Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association

Daily self-reported behavioural efficacy records on hypertension digital therapeutics as digital metrics associated with the reduction in morning home blood pressure: post-hoc analysis of HERB-DH1 trial

Digital therapeutics for hypertension, proven effective in the HERB-DH1 trial, enable patients to record and track their daily actions and achievements to improve their lifestyles using an app. However, the association between recording daily behaviours and blood pressure (BP) reduction has not yet been investigated. We conducted a post-hoc analysis to investigate the relationship between them in the HERB-DH1 trial. We defined the counts of daily records of antihypertensive behaviour taken by the patient into the app as daily self-reported behavioural efficacy records (SER). SER was categorised into quartiles, and the trend of changes from baseline to week 12 in morning home systolic blood pressure (SBP), salt intake checklist score, and body weight was assessed. A total of 156 patients with hypertension were included in the analysis. A higher total count of SER was associated with greater SBP reduction (P for trend: 0.049). Patients with a higher SER for salt intake and weight reduction showed reductions in SBP (P for trend: 0.034 and 0.027, respectively). Furthermore, patients with higher salt intake SER exhibited a decrease in the salt intake checklist scores, and patients with greater weight reduction SER experienced a reduction in body weight (P for trend: 0.001 and 0.007, respectively). SER during digital therapeutics is associated with a reduction in morning home SBP in patients with hypertension. Enhancing patients' intrinsic motivation and self-efficacy, as evaluated by the SER, can play an important role in reducing BP by promoting lifestyle improvement. Daily self-reported behavioural efficacy records (SER) defined as the number of patient's app inputs of recall of day-by-day activity of behaviours at the end of the day, is partially affected by self-efficacy and affinity of app, resulting in the effectiveness of digital therapeutics.

Lost in Translation: Why Are Rates of Hypertension Control Getting Worse Over Time?

Treatment of hypertension to decrease rates of cardiovascular disease is the most well studied and most broadly applicable treatment in cardiovascular prevention. Blood pressure can be measured anywhere, not just in a physician's office; medications are readily available, inexpensive, and have highly favorable benefit/harm ratios with relatively minimal side effects; and stepped medication regimens can be prescribed in algorithmic fashion by a variety of practitioners. Yet overall hypertension control rates in the United States have never exceeded 60%, and the last 5-10 years have seen decreased, rather than increased, rates of control. Here, I describe the scale of this massive failure to deliver on the promise of preventive hypertension care; outline the populations most affected and the contemporaneous events that have impacted hypertension control; discuss the disparate paths of hypertension science and health care delivery; and highlight novel interventions, approaches, and future opportunities to bend the curve back toward improvements in hypertension control.

Feasibility and Methodology of a Pilot Free Blood Pressure Monitoring and Follow-Up Program at Two Free Clinics

BACKGROUND

Hypertension affects approximately 1 in 2 adults in the US. Home blood pressure (BP) monitoring programs are effective in the diagnosis and management of hypertension. Free clinics serve as an integral safety net for millions of uninsured and economically disadvantaged patients in the US. The feasibility and effects of a free home BP monitoring and follow-up program in a free clinic setting is not well characterized.

METHODS

This was a prospective study of the implementation of a pilot BP monitoring and follow-up program between March 2021 and August 2023 at 2 free clinics in the San Francisco Bay Area. A total of 78 hypertensive patients were enrolled in the program and given a free BP monitor. We surveyed via telephone the change in systolic and diastolic BPs and BP monitor use and comfort at 3 weeks. Volunteers in clinic roles involved in the BP monitoring program were surveyed to assess their time spent and perceptions of the program.

RESULTS

Of the 78 patients, 37 provided responses to the 3-week survey. A total of 36 of 37 (97%) patients reported using their BP monitor. A total of 35 patients reported using it at least once a week (95%), with the majority reporting at least four uses a week (68%). A total of 36 patients (97%) planned on continuing to use their BP monitor. At 3 weeks, the mean systolic and diastolic BP changed by -6.40 mmHg (95% CI, -10.8 to -2.01 mmHg; P = .00577) and -2.72 mmHg (95% CI, -5.62 to 0.188 mmHg; P = .0657), respectively. The time commitment for this program ranged from 130 ± 51 min for program leaders to 16 ± 14 min per week for patient-facing roles. All volunteer roles (patient-facing, phone follow-up, program leaders) expressed that they had a clear understanding of their responsibilities in the program (median 4 on Likert scale, IQR 3-5).

CONCLUSION

Home BP monitoring and follow-up is feasible to implement in free clinics, resulting in high rates of patient engagement among respondents. Our findings suggest that home BP monitoring and follow-up programs may be beneficial in vulnerable patient populations.

Content and delivery preferences for information to support the management of high blood pressure

Blood pressure(BP) management interventions have been shown to be more effective when accompanied by appropriate patient education. As high BP remains poorly controlled, there may be gaps in patient knowledge and education. Therefore, this study aimed to identify specific content and delivery preferences for information to support BP management among Australian adults from the general public. Given that BP management is predominantly undertaken by general practitioners(GPs), information preferences to support BP management were also ascertained from a small sample of Australian GPs. An online survey of adults was conducted to identify areas of concern for BP management to inform content preferences and preferred format for information delivery. A separate online survey was also delivered to GPs to determine preferred information sources to support BP management. Participants were recruited via social media. General public participants (n = 465) were mostly female (68%), >60 years (57%) and 49% were taking BP-lowering medications. The management of BP without medications, and role of lifestyle in BP management were of concern among 30% and 26% of adults respectively. Most adults (73%) preferred to access BP management information from their GP. 57% of GPs (total n = 23) preferred information for supporting BP management to be delivered via one-page summaries. This study identified that Australian adults would prefer more information about the management of BP without medications and via lifestyle delivered by their GP. This could be achieved by providing GPs with one-page summaries on relevant topics to support patient education and ultimately improve BP management.

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.

Diagnostic Accuracy of Office Blood Pressure Measurement and Home Blood Pressure Monitoring for Hypertension Screening Among Adults: Results From the IDH Study

BACKGROUND

Using high awake blood pressure (BP; ≥130/80 mm Hg) on ambulatory BP monitoring (ABPM) as a reference, the purpose of this study was to determine the accuracy of high office BP (≥130/80 mm Hg) at an initial visit and high confirmatory office BP (≥130/80 mm Hg), and separately, high home BP (≥130/80 mm Hg) among participants with high office BP (≥130/80 mm Hg) at an initial office visit.

METHODS AND RESULTS

The accuracy of office BP measurements using the oscillometric method for detecting high BP on ABPM was determined among 379 participants with complete office BP and ABPM data in the IDH (Improving the Detection of Hypertension) study. For detecting high BP on ABPM, the accuracy of high confirmatory office BP using the oscillometric method and, separately, high home BP was also determined among the subgroup of 122 participants with high office BP at an initial visit and complete home BP monitoring data. High office BP had moderate sensitivity (0.61 [95% CI, 0.53-0.68]) and high specificity (0.85 [95% CI, 0.80-0.90]) for high awake BP. High confirmatory office BP and high home BP had moderate sensitivity (0.69 [95% CI, 0.59-0.79] and 0.79 [95% CI, 0.71-0.87], respectively) and low and moderate specificity (0.44 [95% CI, 0.27-0.61] and 0.72 [95% CI, 0.56-0.88], respectively).

CONCLUSIONS

Many individuals with high BP on ABPM do not have high office BP. Confirmatory office BP and home blood pressure monitoring also had limited ability to identify individuals with high BP on ABPM.

