0% (control group) had a BP less than 140/90 mmHg ( P  = 0.071).

CONCLUSION

The proportion of participants with a controlled BP of less than 140/90 mmHg increased after using the interactive system for self-management of hypertension for 8 weeks compared with usual care. Although the trend continued, there was no significant difference after 12 months. The results indicate that the effect of the intervention is significant, but the long-term effect is uncertain.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (NCT03554382).

An integrated group decision-making method for the evaluation of hypertension follow-up systems using interval-valued q-rung orthopair fuzzy sets

It is imperative to comprehensively evaluate the function, cost, performance and other indices when purchasing a hypertension follow-up (HFU) system for community hospitals. To select the best software product from multiple alternatives, in this paper, we develop a novel integrated group decision-making (GDM) method for the quality evaluation of the system under the interval-valued q-rung orthopair fuzzy sets (IVq-ROFSs). The design of our evaluation indices is based on the characteristics of the HFU system, which in turn represents the evaluation requirements of typical software applications and reflects the particularity of the system. A similarity is extended to measure the IVq-ROFNs, and a new score function is devised for distinguishing IVq-ROFNs to figure out the best IVq-ROFN. The weighted fairly aggregation (WFA) operator is then extended to the interval-valued q-rung orthopair WFA weighted average operator (IVq-ROFWFAWA) for aggregating information. The attribute weights are derived using the LINMAP model based on the similarity of IVq-ROFNs. We design a new expert weight deriving strategy, which makes each alternative have its own expert weight, and use the ARAS method to select the best alternative based on these weights. With these actions, a GDM algorithm that integrates the similarity, score function, IVq-ROFWFAWA operator, attribute weights, expert weights and ARAS is proposed. The applicability of the proposed method is demonstrated through a case study. Its effectiveness and feasibility are verified by comparing it to other state-of-the-art methods and operators.

Home Blood Pressure Self-monitoring plus Self-titration of Antihypertensive Medication for Poorly Controlled Hypertension in Primary Care: the ADAMPA Randomized Clinical Trial

BACKGROUND

Patient empowerment through pharmacological self-management is a common strategy in some chronic diseases such as diabetes, but it is rarely used for controlling blood pressure.

OBJECTIVE

This study aimed to assess self-monitoring plus self-titration of antihypertensive medication versus usual care for reducing systolic blood pressure (SBP) at 12 months in poorly controlled hypertensive patients.

DESIGN

The ADAMPA study was a pragmatic, controlled, randomized, non-masked clinical trial with two parallel arms in Valencia, Spain.

PARTICIPANTS

Hypertensive patients older than 40 years, with SBP over 145 mmHg and/or diastolic blood pressure (DBP) over 90 mmHg, were recruited from July 2017 to June 2018.

INTERVENTION

Participants were randomized 1:1 to usual care versus an individualized, pre-arranged plan based on self-monitoring plus self-titration.

MAIN MEASURE

The primary outcome was the adjusted mean difference (AMD) in SBP between groups at 12 months.

KEY RESULTS

Primary outcome data were available for 312 patients (intervention n=156, control n=156) of the 366 who were initially recruited. The AMD in SBP at 12 months (main analysis) was -2.9 mmHg (95% CI, -5.9 to 0.1, p=0.061), while the AMD in DBP was -1.9 mmHg (95% CI, -3.7 to 0.0, p=0.052). The results of the subgroup analysis were consistent with these for the main outcome measures. More patients in the intervention group achieved good blood pressure control (<140/90 mmHg) at 12 months than in the control group (55.8% vs 42.3%, difference 13.5%, 95% CI, 2.5 to 24.5%, p=0.017). At 12 months, no differences were observed in behavior, quality of life, use of health services, or adverse events.

CONCLUSION

Self-monitoring plus self-titration of antihypertensive medication based on an individualized pre-arranged plan used in primary care may be a promising strategy for reducing blood pressure at 12 months compared to usual care, without increasing healthcare utilization or adverse events.

TRIAL REGISTRATION

EudraCT, number 2016-003986-25 (registered 17 March 2017) and clinicaltrials.gov , NCT03242785.

Examination of Sexual Identity Differences in the Prevalence of Hypertension and Antihypertensive Medication Use Among US Adults: Findings From the Behavioral Risk Factor Surveillance System

BACKGROUND

Recent evidence suggests that sexual minority (eg, gay/lesbian, bisexual) adults might be at increased risk of hypertension compared with heterosexual adults. However, disparities by sexual identity in antihypertensive medication use among adults with hypertension have not been comprehensively examined.

METHODS

We analyzed data from the Behavioral Risk Factor Surveillance System (2015-2019), to examine sexual identity differences in the prevalence of hypertension and antihypertensive medication use among adults. We ran sex-stratified logistic regression models to estimate the odds ratios of diagnosis of hypertension and antihypertensive medication use among sexual minority (ie, gay/lesbian, bisexual, and other) and heterosexual adults (reference group).

RESULTS

The sample included 420 340 participants with a mean age of 49.7 (±17.0) years, of which 66.7% were Non-Hispanic White. Compared with heterosexual participants of the same sex, bisexual women (adjusted odds ratio, 1.19 [95% CI, 1.03-1.37]) and gay men (adjusted odds ratio, 1.18 [95% CI, 1.03-1.35]) were more likely to report having been diagnosed with hypertension. Among women with diagnosed hypertension, bisexual women had lower odds of current antihypertensive medication use (adjusted odds ratio, 0.71 [95% CI, 0.56-0.90]). Among men with diagnosed hypertension, gay men were more likely than heterosexual men to report current antihypertensive medication use (adjusted odds ratio, 1.39 [95% CI, 1.10-1.78]). Compared with heterosexual participants of the same sex, there were no differences in hypertension or antihypertensive medication use among lesbian women, bisexual men, and participants who reported their sexual identity as other.

CONCLUSIONS

Clinical and public health interventions are needed to reduce the risk of hypertension among bisexual women and gay men. Bisexual women were at higher risk of untreated hypertension, which may be attributed to lower health care utilization due to fear of discrimination from health care providers and socioeconomic disadvantage. Future research is needed to better understand factors that may contribute to untreated hypertension among bisexual women with hypertension.

Interactive Remote Patient Monitoring Devices for Managing Chronic Health Conditions: Systematic Review and Meta-analysis

BACKGROUND

Telemedicine is an expanding and feasible approach to improve medical care for patients with long-term conditions. However, there is a poor understanding of patients' acceptability of this technology and their rate of uptake.

OBJECTIVE

The aim of this study was to systematically review the current evidence on telemonitoring in the management of patients with long-term conditions and evaluate the patients' uptake and acceptability of this technology.

METHODS

MEDLINE, Scopus, and CENTRAL (the Cochrane Central Register of Controlled Trials) were searched from the date of inception to February 5, 2021, with no language restrictions. Studies were eligible for inclusion if they reported any of the following outcomes: intervention uptake and adherence; study retention; patient acceptability, satisfaction, and experience using the intervention; changes in physiological values; all-cause and cardiovascular-related hospitalization; all-cause and disease-specific mortality; patient-reported outcome measures; and quality of life. In total, 2 reviewers independently assessed the articles for eligibility.

RESULTS

A total of 96 studies were included, and 58 (60%) were pooled for the meta-analyses. Meta-analyses showed a reduction in mortality (risk ratio=0.71, 95% CI 0.56-0.89; P=.003; I2=0%) and improvements in blood pressure (mean difference [MD]=-3.85 mm Hg, 95% CI -7.03 to -0.68; P=.02; I2=100%) and glycated hemoglobin (MD=-0.33, 95% CI -0.57 to -0.09; P=.008; I2=99%) but no significant improvements in quality of life (MD=1.45, 95% CI -0.10 to 3; P=.07; I2=80%) and an increased risk of hospitalization (risk ratio=1.02, 95% CI 0.85-1.23; P=.81; I2=79%) with telemonitoring compared with usual care. A total of 12% (12/96) of the studies reported adherence outcomes, and 9% (9/96) reported on satisfaction and acceptance outcomes; however, heterogeneity in the assessment methods meant that a meta-analysis could not be performed.

CONCLUSIONS

Telemonitoring is a valid alternative to usual care, reducing mortality and improving self-management of the disease, with patients reporting good satisfaction and adherence. Further studies are required to address some potential concerns regarding higher hospitalization rates and a lack of positive impact on patients' quality of life.

TRIAL REGISTRATION

PROSPERO CRD42021236291; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=236291.

The Use of Dietary Approaches to Stop Hypertension (DASH) Mobile Apps for Supporting a Healthy Diet and Controlling Hypertension in Adults: Systematic Review

Background

Uncontrolled hypertension is a public health issue, with increasing prevalence worldwide. The Dietary Approaches to Stop Hypertension (DASH) diet is one of the most effective dietary approaches for lowering blood pressure (BP). Dietary mobile apps have gained popularity and are being used to support DASH diet self-management, aiming to improve DASH diet adherence and thus lower BP.

Objective

This systematic review aimed to assess the effectiveness of smartphone apps that support self-management to improve DASH diet adherence and consequently reduce BP. A secondary aim was to assess engagement, satisfaction, acceptance, and usability related to DASH mobile app use.

Methods

The Embase (OVID), Cochrane Library, CINAHL, Web of Science, Scopus, and Google Scholar electronic databases were used to conduct systematic searches for studies conducted between 2008 and 2021 that used DASH smartphone apps to support self-management. The reference lists of the included articles were also checked. Studies were eligible if they (1) were randomized controlled trials (RCTs) or pre-post studies of app-based interventions for adults (aged 18 years or above) with prehypertension or hypertension, without consideration of gender or sociodemographic characteristics; (2) used mobile phone apps alone or combined with another component, such as communication with others; (3) used or did not use any comparator; and (4) had the primary outcome measures of BP level and adherence to the DASH diet. For eligible studies, data were extracted and outcomes were organized into logical categories, including clinical outcomes (eg, systolic BP, diastolic BP, and weight loss), DASH diet adherence, app usability and acceptability, and user engagement and satisfaction. The quality of the studies was evaluated using the Cochrane Collaboration’s Risk of Bias tool for RCTs, and nonrandomized quantitative studies were evaluated using a tool provided by the US National Institutes of Health.

Results

A total of 5 studies (3 RCTs and 2 pre-post studies) including 334 participants examined DASH mobile apps. All studies found a positive trend related to the use of DASH smartphone apps, but the 3 RCTs had a high risk of bias. One pre-post study had a high risk of bias, while the other had a low risk. As a consequence, no firm conclusions could be drawn regarding the effectiveness of DASH smartphone apps for increasing DASH diet adherence and lowering BP. All the apps appeared to be acceptable and easy to use.

Conclusions

There is weak emerging evidence of a positive effect of using DASH smartphone apps for supporting self-management to improve DASH diet adherence and consequently lower BP. Further research is needed to provide high-quality evidence that can determine the effectiveness of DASH smartphone apps.

Complementary medicine usage in surgery: a cross-sectional survey in Germany

Background

Complementary medicine (CM) is frequently used by patients, but little is known about the usage of CM in surgical patients. The study aimed to elucidate the relevance of CM in surgery.

Methods

This cross-sectional, multi-center survey utilized a paper-based questionnaire consisting of 21 questions to capture CM usage and interest as well as CM communication in visceral and thoracic surgical patients being hospitalized at the corresponding departments of surgery at the University Medical Centers in Freiburg, Heidelberg und Ulm, Germany.

Results

Overall, 151 patients consented to the survey. On average, current CM usage was stated by 44% of patients. Most frequently used CM approaches were physical exercise (63%), nutritional supplements (59%) and herbal medicine (56%). Strong interest in CM counselling was stated by 51% of patients. Almost 80% of patients wanted to be treated in a holistic manner and desired for reliable information about CM as well as CM informed physicians. Only 12% of patients communicated CM usage and interest with their attending physician. Review of literature revealed similar results showing an overall CM usage of 43%, preferring nutritional supplements and herbal medicine.

Conclusion

The results of our cross-sectional study indicate a high percentage of CM users and a strong interest in CM among surgical patients. Indeed, the current communication about CM between patients and surgeons is poor. With respect to safety and quality reasons, but also to pay attention to patients’ demands, physicians should be aware of patients’ CM usage in surgery.

Trial registration

German Clinical Trial register (DRKS00015445).

Pilot Results of a Digital Hypertension Self-management Program Among Adults With Excess Body Weight: Single-Arm Nonrandomized Trial

Background

Home-measured blood pressure (HMBP) in combination with comprehensive medication support and lifestyle change are the mainstays of evidence-based hypertension (HTN) management. To date, the precise components needed for effective HTN self-management programs have yet to be defined, and access to multicomponent targeted support for HTN management that include telemonitoring remain inaccessible and costly.