Effect of intelligent hypertension management system on blood pressure: protocol for a randomised controlled multicentre trial

INTRODUCTION

Hypertension is one of the most serious global health problems, and its prevention and treatment mainly rely on lifestyle intervention and medication. However, the current situation of hypertension control in China is still not ideal. Self-monitoring of blood pressure is expected to be a new way to control hypertension. Intervention and the Intelligent Hypertension Management System (IHMS), an information platform relying on the network and smartphone, may help patients self-monitor their blood pressure at home, allowing for intelligent management of hypertension. The aim of this trial is to investigate whether IHMS can effectively reduce blood pressure in patients with hypertension.

METHODS AND ANALYSIS

This is a multiple-centre, prospective, randomised, controlled study. 320 eligible subjects will be randomly divided into the IHMS management group (n=160) and the conventional care group (n=160). Subjects in the IHMS management group will be required to take their blood pressure daily at regular intervals at home and get treatment as directed by the IHMS; the control group will receive conventional treatment. The primary outcome of the trial is the net change in systolic blood pressure at the end point of follow-up after 3 months. The mixed-effects model will be used to compare the primary outcome that there is a greater reduction in blood pressure in the intervention group than in the control group.

ETHICS AND DISSEMINATION

The Ethics Committee of Shanghai Tongren Hospital has reviewed and approved the trial protocols, informed consent and subject information. The findings from the study will be disseminated through publications and conference presentations. The findings of the trial will be published in journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

NCT05526300.

Automated Messaging Program to Facilitate Systematic Home Blood Pressure Monitoring: Qualitative Analysis of Provider Interviews

BACKGROUND

Hypertension is a leading cause of cardiovascular and kidney disease in the United States, yet blood pressure (BP) control at a population level is poor and worsening. Systematic home BP monitoring (HBPM) programs can lower BP, but programs supporting HBPM are not routinely used. The MyBP program deploys automated bidirectional text messaging for HBPM and disease self-management support.

OBJECTIVE

We aim to produce a qualitative analysis of input from providers and staff regarding implementation of an innovative HBPM program in primary care practices.

METHODS

Semistructured interviews (average length 31 minutes) were conducted with physicians (n=11), nurses, and medical assistants (n=6) from primary care settings. The interview assessed multiple constructs in the Consolidated Framework for Implementation Research domains of intervention characteristics, outer setting, inner setting, and characteristics of individuals. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes, followed by mapping to the updated Consolidated Framework for Implementation Research constructs.

RESULTS

Health care providers reported that MyBP has good ease of use and was likely to engage patients in managing their high BP. They also felt that it would directly support systematic BP monitoring and habit formation in the convenience of the patient's home. This could increase health literacy and generate concrete feedback to raise the day-to-day salience of BP control. Providers expressed concern that the cost of BP devices remains an encumbrance. Some patients were felt to have overriding social or emotional barriers, or lack the needed technical skills to interact with the program, use good measurement technique, and input readings accurately. With respect to effects on their medical practice, providers felt MyBP would improve the accuracy and frequency of HBPM data, and thereby improve diagnosis and treatment management. The program may positively affect the patient-provider relationship by increasing rapport and bidirectional accountability. Providers appreciated receiving aggregated HBPM data to increase their own efficiency but also expressed concern about timely routing of incoming HBPM reports, lack of true integration with the electronic health record, and the need for a dedicated and trained staff member.

CONCLUSIONS

In this qualitative analysis, health care providers perceived strong relative advantages of using MyBP to support patients. The identified barriers suggest the need for corrective implementation strategies to support providers in adopting the program into routine primary care practice, such as integration into the workflow and provider education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03650166; https://tinyurl.com/bduwn6r4.

Blood pressure outcomes at 12 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

Remote patient monitoring (RPM) for hypertension enables automatic transmission of blood pressure (BP) and pulse into the electronic health record (EHR), but its effectiveness in primary care is unknown. This pragmatic matched cohort study using EHR data compared BP outcomes between individuals prescribed RPM and temporally-matched controls from six primary care practices. We retrospectively created a cohort of 288 Medicare-enrolled patients prescribed BP RPM (cases) and 1152 propensity score-matched controls (1:4). Matching was based on age, sex, systolic blood pressure (SBP), marital status, and other characteristics. Outcomes at 3, 6, 9 and 12 months were: controlling high BP (most recent BP < 140/90 mm Hg), antihypertensive medication intensification, and most recent SBP assessed using: all measurements, and office measurements only. At baseline, RPM-prescribed patients and controls had similar ages and systolic BP. BP control diverged at 3 months (RPM: 72.2%, control: 51%, p < 0.001). This difference persisted but decreased over follow-up. After 12 months, the RPM-prescribed cohort had greater BP control (RPM: 71.5%, control: 58.1%, p < 0.001) and lower SBP (132.3 versus 136.5 mm Hg, p = 0.003) using all measurements, but they did not differ using only office measurements (12 month BP control: 60.8% versus 58.1%, p = 0.44; SBP: 135.9 versus 136.5 mm Hg, p = 0.91). At 12 months, the most recent BP measurements were more current for RPM-prescribed patients (median [IQR] 8 [0-109] versus 134 [56-239] days). Net increases in antihypertensive medications by 12 months were similar. Implementation of RPM in primary care could inform hypertension management strategies and increase hypertension control. Registration: ClinicalTrials.gov identifier: NCT05562921.

Home blood pressure-centered approach - from digital health to medical practice: HOPE Asia Network consensus statement 2023

Recent innovations in digital technology have enabled the simultaneous accumulation, and the linking and analysis of time-series big data relating to several factors that influence blood pressure (BP), including biological indicators, physical activity, and environmental information. Various approaches can be used to monitor BP: in the office/clinic; at home; 24-h ambulatory recording; or with wearable and cuffless devices. Of these, home BP monitoring is a reliable and convenient method, and is recommended for hypertension management by current national and international guidelines. This recommendation is based on evidence showing that home BP is an important predictor of cardiovascular, cerebrovascular and kidney disease in patients with hypertension. In addition, lifetime personalized health record (PHR)-based home BP with telemonitoring combined with co-interventions has been shown to lower BP more effectively than the traditional approach based on office BP. Thus, home BP represents a key metric for personalized anticipation medicine, from digital healthcare to digital medicine. This paper summarizes the latest evidence on home BP monitoring and proposes a Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network consensus on a home BP-centered approach to the management of hypertension.

Requirements for design and function of blood pressure measuring devices used for the management of hypertension: Consensus Statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and STRIDE BP

OBJECTIVE

To develop scientific consensus recommendations for the optimal design and functions of different types of blood pressure (BP) measuring devices used in clinical practice for the detection, management, and long-term follow-up of hypertension.

METHODS

A scientific consensus meeting was performed by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability and STRIDE BP (Science and Technology for Regional Innovation and Development in Europe) during the 2022 Scientific Meeting of the ESH in Athens, Greece. Manufacturers were also invited to provide their feedback on BP device design and development. Thirty-one international experts in clinical hypertension and BP monitoring contributed to the development of consensus recommendations on the optimal design of BP devices.

STATEMENT

International consensus was reached on the requirements for the design and features of five types of BP monitors, including office (or clinic) BP monitors, ambulatory BP monitors, home BP monitors, home BP telemonitors, and kiosk BP monitors for public spaces. For each device type "essential" requirements (must have), and "optional" ones (may have) are presented, as well as additional comments on the optimal device design and features.

CONCLUSIONS

These consensus recommendations aim at providing manufacturers of BP devices with the requirements that are considered mandatory, or optional, by clinical experts involved in the detection and management of hypertension. They are also directed to administrative healthcare personnel involved in the provision and purchase of BP devices so that they can recommend the most appropriate ones.