Objective

The aim of this pilot study was to evaluate the impact of a digital HTN self-management program on blood pressure (BP) control among adults with excess body weight.

Methods

A single-arm, nonrandomized trial was performed to evaluate a digital HTN self-management program that combines comprehensive lifestyle counseling with HTN education, guided HMBP, support for taking medications, and led by either a registered nurse or certified diabetes care and education specialist. A sample of 151 participants were recruited using a web-based research platform (Achievement Studies, Evidation Health Inc). The primary outcome was change in systolic BP from baseline to 3 months, and secondary outcomes included change in diastolic BP and medication adherence.

Results

Participants’ mean age was 44.0 (SD 9.3) years and mean BP was 139/85 mm Hg. At follow-up, systolic and diastolic BP decreased by 7 mm Hg (P<.001, 95% CI –9.3 to –4.7) and 4.7 mm Hg (P<.001, 95% CI –6.3 to –3.2), respectively. Participants who started with baseline BP at goal remained at goal. For participants with stage 1 HTN, systolic and diastolic BP decreased by 3.6 mm Hg (P=.09, 95% CI –7.8 to 0.6) and 2.5 mm Hg (P=.03, 95% CI –4.9 to –0.3). Systolic and diastolic BP decreased by 10.3 mm Hg (P<.001, 95% CI –13.4 to –7.1) and 6.5 mm Hg (P<.001, 95% CI –8.6 to –4.4), respectively, for participants with stage 2 HTN. Medication adherence significantly improved (P=.02).

Conclusions

This pilot study provides initial evidence that a digital HTN self-management program improves BP and medication adherence.

Choice of home blood pressure monitoring device: the role of device characteristics among Alaska Native and American Indian peoples

BACKGROUND

Home blood pressure monitoring (HBPM) is an effective tool in treatment and long-term management of hypertension. HBPM incorporates more data points to help patients and providers with diagnosis and management. The characteristics of HBPM devices matter to patients, but the relative importance of the characteristics in choosing a device remains unclear.

METHODS

We used data from a randomized cross-over pilot study with 100 Alaska Native and American Indian (ANAI) people with hypertension to assess the choice of a wrist or arm HBPM device. We use a random utility framework to evaluate the relationship between stated likely use, perceived accuracy, ease of use, comfort, and participant characteristics with choice of device. Additional analyses examined willingness to change to a more accurate device.

RESULTS

Participants ranked the wrist device higher compared to the arm on a 5-point Likert scale for likely use, ease of use, and comfort (0.3, 0.5, 0.8 percentage points, respectively). Most participants (66%) choose the wrist device. Likely use (wrist and arm devices) was related to the probability of choosing the wrist (0.7 and - 1.4 percentage points, respectively). Independent of characteristics, 75% of participants would be willing to use the more accurate device. Ease of use (wrist device) and comfort (arm device) were associated with the probability of changing to a more accurate device (- 1.1 and 0.5 percentage points, respectively).

CONCLUSION

Usability, including comfort, ease, and likely use, appeared to discount the relative importance of perceived accuracy in the device choice. Our results contribute evidence that ANAI populations value accurate HBPM, but that the devices should also be easy to use and comfortable to facilitate long-term management.

Effect of an Integrative Mobile Health Intervention in Patients With Hypertension and Diabetes: Crossover Study

Background

Obesity, hypertension, and type 2 diabetes mellitus (T2DM) are worldwide epidemics that inflict burdens on both public health and health care costs. Self-management plays an important role in the proper management of these 3 chronic diseases, and in this context, mobile health (mHealth) can be a cost-effective self-management tool.

Objective

The aim of this pilot study is to evaluate the effects of an integrative mHealth approach for obesity, hypertension, and T2DM on body fat, blood pressure, and blood glucose levels and demonstrate the clinical outcomes. The participants were patients aged 40 to 70 years who were treated for T2DM (hemoglobin A_1c [HbA_1c] above 6.0%) without insulin or hypertension and obesity, controlled with pharmacotherapy.

Methods

This pilot study was performed using a controlled, randomized, 3-month, 2-period crossover design. A total of 37 participants were recruited from 2 university hospitals in South Korea. Integrative mHealth comprised 4 parts: self-measuring home devices for monitoring blood glucose and blood pressure; 2 smartphone apps, where one gathered lifestyle data, giving them feedback with health information, and the other provided drug information and reminders of the medication schedule; unmanned kiosks for official measurement of blood pressure and body composition; and web-based access to participants’ health information.

Results

Data from the 32 participants were analyzed. Their mean HbA_1c level was 7.5% (SD 0.8, ranging from 6.1% to 9.4%). Approximately 38% (12/32) of the participants had hypertension. BMIs of all participants except 1 were >23 kg/m². The input rates of food intake and exercise to the smartphone app were very low (24.9% and 5.3%, respectively). On the contrary, the input rate of medicine intake was high (84.0%). Moreover, there was no significant difference in the input rate of taking medicine irrespective of whether the mHealth period was before or after the conventional treatment period (80.3% and 87.3%, respectively; P=.06). Among the 3 input functions of food intake, exercise, and medicine intake in smartphone apps, the input of medicine intake was a more helpful, easier to use, and better-designed function than the others. There were no significant differences in changes in body weight (−0.519 kg vs 0 kg), BMI (−0.133 kg/m² vs −0.167 kg/m²), body composition (body fat −0.255% vs 0.172%), blood pressure (systolic −0.226 mm Hg vs −2.839 mm Hg), and HbA_1c (−0.269% vs –0.009%) between the integrative mHealth and conventional treatment groups. However, in proportion to the elevation in the input rate of taking medicine, body fat mass (P=.04) and HbA_1c (P=.03) were lower in the integrative mHealth group.

Conclusions

Although smartphone apps can influence body fat and blood glucose levels, they have failed to show clinical improvement. A higher input rate of taking medicine was related to significantly lower body fat mass and HbA_1c levels.

Comparing the Acceptance of Mobile Hypertension Apps for Disease Management Among Patients Versus Clinical Use Among Physicians: Cross-sectional Survey

Background

High blood pressure or hypertension is a vastly prevalent chronic condition among adults that can, if not appropriately treated, contribute to several life-threatening secondary diseases and events, such as stroke. In addition to first-line medication, self-management in daily life is crucial for tertiary prevention and can be supported by mobile health apps, including medication reminders. However, the prescription of medical apps is a relatively novel approach. There is limited information regarding the determinants of acceptance of such mobile health (mHealth) apps among patients as potential users and physicians as impending prescribers in direct comparison.

Objective

The present study aims to investigate the determinants of the acceptance of health apps (in terms of intention to use) among patients for personal use and physicians for clinical use in German-speaking countries. Moreover, we assessed patients’ preferences regarding different delivery modes for self-care service (face-to-face services, apps, etc).

Methods

Based on an extended model of the unified theory of acceptance and use of technology (UTAUT2), we performed a web-based cross-sectional survey to explore the acceptance of mHealth apps for self-management of hypertension among patients and physicians in Germany. In addition to UTAUT2 variables, we measured self-reported self-efficacy, eHealth literacy, previous experiences with health apps, perceived threat to privacy, and protection motivation as additional determinants of mHealth acceptance. Data from 163 patients and 46 physicians were analyzed using hierarchical regression and mediation analyses.

Results

As expected, a significant influence of the unified theory of acceptance and use of technology (UTAUT) predictors on intentions to use hypertension apps was confirmed, especially for performance expectancy. Intention to use was moderate in patients (mean 3.5; SD 1.1; range 1-5) and physicians (mean 3.4, SD 0.9), and did not differ between both groups. Among patients, a higher degree of self-reported self-efficacy and protection motivation contributed to an increased explained variance in acceptance with R²=0.09, whereas eHealth literacy was identified as exerting a positive influence on physicians (increased R²=0.10). Furthermore, our findings indicated mediating effects of performance expectancy on the acceptance among patients but not among physicians.

Conclusions

In summary, this study has identified performance expectancy as the most important determinant of the acceptance of mHealth apps for self-management of hypertension among patients and physicians. Concerning patients, we also identified mediating effects of performance expectancy on the relationships between effort expectancy and social influence and the acceptance of apps. Self-efficacy and protection motivation also contributed to an increase in the explained variance in app acceptance among patients, whereas eHealth literacy was a predictor in physicians. Our findings on additional determinants of the acceptance of health apps may help tailor educational material and self-management interventions to the needs and preferences of prospective users of hypertension apps in future research.

Identification of the Most Suitable App to Support the Self-Management of Hypertension: Systematic Selection Approach and Qualitative Study

BACKGROUND

Smartphone apps are increasingly being used to aid in hypertension self-management, and a large and ever-growing number of self-management apps have been commercially released. However, very few of these are potentially effective and secure, and researchers have yet to establish the suitability of specific hypertension apps to particular contexts.

OBJECTIVE

The aim of this study is to identify the most suitable hypertension app in the context of Saudi Arabia and its health system.

METHODS

This study used a 2-stage approach to selecting the most suitable app for hypertension self-management. First, a systematic selection approach was followed to identify a shortlist of the most suitable apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security. Second, an exploratory qualitative study was conducted to select the most suitable from the shortlist: 12 doctors were interviewed, and 22 patients participated in 4 focus groups. These explored participants' attitudes towards self-management apps in general, and their views towards the apps identified via the systematic selection process. The qualitative data were analyzed using framework analysis.

RESULTS

In the first stage, only 5 apps were found to be potentially effective while also having a theoretical underpinning and protecting users' data. In the second stage, both doctors and patients were generally interested in using hypertension apps, but most had no experience with these apps due to a lack of awareness of their availability and suitability. Patients and doctors liked apps that combine intuitive interfaces with a pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. When the pros and cons of the 5 apps were discussed, 3 apps were identified as being more suitable, with Cora Health rated the highest by the participants.

CONCLUSIONS

Only 5 apps were deemed potentially effective and secure. Patients' and doctors' discussions of the pros and cons of these 5 apps revealed that 3 out of the 5 are clearly more suitable, with the Cora Health app being judged most suitable overall.

Can Remote Patient Monitoring Be the New Standard in Primary Care of Chronic Diseases, Post-COVID-19?

Background: One lesson from the current COVID-19 pandemic is the need to optimize health care provision outside of traditional settings, and potentially over longer periods of time. An important strategy is remote patient monitoring (RPM), allowing patients to remain at home, while they transmit health data and receive follow-up services. Materials and Methods: We conducted an overview of the latest systematic reviews that had included randomized controlled trials with adult patients with chronic diseases. We summarized results and displayed these in forest plots, and used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) to assess our certainty of the evidence. Results: We included 4 systematic reviews that together reported on 11 trials that met our definition of RPM, each including patients with diabetes and/or hypertension. RPM probably makes little to no difference on HbA1c levels. RPM probably leads to a slight reduction in systolic blood pressure, with questionable clinical meaningfulness. RPM probably has a small negative effect on the physical component of health-related quality of life, but the clinical significance of this reduction is uncertain. We have low confidence in the finding that RPM makes no difference to the remaining five primary outcomes. Conclusion: Most of our findings are consistent with reviews of other, broader definitions of RPM. The type of RPM examined in this review is as effective as standard treatment for patients with diabetes/hypertension. If this or other types of RPM are to be used for "long covid" patients or for other chronic disease groups post-pandemic, we need to understand why RPM may negatively affect quality of life.

Continuity of Care and the Control of High Blood Pressure at Colombian Primary Care Services

Continuity of care (COC) has been associated with lower mortality and hospitalizations and higher high blood pressure (HBP) control rates. This evidence mainly came from high income countries. We aimed to identify conditions associated with controlled HBP, particularly COC, in primary care services (PCSs) affiliated to two health insurances in Colombia, a low-median income country. A longitudinal observational study was carried out using clinical records of hypertensive adults >18 years with ≥4 clinic visits attending a contributive and a subsidized PCS in Cali (Colombia) between 2013 and 2014. Subsidized PCSs were for unemployment people and those at low socio-economic position and contributive for formal workers. COC was measured using the Bice and Boxerman index. Logistic regression models were performed to quantify the relation between COC and controlled HBP (blood pressure <140/90 mmHg). Between 2013 and 2014, among 8797 hypertensive people identified, 1358 were included: 935 (68.8%) and 423 (31.1%) from the contributive and subsidized PCSs, respectively. 856 (62.3%) were women and had a mean age of 67.7 years (SD 11.7). All people were on antihypertensive treatment. Over the study period, 522 (38.4%) people had controlled HBP, 410 (43.9%) in the contributive and 112 (26.5%) in subsidized PCSs. An increase in 1 unit of the COC index is associated with a 161% higher probability of having HBP controlled (OR, 2.61; 95% CI, 1.25–5.44). The odds of having controlled HBP increased as the number of visits rose; for example, people at the fourth visit had a 34% (OR, 1.34; 95% CI, 1.08–1.66) higher probability of reaching the target. Continuity of care was positively associated with controlled HBP. The strengthening of COC can improve the observed low HBP control rates and reduce health inequalities.