Implantable Triboelectric Nanogenerators for Self-Powered Cardiovascular Healthcare

Triboelectric nanogenerators (TENGs) have gained significant traction in recent years in the bioengineering community. With the potential for expansive applications for biomedical use, many individuals and research groups have furthered their studies on the topic, in order to gain an understanding of how TENGs can contribute to healthcare. More specifically, there have been a number of recent studies focusing on implantable triboelectric nanogenerators (I-TENGs) toward self-powered cardiac systems healthcare. In this review, the progression of implantable TENGs for self-powered cardiovascular healthcare, including self-powered cardiac monitoring devices, self-powered therapeutic devices, and power sources for cardiac pacemakers, will be systematically reviewed. Long-term expectations of these implantable TENG devices through their biocompatibility and other utilization strategies will also be discussed.

The Impact of COVID-19 on Hypertension and Hypertension Medication Adherence Among Underrepresented Racial and Ethnic Groups: A Scoping Review

PURPOSE OF REVIEW

To conduct a scoping review of articles which examined the impact of COVID-19 on HTN and HTN medication adherence among underrepresented racial/ethnic minorities.

RECENT FINDINGS

Seven studies were included in this review and impact of COVID-19 was examined at 4 levels: patient, provider, health system and society. The results indicated that patient level factors, such as high unemployment and inequitable access to telemedicine due to society factors- lack of access to high-speed Internet and variation in the offering of telehealth by health systems, were most impactful on adherence. Additionally, provider level clinical inertia may have further impacted adherence to HTN medication. Our review showed that the COVID-19 pandemic did not introduce new barriers but exacerbated preexisting barriers. Ongoing efforts are needed to change policies at the state and local levels to dismantle inequities in underrepresented communities to ensure access to health care with telemedicine to promote health equity.

Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial

BACKGROUND

Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity.

METHODS

We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration.

RESULTS

Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity.

CONCLUSIONS

Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity.

REGISTRATION DETAILS

www.

CLINICALTRIALS

gov Identifier: NCT05488795.

The Health and Economic Impact of Expanding Home Blood Pressure Monitoring

INTRODUCTION

Home blood pressure monitoring is more convenient and effective than clinic-based monitoring in diagnosing and managing hypertension. Despite its effectiveness, there is limited evidence of the economic impact of home blood pressure monitoring. This study aims to fill this research gap by assessing the health and economic impact of adopting home blood pressure monitoring among adults with hypertension in the U.S.

METHODS

A previously developed microsimulation model of cardiovascular disease was used to estimate the long-term impact of adopting home blood pressure monitoring versus usual care on myocardial infarction, stroke, and healthcare costs. Data from the 2019 Behavioral Risk Factor Surveillance System and the published literature were used to estimate model parameters. The averted cases of myocardial infarction and stroke and healthcare cost savings were estimated among the U.S. adult population with hypertension and in subpopulations defined by sex, race, ethnicity, and rural/urban area. The simulation analyses were conducted between February and August 2022.

RESULTS

Compared with usual care, adopting home blood pressure monitoring was estimated to reduce myocardial infarction cases by 4.9% and stroke cases by 3.8% as well as saving an average of $7,794 in healthcare costs per person over 20 years. Non-Hispanic Blacks, women, and rural residents had more averted cardiovascular events and greater cost savings related to adopting home blood pressure monitoring compared with non-Hispanic Whites, men, and urban residents.

CONCLUSIONS

Home blood pressure monitoring could substantially reduce the burden of cardiovascular disease and save healthcare costs in the long term, and the benefits could be more pronounced in racial and ethnic minority groups and those living in rural areas. These findings have important implications in expanding home blood pressure monitoring for improving population health and reducing health disparities.

Randomized Trial of a Social Support Intervention to Improve Home Blood Pressure Monitoring in Patients With Cerebrovascular Disease

BACKGROUND

A pilot randomized trial evaluating whether a social support intervention improves adherence to home blood pressure (BP) monitoring among patients with cerebrovascular disease.

METHODS

Subjects with ischemic stroke, intracerebral hemorrhage, or transient ischemic attack within 5 years with BP >140/90, were given a centrally monitored home BP cuff and asked to check their BP twice a day for 90 ± 7 days. Subjects received text and/or email reminders for missed measurements and weekly reports on adherence/BP control. Subjects were randomized 1:1 to a social support intervention, in which close personal contact also received all study-related education and communications. The primary outcome was the proportion of requested measurements completed. A secondary outcome was a change in BP over time.

RESULTS

Thirty-three subjects were enrolled, 15 in the control arm and 18 in the social support arm. The social support arm completed a greater proportion of BP measurements at day 30 (88% vs 78%), day 60 (72% vs 54%), and day 83 (60% vs 40%), but none of these differences were statistically significant ( P > 0.05). Comparing the first 7 days of BP readings to the last 7 days across subjects, there was a nonsignificant decrease in BP over time (systolic BP = -2.8 mm Hg, P = 0.29 and diastolic BP = -1.7, P = 0.36). The social support intervention did not modify the change in BP over time.

CONCLUSION

A social support intervention may increase adherence to home BP monitoring. This pilot study provides important preliminary data to inform the design of larger more definitive trials utilizing self-monitoring of BP in patients with cerebrovascular disease.

The HOPE Asia Network consensus on blood pressure measurements corresponding to office measurements: Automated office, home, and ambulatory blood pressures

For adopting recently introduced hypertension phenotypes categorized using office and out of office blood pressure (BP) for the diagnosis of hypertension and antihypertension drug therapy, it is mandatory to define the corresponding out of office BP with the specific target BP recommended by the major guidelines. Such conditions include white-coat hypertension (WCH), masked hypertension (MH), white-coat uncontrolled hypertension (WUCH), and masked uncontrolled hypertension (MUCH). Here, the authors review the relevant literature and discuss the related issue to facilitate the use of corresponding BPs for proper diagnosis of WCH, MH, WUCH, and MUCH in the setting of standard target BP as well as intensive target BP. The methodology of deriving the corresponding BP has evolved from statistical methods such as standard deviation, percentile value, and regression to an outcome-based approach using pooled international cohort study data and comparative analysis in randomized clinical trials for target BPs such as the SPRINT and STEP studies. Corresponding BPs to 140/90 and 130/80 mm Hg in office BP is important for safe and strict achievement of intensive BP targets. The corresponding home, daytime, and 24-h BPs to 130/80 mm Hg in office BP are 130/80, 130/80, and 125/75 mm Hg, respectively. However, researchers have found some discrepancies among the home corresponding BPs. As tentative criterion for de-escalation of antihypertensive therapy as shown in European guidelines was 120 mm Hg in office BP, corresponding home, daytime, and 24-h systolic BPs to 120 mm Hg in office systolic BP are 120, 120, and 115 mm Hg, respectively.

Uncontrolled blood pressure and therapeutic inertia in treated hypertensive patients: A retrospective cohort study using a UK general practice database

Uncontrolled blood pressure (BP) and therapeutic inertia pose significant challenges in effectively managing hypertension. This study objective was to quantify levels of uncontrolled BP and therapeutic inertia among patients treated for hypertension in primary care. This retrospective cohort study used data recorded by general practitioners from the UK Clinical Practice Research Datalink database. Adults with primary hypertension who received a recorded prescription for any antihypertensive drug between January 2015 and June 2017 (index date) were included, with a follow-up of 18 months. Primary outcomes included the percentage of patients with uncontrolled BP (defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) and of apparent therapeutic inertia (defined as two consecutive uncontrolled BP records without treatment change) during follow-up. Finally, of 581 260 patients receiving antihypertensive drug(s), 37.2% (n = 216 014) had uncontrolled BP at the index date and 30.3% (n = 175 955) had no record of BP at this date. During follow-up, 59.2% had ≥1 record of uncontrolled BP, in 22% all records showed uncontrolled BP, and 12.8% had no record of BP. Among those with uncontrolled BP at the index date, 72.9% had ≥1 record of uncontrolled BP during follow-up, and in 28.3% all records showed uncontrolled BP. Therapeutic inertia was observed in 33.1% of patients overall, and in 55.7% of those with uncontrolled BP at the index date. In conclusion, BP recording was infrequent, possibly reflecting both a low frequency of measurement and potential under-recording. Uncontrolled BP and therapeutic inertia appear to be widespread in UK general practice.