Comparative effect of eHealth interventions on hypertension management-related outcomes: A network meta-analysis

BACKGROUND

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).

METHODS

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.

RESULTS

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 CONCLUSIONS: 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.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187468.

Self-Efficacy of Older People Using Technology to Self-Manage COPD, Hypertension, Heart Failure, or Dementia at Home: An Overview of Systematic Reviews

BACKGROUND AND OBJECTIVES

Although telehealth research among the general population is voluminous, the quality of studies is low and results are mixed. Little is known specifically concerning older people and their self-efficacy to engage with and benefit from such technologies. This article reviews the evidence for which self-care telehealth technology supports the self-efficacy of older people with long-term conditions (LTCs) living at home.

RESEARCH DESIGN AND METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) guidelines, this overview of systematic reviews focused on four LTCs and the concept of "self-efficacy." Quality was appraised using R-AMSTAR and study evaluation was guided by the PRISMS taxonomy for reporting of self-management support. Heterogeneous data evidencing technology-enhanced self-efficacy were narratively synthesized.

RESULTS

Five included articles contained 74 primary studies involving 9,004 participants with chronic obstructive pulmonary disease, hypertension, heart failure, or dementia. Evidence for self-care telehealth technology supporting the self-efficacy of older people with LTCs living at home was limited. Self-efficacy was rarely an outcome, also attrition and dropout rates and mediators of support or education. The pathway from telehealth to self-efficacy depended on telehealth modes and techniques promoting healthy lifestyles. Increased self-care and self-monitoring empowered self-efficacy, patient activation, or mastery.

DISCUSSION AND IMPLICATIONS

Future research needs to focus on the process by which the intervention works and the effects of mediating variables and mechanisms through which self-management is achieved. Self-efficacy, patient activation, and motivation are critical components to telehealth's adoption by the patient and hence to the success of self-care in self-management of LTCs. Their invisibility as outcomes is a limitation.

Reported self-management of hypertension among adult hypertensive patients in a developing country: a cross-sectional study in a Nigerian tertiary hospital

Background

Sustained control of blood pressure, is dependent on degree of self-management, which includes self-integration, self-regulation, self-monitoring and adherence to regimen. We assessed the pattern of self-management of hypertension among adult hypertensive patients in a developing country.

Methods

Cross-sectional study design and convenience sampling, was used to recruit adult hypertensive patients, attending Lagos State University Teaching Hospital, Lagos, Nigeria. Interviewer-administered questionnaire was used to obtain data on self-management components. SPSS version 21.0 was used to analyze data, with p-value set at 0.05.

Result

One hundred and seven (107) respondents, had mean age of 49.0 ± 12.0 years. Mean value for self-management was 3.15 ± 0.55, comprising self-integration (3.06 ± 0.36), self-regulation (3.32 ± 0.63), self-monitoring (3.29 ± 0.84) and adherence to regimen (3.15 ± 0.55). Most components of self-management, had high levels of mean score. Respondents that were less than 40 years, compared with those that were more than 40 years, had greater mean values for self-integration (3.37 vs 3.05), but significantly lesser values for all other components (p < 0.05).

Conclusion

Young hypertensives had poor levels of most components of self-management. There is urgent need for health educational programs on self-management of hypertension among young people in sub-Saharan Africa.

Patients and Professionals as Partners in Hypertension Care: Qualitative Substudy of a Randomized Controlled Trial Using an Interactive Web-Based System Via Mobile Phone

BACKGROUND

The use of technology has the potential to support the patient´s active participation regarding treatment of hypertension. This might lead to changes in the roles of the patient and health care professional and affect the partnership between them.

OBJECTIVE

The aim of this qualitative study was to explore the partnership between patients and health care professionals and the roles of patients and professionals in hypertension management when using an interactive web-based system for self-management of hypertension via the patient's own mobile phone.

METHODS

Focus group interviews were conducted with 22 patients and 15 professionals participating in a randomized controlled trial in Sweden aimed at lowering blood pressure (BP) using an interactive web-based system via mobile phones. The interviews were audiorecorded and transcribed and analyzed using thematic analysis.

RESULTS

Three themes were identified: the technology, the patient, and the professional. The technology enabled documentation of BP treatment, mainly for sharing knowledge between the patient and the professional. The patients gained increased knowledge of BP values and their relation to daily activities and treatment. They were able to narrate about their BP treatment and take a greater responsibility, inspired by new insights and motivation for lifestyle changes. Based on the patient's understanding of hypertension, professionals could use the system as an educational tool and some found new ways of communicating BP treatment with patients. Some reservations were raised about using the system, that it might be too time-consuming to function in clinical practice and that too much measuring could result in stress for the patient and an increased workload for the professionals. In addition, not all professionals and patients had adopted the instructions regarding the use of the system, resulting in less realization of its potential.

CONCLUSIONS

The use of the system led to the patients taking on a more active role in their BP treatment, becoming more of an expert of their BP. When using the system as intended, the professionals experienced it as a useful resource for communication regarding BP and lifestyle. Patients and professionals described a consultation on more equal grounds. The use of technology in hypertension management can promote a constructive and person-centered partnership between patient and professional. However, implementation of a new way of working should bring benefits and not be considered a burden for the professionals. To establish a successful partnership, both the patient and the professional need to be motivated toward a new way of working.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03554382; https://clinicaltrials.gov/ct2/show/NCT03554382.

The Role of Health Care Quality in Hypertension Self-Management: A Qualitative Study of the Experience of Patients in a Public Hospital, North-West Ethiopia

Purpose

Hypertension is becoming a global epidemic in all population groups. For its effective management and control, patients should have enhanced self-management skills and get adequate support from care providers. Although the quality of health care is critical in enhancing self-management behaviors of patients with hypertension, the issue has not been fully explored in the Ethiopian context. Therefore, the purpose of this study was to explore the experience of hypertensive patients on the quality of health care and the self-management practice in a public hospital in North-west Ethiopia.

Patients and Methods

This qualitative study involves a phenomenological approach. Participants were hypertension patients who are on treatment follow-up. They were recruited purposively with maximum variation approach. Eleven in-depth interviews and two key informant interviews were undertaken using a semi-structured interview guide with hypertensive patients and nurses respectively. Interviews were audio recorded, transcribed verbatim, translated into English, and then analyzed thematically by the investigators.

Results

The analysis identified two main themes and seven sub-themes. The first theme “experience in self-management practice” describes medication adherence, lifestyle modification, and self-monitoring of blood pressure. The second theme “experience in the quality of health care” discusses access to health services, patient-centered care, behavior of health care providers, and time and patient flow management.

Conclusion

The self-management practice of hypertensive patients is sub-optimal. Although several individual patient issues were identified, facility-level problems are mainly responsible for poor self-management practice. The main facility-level barriers, as reported by participants, include shortage of medicines, high cost of medicines, busyness of doctors due to high patient load, lack of appropriate education and counseling services, poor patient-provider interaction, and long waiting times. Intervention areas should focus on providing appropriate training for health care providers to enhance the patient–provider relationship. Improving the supply of hypertensive medications is also paramount for better medication adherence.

Patients' and Clinicians' Visions of a Future Internet-of-Things System to Support Asthma Self-Management: Mixed Methods Study

BACKGROUND

Supported self-management for asthma reduces acute attacks and improves control. The internet of things could connect patients to health care providers, community services, and their living environments to provide overarching support for self-management.

OBJECTIVE

We aimed to identify patients' and clinicians' preferences for a future internet-of-things system and explore their visions of its potential to support holistic self-management.

METHODS

In an exploratory sequential mixed methods study, we recruited patients from volunteer databases and charities' social media. We purposively sampled participants to interview them about their vision of the design and utility of the internet of things as a future strategy for supporting self-management. Respondents who were not invited to participate in the interviews were invited to complete a web-based questionnaire to prioritize the features suggested by the interviewees. Clinicians were recruited from professional networks. Interviews were transcribed and analyzed thematically using PRISMS self-management taxonomy.

RESULTS

We interviewed 12 patients and 12 clinicians in the United Kingdom, and 140 patients completed the web-based questionnaires. Patients expressed mostly wanting a system to log their asthma control status automatically; provide real-time advice to help them learn about their asthma, identify and avoid triggers, and adjust their treatment. Peak flow (33/140, 23.6%), environmental (pollen, humidity, air temperature) (33/140, 23.6%), and asthma symptoms (25/140, 17.9%) were the specific data types that patient most wanted. Information about asthma and text or email access to clinical advice provided a feeling of safety for patients. Clinicians wanted automated objective data about the patients' condition that they could access during consultations. The potential reduction in face-to-face consultations was appreciated by clinicians which they perceived could potentially save patients' travel time and health service resources. Lifestyle logs of fitness regimes or weight control were valued by some patients but were of less interest to clinicians.

CONCLUSIONS

An automated internet-of-things system that requires minimal input from the user and provides timely advice in line with an asthma action plan agreed by the patient with their clinician was preferred by most respondents. Links to asthma information and the ability to connect with clinicians by text or email were perceived by patients as features that would provide a sense of safety. Further studies are needed to evaluate the usability and effectiveness of internet-of-things systems in routine clinical practice.

Role of Klotho in the Development of Essential Hypertension

Klotho has antiaging properties, and serum levels decrease with physiological aging and aging-related diseases, such as hypertension, cardiovascular, and chronic kidney disease. Klotho deficiency in mice results in accelerated aging and cardiovascular injury, whereas Klotho supplementation slows down the progression of aging-related diseases. The pleiotropic functions of Klotho include, but are not limited to, inhibition of insulin/IGF-1 (insulin-like growth factor 1) and WNT (wingless-related integration site) signaling pathways, suppression of oxidative stress and aldosterone secretion, regulation of calcium-phosphate homeostasis, and modulation of autophagy with inhibition of apoptosis, fibrosis, and cell senescence. Accumulating evidence shows an interconnection between Klotho deficiency and hypertension, and Klotho gene polymorphisms are associated with hypertension in humans. In this review, we critically review the current understanding of the role of Klotho in the development of essential hypertension and the most important underlying pathways involved, such as the FGF23 (fibroblast growth factor 23)/Klotho axis, aldosterone, Wnt5a/RhoA, and SIRT1 (Sirtuin1). Based on this critical review, we suggest avenues for further research.

Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: Meta-analysis of randomized controlled trials

AIM

To assess the effects of self-management interventions on systolic blood pressure, diastolic blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension.

BACKGROUND

Effective treatment of hypertension may require the practice of self-management behaviours. However, evidence on effects of self-management interventions on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension is lacking.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

CINAHL, Cochrane Library, Embase, Ovid-Medline, PubMed, Scopus, Web of Science and other sources were searched to October 2020.

REVIEW METHODS

Data were analysed using Comprehensive Meta-Analysis 2.0 and quality assessment was done using ROB 2.0. The pooled effect sizes were reported as Hedges' g values with corresponding 95% confidence intervals using a random-effects model.

RESULTS

Twelve randomized controlled trials met our inclusion criteria. The results revealed that self-management interventions significantly decreased blood pressure and increased self-efficacy and medication adherence in older adult patients with hypertension, with no significant effect on body mass index.

CONCLUSIONS

Self-management interventions have considerable beneficial effects in older adults with hypertension. Health care providers should implement self-management interventions to strengthen the patient's role in managing their health.

Best care for older people with epilepsy: A scoping review

There are two peaks of diagnosis of epilepsy: in childhood and in people over 65. Older people may have complex needs like co-morbidity, polypharmacy, frailty, and social isolation. This scoping review focusses on the care of older people with epilepsy beyond diagnosis and medical treatment. We sought to identify areas within the UK health service needing development either in clinical practice or through further research. The search returned 4864 papers with 33 papers included in the review. The papers were grouped into psychosocial, self-management and services themes. Only one randomised controlled trial was found. Research was mainly based on cohort and case-control studies. Older people require more information to self-manage epilepsy and more psychological support to help with symptoms of anxiety and depression. People reported experiencing stigma and a reluctance to disclose their condition. This may increase the risk of isolation and difficulties in managing epilepsy. Studies reported that older people are referred less to neurologists, suggesting there may be a gap in care provision compared to younger people. Generalist health professionals may be better placed to provide holistic care, but they may need additional training to alleviate uncertainties in managing epilepsy. Care plans could help provide information, particularly for co-morbidity, but few had one. Our findings highlight psychological and self-management needs for managing epilepsy in older people. Health service staff may require upskilling to shift epilepsy management from neurologists to generalists. More research is needed regarding psychological and self-management interventions, particularly in the form of randomised controlled trials.