Use of Different Blood Pressure Thresholds to Reduce the Number of Home Blood Pressure Monitoring Days Needed for Detecting Hypertension

BACKGROUND

Home blood pressure (BP) monitoring over a 7-day period is recommended to confirm the diagnosis of hypertension.

METHODS

We determined upper and lower home BP thresholds with >90% positive predictive value and >90% negative predictive value using 1 to 6 days of monitoring to identify high home BP (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg) based on 7 days of home BP monitoring. The sample included 361 adults from the Improving the Detection of Hypertension Study who were not taking antihypertensive medication. We used two 7-day periods, at least 3 days apart, the first being a sampling period and the second a reference period. For each number of days in the sampling period, we determined the percentage of participants who had a high likelihood of having (>90% positive predictive value) or not having (>90% negative predictive value) high BP and would not need to continue home BP monitoring. Only the participants in an uncertain category (ie, positive predictive value ≤90% and negative predictive value ≤90%) after each day were carried forward to the next day of home BP monitoring.

RESULTS

Of the 361 participants (mean [SD] age of 41.3 [13.2] years; 60.4% women), 38.0% had high home BP during the reference period. There were 63.7%, 17.1%, 10.5%, 3.3%, 3.6%, and 1.4% participants who would not need to continue after 1, 2, 3, 4, 5, and 6 days of monitoring.

CONCLUSIONS

In most people, high home BP can be identified or excluded with a high degree of confidence with 3 days or less of monitoring.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

The promise of digital healthcare technologies

Digital health technologies have been in use for many years in a wide spectrum of healthcare scenarios. This narrative review outlines the current use and the future strategies and significance of digital health technologies in modern healthcare applications. It covers the current state of the scientific field (delineating major strengths, limitations, and applications) and envisions the future impact of relevant emerging key technologies. Furthermore, we attempt to provide recommendations for innovative approaches that would accelerate and benefit the research, translation and utilization of digital health technologies.

Digital hypertension management: clinical and cost outcomes of a pilot implementation of the OMRON hypertension management platform

Importance

Home monitoring of blood pressure (BP) in hypertensive patients can improve outcomes, but challenges to both patient compliance and the effective transmission of home BP readings to physicians can limit the extent to which physicians can use this information to improve care. The OMRON Hypertension Management Platform (OMRON HMP) pairs a home BP cuff with a digital product that tracks data, provides reminders to improve patient compliance, and provides a streamlined source of information to physicians.

Objective

The primary objective of the quality improvement (QI) project was to test the hypothesis that use of the OMRON HMP could reduce the number and cost of hypertension related claims, relative to a retrospectively matched cohort of insured members. A secondary objective was to demonstrate improvement in control of BP among patients.

Design

Eligible members were recruited to the QI project between December 1, 2018 and December 30, 2020 and data collected for six months following recruitment. All members received the OMRON HMP intervention.

Setting

Enrollment and data collection were coordinated on-site at selected PCP partner providers in Western Pennsylvania. Eligible members were identified from insurance claims data as those receiving care for primary hypertension from participating primary care physicians and/or cardiologists.

Participants

Eligible members were between the ages of 35 and 85, with a diagnosis of primary hypertension. The retrospective cohort was selected from electronic medical records of Highmark-insured patients with hypertension who received care at Allegheny Health Network (AHN), a subsidiary of Highmark Health. Members were matched on baseline BP and lipid measures, age, smoking status, diabetes status, race and sex.

Intervention

Daily home BP readings were recorded by the OMRON HMP app. Patient data was reviewed by clinical staff on a weekly basis and treatment plans could be adjusted in response to this data.

Results

OMRON HMP users showed a significant increase in the number and cost of hypertension-related claims, contrary to the hypothesis, but did display improvements in control of BP.

Conclusions and Relevance

The use of a digital platform to facilitate at-home BP monitoring appeared to improve BP control but led to increased hypertension-related costs in the short-term.

Heterogeneity of the Effect of Telemedicine Hypertension Management Approach on Blood Pressure: A Systematic Review and Meta-analysis of US-based Clinical Trials

Background

Telemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown.

Methods

We conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at ≥6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials (≥25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials.

Results

Thirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP).

Conclusions

TM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation.

Clinical Perspective

What Is New?: In this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care.The BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses,Non-White patient predominant trials achieved lesser BP reductions than White patient predominant trials.What Are the Clinical Implications?: Before wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control.Without equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US.

[Twenty-year experience in strict versus non-strict control of arterial hypertension in a health center in Spain]

INTRODUCTION AND AIMS

During clinical trials effective reduction of blood pressure (BP) leads to a reduction in the incidence of cardiovascular (CV) morbimortality. Our main aim is to ascertain whether, under actual conditions of clinical practice, BP monitoring leads to a long-term reduction in CV events.

PATIENTS AND METHODS

The study was performed on 164 patients with hypertension (HT) selected among patients who came to family medicine consultations because of HT. An analysis was performed between patients who presented clinical BP lower than 140/90mmHg and those that had higher levels. When patients entered the study, they were followed up until a CV event occurred or up to a maximum of 20 years, at which time follow up ended.

RESULTS

Of the total of 164 patients, good control of BP was attained by 93 (56.7%), and 71 did not attain good control (42.2%). In the multivariate analysis, the only predictive variable for CV events was the lack of strict control of BP (HR: 2.93; 95% CI: 1.45-5.89; p=0.003), and the female sex was protective for CV events (HR: 0.37; 95% CI: 0.18-0.74; p=0.005).

CONCLUSIONS

The fundamental predictor variable of CV morbimortality in patients with HT is the lack of HT strict control; the women also had fewer CV complications.

Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up

Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, printable appendices with concise summaries of the care plan's recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.

Peak home blood pressure as an earlier and strong novel risk factor for stroke: the practitioner-based nationwide J-HOP study extended

While home blood pressure (BP) measurement is recommended for hypertension management, the clinical implications of peak home BP values have not been well studied. This study investigated the association between pathological threshold or frequency of peak home BP and cardiovascular events in patients with ≥1 cardiovascular risk factor. The Japan Morning Surge-Home Blood Pressure (J-HOP) study enrolled participants from 2005-2012 with extended follow-up from December 2017 to May 2018, which generated the dataset for this analysis. Average peak home systolic BP (SBP) was defined as average of the highest three BP values on 14-day measurement period. Patients were divided into quintiles of peak home BP, and the risk of stroke, coronary artery disease (CAD) and atherosclerotic cardiovascular disease (ASCVD; stroke+CAD) was determined. In 4231 patients (mean 65 years) followed for 6.2 years there were 94 strokes and 124 CAD events. The adjusted hazard ratio (HR) (95% CI) for the risk of stroke and ASCVD in patients with average peak home SBP in the highest versus lowest quintile was 4.39 (1.85-10.43) and 2.04 (1.24-3.36), respectively. Risk was greatest for stroke in the first 5 years: HR 22.66 (2.98-172.1). The pathological threshold of average peak home SBP for 5-year stroke risk was 176 mmHg. There was a linear association between the number of times peak home SBP > 175 mmHg and stroke risk. Peak home BP was a strong risk factor for stroke, especially within the first 5 years. We propose exaggerated peak home SBP > 175 mmHg as an early and strong novel risk factor for stroke.

Telehealth in antenatal care: recent insights and advances

BACKGROUND

For decades, antenatal care in high-resource settings has involved 12-14 face-to-face visits across pregnancy. The COVID-19 pandemic forced many care providers to rapidly embrace telehealth to reduce face-to-face visits. Here we review recent advances in telehealth used to provide antenatal care.

MAIN BODY

We conducted a narrative review examining the impact of telehealth on obstetric care. Two broad types of telehealth are used in antenatal care. The first is real-time telehealth, where consultations are done virtually instead of face-to-face. The second is remote monitoring, where in-clinic physical examinations are replaced with at-home alternatives. These can include blood pressure monitoring, fetal heart rate monitoring, and emerging technologies such as tele-ultrasound. Large cohort studies conducted during the pandemic era have shown that telehealth appears not to have increased adverse clinical outcomes for mothers or babies. However, further studies may be required to confidently conclude rare outcomes are unchanged, such as maternal mortality, serious morbidity, or stillbirth. Health economic studies suggest telehealth has the potential to reduce the financial cost of care provision. Telehealth in antenatal care seems to be acceptable to both pregnant women and healthcare providers.

CONCLUSION

Adoption of telehealth technologies may improve the antenatal care experience for women and reduce healthcare expenditure without adversely impacting health outcomes for the mother or baby. More studies are warranted to confirm telehealth does not alter the risk of rare outcomes such as maternal or neonatal mortality.

Prediction and prevention of preeclampsia in women with preexisting diabetes: the role of home blood pressure, physical activity, and aspirin

Women with type 1 or type 2 (preexisting) diabetes are four times more likely to develop preeclampsia compared with women without diabetes. Preeclampsia affects 9%-20% of pregnant women with type 1 diabetes and 7%-14% of pregnant women with type 2 diabetes. The aim of this narrative review is to investigate the role of blood pressure (BP) monitoring, physical activity, and prophylactic aspirin to reduce the prevalence of preeclampsia and to improve pregnancy outcome in women with preexisting diabetes. Home BP and office BP in early pregnancy are positively associated with development of preeclampsia, and home BP and office BP are comparable for the prediction of preeclampsia in women with preexisting diabetes. However, home BP is lower than office BP, and the difference is greater with increasing office BP. Daily physical activity is recommended during pregnancy, and limiting sedentary behavior may be beneficial to prevent preeclampsia. White coat hypertension in early pregnancy is not a clinically benign condition but is associated with an elevated risk of developing preeclampsia. This renders the current strategy of leaving white coat hypertension untreated debatable. A beneficial preventive effect of initiating low-dose aspirin (150 mg/day) for all in early pregnancy has not been demonstrated in women with preexisting diabetes.

A Communitywide Collaboration to Increase Enrollment, Retention, and Success in Evidence-Based Lifestyle-Change Programs in Racial and Ethnic Minority Populations

PURPOSE AND OBJECTIVES

Chronic diseases (eg, diabetes, hypertension) are the leading causes of death in the US and disproportionally affect racial and ethnic minority populations. This disparity is partially due to the unequal burden of unmet social needs that stem from several factors, including racism.

INTERVENTION APPROACH

The Alliance is a collaboration among health care, public health, and community organizations formed to improve referral, enrollment, and successful completion of evidence-based lifestyle-change programs, particularly among Black people. The Alliance built 1) a system to assess and address social barriers through the screening and referral process and 2) a training center for frontline staff (eg, community health workers).

EVALUATION METHODS

From January 2020 through September 2022, we conducted an evaluation that included both quantitative and qualitative methods. We developed an electronic database to make referrals and track key barriers to participation. Additionally, we conducted a focus group among frontline staff (N = 15) to understand the challenges in making referrals and discussing, documenting, and addressing barriers to participation. We used surveys that collected quantitative and open-ended qualitative responses to evaluate the training center and to understand perceptions of training modules as well as the skills gained.

RESULTS

Frontline staff engaged with 6,036 people, of whom 847 (14%) were referred to a lifestyle-change program from January 2020 through September 2022. Of those referred, 257 (30%) were eligible and enrolled in a program. Food access and unreliable internet were the most common barriers to participation. Thirteen of 15 frontline staff participated in trainings, and, on average, trainees completed 4.2 trainings and gained several skills (eg, ability to monitor personal bias, de-escalate a crisis, educate on mental health, understand community and environmental factors).

IMPLICATIONS FOR PUBLIC HEALTH

The Alliance is an example of how health care, public health, and community partners can work together to increase enrollment in lifestyle-change programs of residents disproportionately affected by chronic diseases. Lessons learned from implementation and evaluation can inform other complex partnerships to improve public health.

Self-Measured Blood Pressure Telemonitoring Programs: A Pragmatic How-to Guide

Self-measured blood pressure (SMBP) telemonitoring is the process of securely storing and tele-transmitting reliably measured, patient self-performed blood pressure (BP) measurements to healthcare teams, while ensuring that these data are viewable and clinically actionable for the purposes of improving hypertension diagnosis and management. SMBP telemonitoring is a vital component of an overall hypertension control strategy. Herein, we present a pragmatic guide for implementing SMBP in clinical practice and provide a comprehensive list of resources to assist with implementation. Initial steps include defining program goals and scope, selecting the target population, staffing, choosing appropriate (clinically validated) BP devices with proper cuff sizes, and selecting a telemonitoring platform. Adherence to recommended data transmission, security, and data privacy requirements is essential. Clinical workflow implementation involves patient enrollment and training, review of telemonitored data, and initiating or titrating medications in a protocolized fashion based upon this information. Utilizing a team-based care structure is preferred and calculation of average BP for hypertension diagnosis and management is important to align with clinical best practice recommendations. Many stakeholders in the United States are engaged in overcoming challenges to SMBP program adoption. Major barriers include affordability, clinician and program reimbursement, availability of technological elements, challenges with interoperability, and time/workload constraints. Nevertheless, it is anticipated that uptake of SMBP telemonitoring, still at a nascent stage in many parts of the world, will continue to grow, propagated by increased clinician familiarity, broader platform availability, improvements in interoperability, and reductions in costs that occur with scale, competition, and technological innovation.

Interindividual Variability in Self-Monitoring of Blood Pressure Using Consumer-Purchased Wireless Devices

BACKGROUND

Engagement with self-monitoring of blood pressure (BP) declines, on average, over time but may vary substantially by individual.

OBJECTIVES

We aimed to describe different 1-year patterns (groups) of self-monitoring of BP behaviors, identify predictors of those groups, and examine the association of self-monitoring of BP groups with BP levels over time.

METHODS

We analyzed device-recorded BP measurements collected by the Health eHeart Study-an ongoing prospective eCohort study-from participants with a wireless consumer-purchased device that transmitted date- and time-stamped BP data to the study through a full 12 months of observation starting from the first day they used the device. Participants received no instruction on device use. We applied clustering analysis to identify 1-year self-monitoring, of BP patterns.

RESULTS

Participants had a mean age of 52 years and were male and White. Using clustering algorithms, we found that a model with three groups fit the data well: persistent daily use (9.1% of participants), persistent weekly use (21.2%), and sporadic use only (69.7%). Persistent daily use was more common among older participants who had higher Week 1 self-monitoring of BP frequency and was associated with lower BP levels than the persistent weekly use or sporadic use groups throughout the year.

CONCLUSION

We identified three distinct self-monitoring of BP groups, with nearly 10% sustaining a daily use pattern associated with lower BP levels.