Prioritizing Community-Based Intervention Programs for Improving Treatment Compliance of Patients with Chronic Diseases: Applying an Analytic Hierarchy Process

The purpose of this study was to apply multicriteria decision making and an analytic hierarchy process (AHP) model for assessing sustainable management of hypertension and diabetes. Perception of two alternative health care priorities was also investigated. One priority was improving treatment compliance of patients with hypertension and diabetes. The other priority was strengthening the healthcare system for continuous care. Our study design to evaluate community-based intervention programs for hypertension and diabetes was developed using brainstorming, Delphi techniques, and content analysis along with literature review. We finally proposed a hierarchical structure of the AHP model with 50 third sub-criteria in six levels. By surveying this AHP questionnaire to a total of 185 community health practitioners in Korea, we found that improving treatment compliance of patients with chronic diseases should be relatively more important than strengthening the healthcare system. Further research is needed to expand survey subjects to primary care physicians and even policymakers of central government for the appropriate application of this AHP model.

Home blood pressure monitoring and e-Health: investigation of patients' experience with the Hy-Result system

BACKGROUND

Hy-Result is a validated system designed to help patients complying with the home blood pressure monitoring (HBPM) protocol and understanding their blood pressure (BP) readings. It is available as a standalone web application or within a wireless BP monitor app.

OBJECTIVE

The aim of the study was to explore patients' experience with Hy-Result.

METHODS

Online survey completed by 512 users of the Hy-Result web application or monitor app, and three focus groups with 24 hypertensive patients who monitor their BP at home and use the Hy-Result web application to record their data. We assessed the experience of patients with the functionalities and medical content of Hy-Result, their feelings and expectations, and the impact of Hy-Result on the physician-patient relationship.

RESULTS

(1) Functionalities: Over 90% of survey respondents and all focus group participants found Hy-Result easy to use. The main drawback of the web application is the need to manually enter all BP values at once. (2) Medical content: Hy-Result offers information on arterial hypertension and HBPM that most patients found useful. Users found that Hy-Result triggers appropriate reactions to BP readings, including adequately timed general practitioner visits. (3) Feelings and expectations: Over 90% of survey respondents trust Hy-Result and focus group participants understood that text messages are suggestions, not diagnoses. Hy-Result did not cause anxiety or excessive BP measurements. (4) Physician-patient relationship: Three-quarter of survey respondents agreed that Hy-Result may help when talking with their doctor about their BP values but only one-third of those have shown the report to their physician. For focus group participants, using Hy-Result should ideally be a physician prescription. They were aware that Hy-Result does not replace clinical judgment and that physicians still have a decisive role in BP management.

CONCLUSION

Most of the users described Hy-Result as an easy-to-use and useful tool. Patients are willing to use it on physician request.

Effect of Telemedicine on Quality of Care in Patients with Coexisting Hypertension and Diabetes: A Systematic Review and Meta-Analysis

Background: With the development of technology and the need for individualized and continuous support for patients with chronic conditions, telemedicine has been widely used. Despite the potential benefits of telemedicine, little is known about its effect on the quality of care (QoC) in people with hypertension and comorbid diabetes, who face more challenges in disease management than those with hypertension or diabetes alone. This study aimed to examine the effect of telemedicine on QoC for patients with hypertension and comorbid diabetes by synthesizing findings from clinical trials. Methods: This systematic review and meta-analysis were developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four major electronic databases from inception to March 2020 were searched. Studies were screened using predetermined criteria. Data were extracted and tabulated into tables. The primary outcomes were QoC indicators, including outcomes (e.g., blood pressure [BP] and glycemic control), process, and experience of care. Quantitative data were pooled and presented in forest plots. Qualitative narratives were also used. Results: Five studies from four clinical trials were included in this review, with intervention durations ranging from 3 to 6 months. Telemedicine significantly decreased BP by 10.4/4.8 mm/Hg, but its effect on glycemic control was inconsistent. Telemedicine also improved experience of care (e.g., patient perception and engagement). Various indicators for process of care were assessed, including medication adherence, BP monitoring, and self-efficacy, with mixed findings. Conclusions: Telemedicine has great potential to improve the QoC, particularly outcomes of care, for patients with hypertension and comorbid diabetes. Health care professionals may consider using available telemedicine to facilitate communication and interaction with their patients, thereby helping them with disease management. Long-term, large-scale studies are needed to test the generalizability and sustainability of the telemedicine programs.

Primary care doctors' views on self-monitoring of blood pressure and self-titration among patients with uncontrolled hypertension in Spain. The ADAMPA trial focus group study

Background

Despite the increased use of blood pressure (BP) monitoring devices at home, the hypertension of more than 50% of European patients remains uncontrolled. Nevertheless, the self-management of BP, through the combination of home monitoring of BP with self-titration, could be anaccessible and effective tool for improving hypertension control in the primary care setting. The ADAMPA study is a trial with participants randomised to BP self-management (BPSM) with self-titration of antihypertensive medication or to usual care, in a population of patients with poorly controlled hypertension.

Aim

To explore the views and attitudes of primary care doctors participating in the ADAMPA trial regarding BPSM with self-titration.

Design & setting

A focus group study took place with primary care doctors participating in the ADAMPA trial, which was carried out in one health district of the Valencia Health System in Spain.

Method

Nine primary care doctors participating in the ADAMPA trial were included in the focus group. Three researchers (two using manual methods and one using NVivo software) independently conducted a content analysis, reading the transcripts, identifying, classifying, and coding the contents, and developing a conceptual scheme based on these topics.

Results

Participating doctors clearly support home BP monitoring (HBPM), the setting of individual BP targets, and incorporating patient readings into decision-making. They consider it an investment to educate patients for medication self-adjustment and estimate that an important proportion of their patients are potential candidates for hypertension self-management with medication self-titration. However, they show important divergences regarding the role of nursing in BP control.

Conclusion

Primary care doctors participating in the ADAMPA trial feel comfortable with BPSM with self-titration, and would consider extending its use (or the use of some components, such as BP target setting) to other patients with hypertension outside the trial.