Home Pulse Pressure Predicts Death and Cardiovascular Events in Peritoneal Dialysis Patients

Increased arterial hypertension represents a prevalent condition in peritoneal dialysis patients that is often related to volume expansion. Pulse pressure is a robust predictor of mortality in dialysis patients, but its association with mortality is unknown in peritoneal patients. We investigated the relationship between home pulse pressure and survival in 140 PD patients. During a mean follow-up of 35 months, 62 patients died, and 66 experienced the combined event death/CV events. In a crude COX regression analysis, a five-unit increase in HPP was associated with a 17% increase in the hazard ratio of mortality (HR: 1.17, 95% CI 1.08-1.26 p < 0.001). This result was confirmed in a multiple Cox model adjusted for age, gender, diabetes, systolic arterial pressure, and dialysis adequacy (HR: 1.31, 95% CI 1.12-1.52, p = 0.001). Similar results were obtained considering the combined event death-CV events as an outcome. Home pulse pressure represents, in part, arterial stiffness, and it is strongly related to all-cause mortality in peritoneal patients. In these high cardiovascular risk populations, it is important to maintain optimal blood pressure control, but it is fundamental to consider all the other cardiovascular risk indicators, such as pulse pressure. Home pulse pressure measurement is easy and feasible and can add important information for the identification and management of high-risk patients.

Ultra-low-cost mechanical smartphone attachment for no-calibration blood pressure measurement

We propose an ultra-low-cost at-home blood pressure monitor that leverages a plastic clip with a spring-loaded mechanism to enable a smartphone with a flash LED and camera to measure blood pressure. Our system, called BPClip, is based on the scientific premise of measuring oscillometry at the fingertip to measure blood pressure. To enable a smartphone to measure the pressure applied to the digital artery, a moveable pinhole projection moves closer to the camera as the user presses down on the clip with increased force. As a user presses on the device with increased force, the spring-loaded mechanism compresses. The size of the pinhole thus encodes the pressure applied to the finger. In conjunction, the brightness fluctuation of the pinhole projection correlates to the arterial pulse amplitude. By capturing the size and brightness of the pinhole projection with the built-in camera, the smartphone can measure a user's blood pressure with only a low-cost, plastic clip and an app. Unlike prior approaches, this system does not require a blood pressure cuff measurement for a user-specific calibration compared to pulse transit time and pulse wave analysis based blood pressure monitoring solutions. Our solution also does not require specialized smartphone models with custom sensors. Our early feasibility finding demonstrates that in a validation study with N = 29 participants with systolic blood pressures ranging from 88 to 157 mmHg, the BPClip system can achieve a mean absolute error of 8.72 and 5.49 for systolic and diastolic blood pressure, respectively. In an estimated cost projection study, we demonstrate that in small-batch manufacturing of 1000 units, the material cost is an estimated $0.80, suggesting that at full-scale production, our proposed BPClip concept can be produced at very low cost compared to existing cuff-based monitors for at-home blood pressure management.

Awareness and recommendation of home blood pressure measurement among physicians in India: Results from Asia HBPM survey 2020

BACKGROUND

Awareness of hypertension and blood pressure (BP) control rates are still low in India. Home blood pressure monitoring (HBPM) is recognized as a valuable tool to diagnose and support hypertension treatment including the prevention of cardiovascular diseases(CVD) and target organ damage. We explored the prevailing knowledge and current recommendation of HBPM in daily practice by physicians in India.

MATERIALS AND METHODS

As part of Asia HBPM Survey 2020, a cross-sectional survey was conducted among healthcare providers from India between June 2020 to June 2021. The questionnaire consisted of 37 questions and sub-questions related to HBPM awareness and recommendations to patients.

RESULTS

A total of 832 physicians participated in the survey. Almost 83% were male, whereas age, specialty and workplace were well distributed. 31.3% of physicians instruct their patients to measure their BP before taking antihypertensive drugs, while around 30% of physicians gave no instructions. The reference value of hypertension diagnosis amongst the physicians was substantially low based on clinic BP (34.4%) and home BP (15.1%). Among physicians who manage hypertensive patients, nearly 88% recommend HBPM to their patients, however, only 34.9% of their patients own HBPM device and 30.4% of the patients measure their own BP at home.

CONCLUSION

The survey reveals that HBPM instructions to the patients are either lacking or not well aligned with the local hypertension guidelines which may have led to the low HBPM use among patients. Clear and practical educational material and sessions are needed to improve the understanding of HBPM amongst physicians.

Prospective Cohort Study of Remote Patient Monitoring with and without Care Coordination for Hypertension in Primary Care

BACKGROUND

Out-of-office blood pressure (BP) measurements contribute valuable information for guiding clinical management of hypertension. Measurements from home devices can be directly transmitted to patients' electronic health record for use in remote monitoring programs.

OBJECTIVE

This study aimed to compare in primary care practice care coordinator-assisted implementation of remote patient monitoring (RPM) for hypertension to RPM implementation alone and to usual care.

METHODS

This was a pragmatic observational cohort study. Patients aged 65 to 85 years with Medicare insurance from two populations were included: those with uncontrolled hypertension and a general hypertension group seeing primary care physicians (PCPs) within one health system. Exposures were clinic-level availability of RPM plus care coordination, RPM alone, or usual care. At two clinics (13 PCPs), nurse care coordinators with PCP approval offered RPM to patients with uncontrolled office BP and assisted with initiation. At two clinics (39 PCPs), RPM was at PCPs' discretion. Twenty clinics continued usual care. Main measures were controlling high BP (<140/90 mm Hg), last office systolic blood pressure (SBP), and proportion with antihypertensive medication intensification.

RESULTS

Among the Medicare cohorts with uncontrolled hypertension, 16.7% (39/234) of patients from the care coordination clinics were prescribed RPM versus <1% (4/600) at noncare coordination sites. RPM-enrolled care coordination group patients had higher baseline SBP than the noncare coordination group (148.8 vs. 140.0 mm Hg). After 6 months, in the uncontrolled hypertension cohorts the prevalences of controlling high BP were 32.5% (RPM with care coordination), 30.7 % (RPM alone), and 27.1% (usual care); multivariable adjusted odds ratios (95% confidence interval) were 1.63 (1.12-2.39; p = 0.011) and 1.29 (0.98-1.69; p = 0.068) compared with usual care, respectively.

CONCLUSION

Care coordination facilitated RPM enrollment among poorly controlled hypertension patients and may improve hypertension control in primary care among Medicare patients.

Innovative Remote Management Solutions for the Control of Hypertension

We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.

Reach Out Emergency Department: A Randomized Factorial Trial to Determine the Optimal Mobile Health Components to Reduce Blood Pressure

BACKGROUND

Mobile health (mHealth) strategies initiated in safety-net Emergency Departments may be one approach to address the US hypertension epidemic, but the optimal mHealth components or dose are unknown.

METHODS

Reach Out is an mHealth, health theory-based, 2×2×2 factorial trial among hypertensive patients evaluated in a safety-net Emergency Department in Flint, Michigan. Reach Out consisted of 3 mHealth components, each with 2 doses: (1) healthy behavior text messaging (yes versus no), (2) prompted self-measured blood pressure (BP) monitoring and feedback (weekly versus daily), and (3) facilitated primary care provider appointment scheduling and transportation (yes versus no). The primary outcome was a change in systolic BP from baseline to 12 months. In a complete case analysis, we fit a linear regression model and accounted for age, sex, race, and prior BP medications to explore the association between systolic BP and each mHealth component.

RESULTS

Among 488 randomized participants, 211 (43%) completed follow-up. Mean age was 45.5 years, 61% were women, 54% were Black people, 22% did not have a primary care doctor, 21% lacked transportation, and 51% were not taking antihypertensive medications. Overall, systolic BP declined after 6 months (-9.2 mm Hg [95% CI, -12.2 to -6.3]) and 12 months (-6.6 mm Hg, -9.3 to -3.8), without a difference across the 8 treatment arms. The higher dose of mHealth components were not associated with a greater change in systolic BP; healthy behavior text messages (point estimate, mmHG=-0.5 [95% CI, -6.0 to 5]; P=0.86), daily self-measured BP monitoring (point estimate, mmHG=1.9 [95% CI, -3.7 to 7.5]; P=0.50), and facilitated primary care provider scheduling and transportation (point estimate, mmHG=0 [95% CI, -5.5 to 5.6]; P=0.99).

CONCLUSIONS

Among participants with elevated BP recruited from an urban safety-net Emergency Department, BP declined over the 12-month intervention period. There was no difference in change in systolic BP among the 3 mHealth components. Reach Out demonstrated the feasibility of reaching medically underserved people with high BP cared for at a safety-net Emergency Departments, yet the efficacy of the Reach Out mHealth intervention components requires further study.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03422718.

Postpartum Home Blood Pressure Monitoring Program: Improving Care for Hypertension During Postpartum after a Hospital Birth

BACKGROUND AND SIGNIFICANCE

Hypertensive disorders of pregnancy complicate about 10% of pregnancies and are a leading cause of maternal morbidity and mortality.

PURPOSE

The purpose of this quality improvement project was to evaluate a program to provide a home blood pressure monitor to all postpartum patients who had a hypertensive diagnosis and elevated blood pressure.

METHODS

The program includes a blood pressure monitor, instructions for its use, education about hypertension, and a guidance grid with standardized blood pressure parameters reviewed prior to discharge from the hospital. Patients are taught about potential adverse outcomes during postpartum. Patients are instructed to follow-up with their care provider based on the parameters. A retrospective medical record review was used to evaluate clinical outcomes.

RESULTS

Medical records of 185 patients indicated that 20% ( n = 36) who received the home BP monitor reported one or more mild-to-severe range blood pressure(s) during postpartum. Twenty-eight percent ( n = 52) had outpatient medication adjustments, including decreasing, increasing, starting, and discontinuing medications. Nine percent ( n = 17) of patients returned to the obstetric triage for evaluation. There was patient overlap between those experiencing elevated blood pressures, medication adjustments, and those who returned to hospital for evaluation.

CLINICAL IMPLICATIONS

Ongoing monitoring may improve identification and management of postpartum hypertension and potentially prevent progression to hypertensive-related adverse events.

Development and Initial Use of an Evidence-Based Home Blood Pressure Monitoring mHealth Platform

Home blood pressure monitoring (HBPM) has been shown to provide a more reliable assessment of blood pressure (BP) than in-office measurement and may lead to improved BP control. While many mHealth apps are available to help users track their blood pressure (BP), no apps incorporate the full set of evidence-based HBPM recommendations for ensuring accurate measurement at home. Through an agile development approach employing user stories, we translated an evidence-based standardized protocol for BP measurement and monitoring over a recommended 3-7 day monitoring period into a mHealth app and corresponding clinician portal. We then pilot tested this platform to assess its feasibility for guiding users to measure BP over multiple days according to this protocol. During this pilot testing, one hundred and twenty five users created an app account; 75 (60.0%) of these users recorded at least one BP reading and 47 (37.6%) completed at least one monitoring period. Through this work, we have demonstrated how a series of guidelines can be systematically translated into a mHealth platform for HBPM. Such platforms may be accessible resources to facilitate standardized HBPM and sharing of readings with providers.

Mobile health technology for hypertension management with Hmong and Latino adults: mixed-methods community-based participatory research

OBJECTIVE

To identify Hmong and Latino adults' perspectives about a mHealth-based care model for hypertension (HTN) management involving blood pressure (BP) self-monitoring, electronic transmission of BP readings, and responsive HTN medication adjustment by a provider team.

DESIGN

We conducted a mixed-methods formative study with 25 Hmong and 25 Latino participants with HTN at an urban federally-qualified health center. We used a tool to assess HTN knowledge and conducted open-ended interviews to identify perspectives about mHealth-based care model.

RESULTS

While most participants agreed that lowering high blood pressure decreased the risk of strokes, heart attacks, and kidney failure, there were gaps in medical knowledge. Three major themes emerged about the mHealth-based care model: (1) Using mHealth technology could be useful, especially if assistance was available to patients with technological challenges; (2) Knowing blood pressures could be helpful, especially to patients who agreed with doctors' medical diagnosis and prescribed treatment; (3) Transmitting blood pressures to the clinic and their responsive actions could feel empowering, and the sense of increased surveillance could feel entrapping. Some people may feel empowered since it could increase patient-provider communication without burden of clinic visits and could increase involvement in BP control for those who agree with the medical model of HTN. However, some people may feel entrapped as it could breach patient privacy, interfere with patients' lifestyle choices, and curtail patient autonomy.

CONCLUSIONS

In general, Hmong and Latino adults responded positively to the empowering aspects of the mHealth-based care model, but expressed caution for those who had limited technological knowledge, who did not agree with the medical model and who may feel entrapped. In a shared decision-making approach with patients and possibly their family members, health care systems and clinicians should explore barriers and potential issues of empowerment and entrapment when offering a mHealth care model in practice.

Hypertension management before and under the COVID-19 pandemic: lessons and future directions

Hypertension is a significant risk factor for cardiovascular diseases. The prevalence of hypertension and its complications is increasing yearly, yet it remains inadequately controlled worldwide. It has already been recognized that self-management, including self-measured blood pressure monitoring at home, is more important than office blood pressure monitoring. The practical application of telemedicine using digital technology was already underway. COVID-19 has promoted the popularization of these management systems in primary care, although the COVID-19 pandemic disrupted lifestyle and healthcare access. At the beginning of the pandemic, we were at the mercy of information on whether certain antihypertensive drugs, for example, might pose a risk of infection in the face of unknown infectious diseases. Over the past three years, however, much knowledge has been accumulated. It has been scientifically proven that there is no serious problem in managing hypertension in the same way as before the pandemic. That is to control blood pressure mainly through home blood pressure monitoring and continuing conventional drug therapy while modifying lifestyle. On the other hand, in the New Normal era, it is necessary to accelerate digital hypertension management and the establishment of new social networks and medical systems to prepare for the re-emergence of future pandemics while continuing to protect against infection. This review will summarize the lessons and future directions we learned from the impact of the COVID-19 pandemic on hypertension management. The COVID-19 pandemic has disrupted our daily life, restricted access to healthcare, and altered some of the conventional management of hypertension.

Improving Access to Home Blood Pressure Monitors at a Federally Qualified Health Center

Background: Self-monitoring of blood pressure (BP) clinically decreases BP. However, cost can limit access, especially in underserved populations. Objective: This mixed-methods pilot study aims to determine the impact of providing home BP monitors free of charge to patients at a federally qualified health center (FQHC) by quantifying the effect on BP and surveying patients to measure satisfaction and engagement. Methods: One hundred eighty patients with clinically diagnosed hypertension received BP monitors. Patient charts were reviewed to collect demographics and office BP readings 3 months before and after receiving a monitor. A 13-question phone survey was conducted to a sample of patients addressing satisfaction and engagement. Answers were based on a Likert scale and dichotomous yes/no. Results were analyzed with descriptive statistics and paired t tests. Results: The chart review demonstrated a significant mean decrease in systolic BP by 5.44 mm Hg ( P < 0.001, −8.03 to −2.84) and a mean decrease in diastolic BP by 2.70 mm Hg ( P < 0.001, −4.08 to −1.32) after the intervention. For those included who responded to the survey (13%), there was a significant mean increase in the frequency of checking BP per week by 1.5 Likert points ( P < 0.00001, −1.0 to −1.9), and a majority (57.8%) felt slightly or much more active in their health care in addition to other benefits. Conclusion: Providing BP monitors to FQHC patients free of charge may have contributed to a significantly decreased office BP, improved engagement, and satisfaction. This program removed cost barriers and allowed patients to be more active in their health care.