A cluster-randomized study on the Risk Assessment and Management Program for home blood pressure monitoring in an older population with inadequate health literacy

The Risk Assessment and Management Program (RAMP) has successfully demonstrated a reduction of blood pressure (BP) and cardiovascular (CVD) risk of patients with hypertension. This study aimed to compare the blood pressure control rate of participants after attended RAMP group, with those attended RAMP individual from usual care. A prospective open cluster-randomized controlled trial was performed in five public primary care clinics. Patients with uncontrolled hypertension were recruited. RAMP group consisted of multi-disciplinary group education on knowledge of hypertension, lifestyle modification, and hands-on home blood pressure monitoring (HBPM) training. Each participant was given a branchial HBPM device. An individual face-to-face nurse follow-up was arranged 6 weeks later. Participants' office BP and clinical parameters were assessed at 6, 12, and 18 months. Three RAMP group and two RAMP-individual clusters recruited 152 and 139 participants, respectively. The mean age was 67.0 (SD 9.9) year. After 18 months of treatment, there was a significantly higher BP control rate in the RAMP-group participants than the RAMP-individual participants (78.9% vs 36.5%, P < .001). The systolic BP was reduced by 19.7 mm Hg (95% CI -22.03, -17.40, P < .001) and diastolic BP by 8.1 mm Hg (95% CI -9.66, -6.61, P < .001) in RAMP group while the RAMP individual demonstrated 9.3 mm Hg (95% CI -12.1, -6.4, P < .001) reduction in systolic BP without any significant difference in diastolic BP. The RAMP-group participants' body weight (BW) and body mass index(BMI) had no significant changes, while the RAMP-individual participants had a significant increase in BW and BMI. No adverse effect was reported.

Patients' perceptions of self-management of high blood pressure in three low- and middle-income countries: findings from the BPMONITOR study

Hypertension is the leading risk factor for global disease burden. Self-management of high blood pressure (BP) through self-monitoring and self-titration of medications, has proved to be one successful and cost-effective tool to achieve better BP control in many high-income countries but not much is known about its potential in low- and middle-income countries (LMICs). We used semi-structured questionnaires and focus groups in three LMICs; Peru, Cameroon and Malawi to examine perceptions and attitudes of patients diagnosed with essential hypertension towards living with hypertension, BP measurement and treatment, patient-physician relationship and opinions about self-management of high blood pressure. Results in all three countries were comparable. Patients showed varied levels of health literacy related to hypertension. BP measurement habits were mostly affected by resources available and caregiver support. Treatment and adherence to it were primarily affected by cost. Most patients were welcoming of the idea of self-management but skeptical about the ability to do self-monitoring accurately and the safety involving self-titration of medications.

Telemonitoring at scale for hypertension in primary care: An implementation study

BACKGROUND

While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care.

METHODS AND FINDINGS

This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants' views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56-70, range 22-89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6-10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy.

CONCLUSIONS

Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative.

Telemonitoring and remote counseling in hypertensive patients. Looking for new ways to do old jobs

XXI century emphasized humanity to embrace the digital era after a reality of Third and Fourth Industrial Revolutions, nowadays dictating new terms of social networking. It is expected that information and communication technologies integrated with value-based medicine will significantly impact healthcare delivery to tremendous number of patients with socially important noncommunicable diseases. Cardiovascular illnesses comprise the greatest part of such pathologies. Hypertension (HTN) being the most prevalent cardiovascular disease is also the key modifiable cardiovascular risk factor yet seems to be an attractive target for both value-based concept and telehealth interventions. Present review addresses up-to-date science on telehealth, sets out the main well-known, but yet unsolved challenges in management of HTN along with the new approaches involving telemedicine programs, digital health outlooks. The main barriers of telehealth implementation are also considered along with the possible solutions.

Home Blood Pressure Monitoring by a Mobile-Based Model in Chongqing, China: A Feasibility Study

Purpose: Increasing attention is being paid to the role of the intelligent self-management of hypertension under the context of increasing prevalence but limited medical resources. However, heterogeneity in interventions and outcome measures has hindered the interpretation of research evaluating mobile health technologies for hypertension control, and little study of such technology has been performed in China. Objective: This was a feasibility study aimed to understand patient and medical practitioners' acceptance and experience of a mobile-phone based platform for the management of hypertensive patients. Methods: The model used behavioral incentives for daily blood pressure measurement and physician-facing prioritization of patients based on level of blood-pressure control. Patients were enrolled by purposive sampling. The platform was used for two-week blood pressure monitoring through WeChat, which simulated our future app. Qualitative interviews with patients and providers were conducted in time. Results: Twenty hypertensive patients and two providers were enrolled and used the platform throughout the two weeks. Patients reported daily home blood pressure monitoring to be simple, feasible and increased their health awareness. Specifically, patients self-reported that reminders, the daily frequency and time of monitoring, and positive reinforcement were important for maintaining adherence. Providers reported that they could manage patients more quickly and accurately, but reasonable feedback information was needed to avoid excessive increases in workload. Conclusion: The adoption of mobile-based technology to monitor patient's blood pressure may provide a practical solution for managing patients in Chongqing, China. Patient health education and enhanced app functionality could improve patient compliance and satisfaction while reducing provider workload.

Apps to Support Self-Management for People With Hypertension: Content Analysis

BACKGROUND

Home blood pressure monitoring (HBPM) is one component of effective supported self-management, which may potentially be mediated by mobile apps.

OBJECTIVE

The aim of this study was to identify the self-management features (HBPM and broader support strategies) offered by currently available apps and to determine the features associated with download frequency and user ratings.

METHODS

We searched Google Play store, Apple App store, National Health Services Apps Library and myhealthapps.net (first search on February 1, 2018; updated August 18, 2018). We included high blood pressure apps available in the United Kingdom and extracted their features, number of downloads, and the average users' rating from the app stores. We mapped the features to the holistic Practical Reviews In Self-Management Support (PRISMS) taxonomy of self-management support. We employed a regression analysis to determine if any features were associated with download frequency or user rating.

RESULTS

We included 151 apps. The 3 most common features were as follows: monitoring blood pressure (BP) and charting logs; lifestyle (exercise or dietary) advice; and providing information about hypertension. The other 11 components of the PRISMS taxonomy were rarely featured. There was little evidence to support associations between specific features and the download statistics and rating scores, with only 2 uncommon features achieving borderline significant associations. The presence of social support features, such as a forum, was weakly but significantly (R²=.04, P=.02) correlated with the number of downloads. Apps designed specifically for particular BP monitors/smart watches were weakly associated with a higher rating score (R²=.05, P<.001). Apps with more ratings were associated with more downloads (R²=.91, P<.001).

CONCLUSIONS

The functionality of currently available apps is limited to logging BP, offering lifestyle advice, and providing information about hypertension. Future app development should consider broadening the remit to produce a system that can respond flexibly to the diversity of support that enables people to self-manage their hypertension.