Status of ambulatory blood pressure monitoring and home blood pressure monitoring for the diagnosis and management of hypertension in the US: an up-to-date review

The diagnosis and management of hypertension has been based on the measurement of blood pressure (BP) in the office setting. However, data have demonstrated that BP may substantially differ when measured in the office than when measured outside the office setting. Higher out-of-office BP is associated with increased cardiovascular risk independent of office BP. Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are validated approaches for out-of-office BP measurement. In the 2015 and 2021 United States Preventive Services Task Force (USPSTF) reports on screening for hypertension, ABPM was recommended as the reference standard for out-of-office BP monitoring and for confirming an initial diagnosis of hypertension. This recommendation was based on data from more published studies of ABPM vs. HBPM on the predictive value of out-of-office BP independent of office BP. Therefore, HBPM was recommended as an alternative approach when ABPM was not available or well tolerated. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline recommended ABPM as the preferred initial approach for detecting white-coat hypertension and masked hypertension among adults not taking antihypertensive medication. In contrast, HBPM was recommended as the preferred initial approach for detecting the white-coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. The current review provides an overview of ABPM and HBPM in the US, including best practices, BP thresholds that should be used for the diagnosis and treatment of hypertension, barriers to widespread use of such monitoring, US guideline recommendations for ABPM and HBPM, and data supporting HBPM over ABPM.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

The Patient-Provider Gap: A Cross-sectional Survey to Understand Barriers and Motivating Factors for Home Blood Pressure Monitoring in a CKD Cohort

Background

Blood pressure (BP) management can decrease morbidity and mortality in chronic kidney disease (CKD) patients. Evidence-based hypertension guidelines endorse home BP monitoring (HBPM), and the growing use of virtual health has highlighted the need for HBPM. A comprehensive understanding of HBPM adoption in our province is lacking.

Objective

To identify the baseline practices, perspectives, barriers, and enablers in both providers and patients in our kidney care clinics regarding HBPM. Ultimately, this will inform the development of a provincial intervention that empowers providers to both increase patient understanding and equip them for accurate and reliable home BP measurement.

Design

Cross-sectional, descriptive study using online survey methodology.

Setting

Kidney care clinic network in the province of British Columbia, Canada.

Patients or Sample or Participants

Kidney care clinic staff and patients who perform HBPM.

Methods

Data were collected using semi-structured online surveys, one for staff and one for patients and/or caregivers. These surveys were developed by an interdisciplinary working group that included patient partners and addressed some key components of the implementation of an HBPM program (including perceived barriers to uptake, education, and adoption of best practices).

Results

In all, 46 patients and 43 staff responded to the survey from 16 kidney care clinics. Of the patients 53% were women, and the most common age range was 60 to 69 years (25%); 93% of the staff respondents were women and 63% were nurses. We identified numerous areas of discordance between providers and patients and the need for improvement from the perspective of implementing best practices from hypertension guidelines, both in staff teaching and patient usage of HBPM. Blood pressure targets were not known to 18% of patients and 39% of patients had received a BP target from their kidney care clinic team; 89% of patients had not had their upper arm circumference measured for cuff size. Furthermore, 54% of patients knew what to do when their BP is off-target. All recognized the benefits of HBPM, providers were more likely to perceive anxiety as a barrier relative to patients, and patients were more likely to report expense as a barrier than providers.

Limitations

This study includes only a single provincial health care system limiting generalizability to other jurisdictions and sampled a small subset of patients and providers.

Conclusions

The systematic evaluation of education, understanding, implementation of best practices, and barriers and motivating factors for HBPM from both patient and clinician perspectives is an important step in designing strategies to improve the use of HBPM. Given differences in staff and patient perspectives, targeted interventions based on these responses may lead to improved use of HBPM, and ultimately enhance hypertension self-management and BP control in our CKD patients.

Global proliferation and clinical consequences of non-validated automated BP devices

Professional societies, guideline writing committees, and other interested parties emphasize the importance of accurate measurement of blood pressure for clinical and public health decisions related to prevention, treatment, and follow-up of high blood pressure. Use of a clinically validated instrument to measure blood pressure is a central component of measurement accuracy and precision. Despite this, most regulatory authorities do not specify validation requirements that manufacturers must meet to sell their blood pressure measurement devices. Likewise, device validity is not a major area of focus for most consumers and healthcare providers, perhaps because they assume it is a pre-requisite for market approval. This has led to a global proliferation of non-validated blood pressure measurement devices, with only a small minority of blood pressure measurement devices having passed internationally accepted validation protocols. The clinical consequences are likely to be significant because non-validated devices are more likely to provide inaccurate estimates of blood pressure compared with validated devices. Even small inaccuracies in blood pressure measurement can result in substantial misdiagnosis and mistreatment of hypertension. There is an urgent need for clinical validation of blood pressure measurement devices prior to marketing them to consumers. There is also need for simplification of the process for consumers and healthcare providers to determine whether a blood pressure measurement device has successfully met an internationally accepted test of validity.

Barriers and Determinants to the Underutilized Hypertension Screening in Primary Care Patients in Hong Kong: A Mixed-Method Study

(1) Background: Hypertension (HT) is the most common chronic condition, affecting approximately 1.13 billion people worldwide. Despite freely available blood pressure (BP) devices in primary care (PC) clinics, many patients do not regularly screen for HT and are untreated. (2) Methods: This study investigated the proportion of PC patients who did not screen for HT and the underlying reasons in Hong Kong. An explanatory mixed-method cross-sectional study was conducted in 2020, which included a questionnaire survey, office BP measurements, and subsequent semi-structured interviews. Adult patients who had no diagnosis of HT were recruited in a large PC clinic by convenience sampling. The relationships between not having HT screening and sociodemographic data were investigated by logistic regression. Twenty-four patients were purposefully sampled (based on demographics) and were interviewed until data saturation. (3) Results: Among 428 participants, 190 (44.4%) had not had HT screening in the last two years, but 197 (46.0%) had HT. No HT screening in the last two years or ever was associated with being male, being single, being of younger age, having no family history of HT, having no clinic visits in the last two years, employment status, and self-perceived HT condition. Most participants (77.8%) misinterpreted their BP readings. Individual, social, and healthcare service barriers were identified in patients' interviews. Many PC patients had no regular HT screening but around half had elevated BP. (4) Conclusion: The study results indicate that the barriers to HT screening were multifactorial. HT screening in PC is urgently needed.

Adherence to unsupervised exercise in sedentary individuals: A randomised feasibility trial of two mobile health interventions

Introduction

Adherence to unsupervised exercise is poor, yet unsupervised exercise interventions are utilised in most healthcare settings. Thus, investigating novel ways to enhance adherence to unsupervised exercise is essential. This study aimed to examine the feasibility of two mobile health (mHealth) technology-supported exercise and physical activity (PA) interventions to increase adherence to unsupervised exercise.

Methods

Eighty-six participants were randomised to online resources (n = 44, females n = 29) or MOTIVATE (n = 42, females n = 28). The online resources group had access to booklets and videos to assist in performing a progressive exercise programme. MOTIVATE participants received exercise counselling sessions supported via mHealth biometrics which allowed instant participant feedback on exercise intensity, and communication with an exercise specialist. Heart rate (HR) monitoring, survey-reported exercise behaviour and accelerometer-derived PA were used to quantify adherence. Remote measurement techniques were used to assess anthropometrics, blood pressure, HbA1c and lipid profiles.

Results

HR-derived adherence rates were 22 ± 34% and 113 ± 68% in the online resources and MOTIVATE groups, respectively. Self-reported exercise behaviour demonstrated moderate (Cohen's d = 0.63, CI = 0.27 to 0.99) and large effects (Cohen's d = 0.88, CI = 0.49 to 1.26) in favour of online resources and MOTIVATE groups, respectively. When dropouts were included, 84% of remotely gathered data were available, with dropouts removed data availability was 94%.

Conclusion

Data suggest both interventions have a positive impact on adherence to unsupervised exercise but MOTIVATE enables participants to meet recommended exercise guidelines. Nevertheless, to maximise adherence to unsupervised exercise, future appropriately powered trials should explore the effectiveness of the MOTIVATE intervention.