Hypertension management in the digital era

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.

Blood Pressure Monitoring as a Digital Health Tool for Improving Diabetes Clinical Outcomes: Retrospective Real-world Study

BACKGROUND

Remote data capture for blood glucose (BG) or blood pressure (BP) monitoring and the use of a supportive digital app are becoming the model in diabetes and hypertension chronic care. One of the goals in chronic condition management is to increase awareness and generate behavioral change in order to improve outcomes in diabetes and related comorbidities, such as hypertension. In addition, there is a lack of understanding of the association between BG and BP levels when using digital health tools.

OBJECTIVE

By applying a rigorous study framework to digital health data, this study investigated the relationship between BP monitoring and BG and BP levels, as well as a lagged association between BP and BG. We hypothesized that during the first 6 months of BP monitoring, BG and BP levels would decrease. Finally, we suggested a positive association between BP levels and the following month's BG levels.

METHODS

In this retrospective, real-world case-control study, we extracted the data of 269 people with type 2 diabetes (T2D) who tracked their BG levels using the Dario digital platform for a chronic condition. We analyzed the digital data of the users who, in addition to BG, monitored their BP using the same app (BP-monitoring [BPM] group, n=137) 6 months before and after starting their BP monitoring. Propensity score matching established a control group, no blood pressure monitoring (NBPM, n=132), matched on demographic and baseline clinical measures to the BPM group. A piecewise mixed model was used for analyzing the time trajectories of BG, BP, and their lagged association.

RESULTS

Analysis revealed a significant difference in BG time trajectories associated with BP monitoring in BPM and NBPM groups (t=-2.12, P=.03). The BPM group demonstrated BG reduction improvement in the monthly average BG levels during the first 6 months (t=-3.57, P<.001), while BG did not change for the NBPM group (t=0.39, P=.70). Both groups showed similarly stable BG time trajectories (B=0.98, t=1.16, P=.25) before starting the use of the BP-monitoring system. In addition, the BPM group showed a significant reduction in systolic (t=-6.42, P<.001) and diastolic (t=-4.80, P<.001) BP during the first 6 months of BP monitoring. Finally, BG levels were positively associated with systolic (B=0.24, t=2.77, P=.001) and diastolic (B=0.30, t=2.41, P=.02) BP.

CONCLUSIONS

The results of this study shed light on the association between BG and BP levels and on the role of BP self-monitoring in diabetes management. Our findings also underscore the need and provide a basis for a comprehensive approach to understanding the mechanism of BP regulation associated with BG.

New aspects in the management of hypertension in the digital era

PURPOSE OF REVIEW

Hypertension (HTN) is the most common chronic disease impacting over half the US adult population. Our current office-based model of care is failing in its ability to control blood pressure (BP) as only 44% of adult US hypertensives are achieving minimal levels of BP control (< 140/90 mmHg), leading to high rates of preventable cardiovascular events and death.

RECENT FINDINGS

Reengineering care delivery using a fully digital platform combined with a dedicated team-based approach to HTN management has demonstrated superior BP control rates, very high levels patient acceptance, and the ability to better diagnose and treat masked and white coat HTN.

SUMMARY

A digital medicine program in the clinical care setting can be an effective and convenient mechanism of delivering HTN management, outperforming traditional office-based care, and is well accepted by patients.

Value-based approach to blood pressure telemonitoring and remote counseling in hypertensive patients

PURPOSE

Blood pressure telemonitoring and remote counselling (BPTM) improves blood pressure (BP) control in patients with hypertension (HTN). Studies assessing the efficacy of BPTM from a value-based perspective are lacking. We investigated whether BPTM fits all principles of the value-based approach (clinical and economic effectiveness, improvement in patient-reported outcome/experience measures (PROM/PREM)).

MATERIALS AND METHODS

Two hundred and forty ambulatory patients with uncontrolled HTN were randomised in a 2: 1 manner to BPTM (n = 160, mean age 47 y.o.) and usual care (UC, n = 80; 49 y.o.) with baseline and 3-month follow-up clinic visits. BPTM employed a mobile application (for patients) and a desktop version (for clinician), which allowed communication and exchange of medical data. The main outcomes were changes in office and ambulatory systolic (S) BPs, rate of BP control. The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were evaluated in economic analysis. The MOS SF-36 score was taken as a PROM, and the PEQ score was used as a PREM.

RESULTS

Larger decreases in office and ambulatory SBPs (-16.8 and -8.9 mm Hg, respectively; p < .05) was achieved in BPTM group while the treatment intensity was equal (2.4 drugs). The ICER 11.1 EUR/-1 mm Hg 24-hour SBP/1 year was 75% effective as per willingness-to-pay threshold. BPTM improved PROM (+2.1 in mean MOS SF-36; p = .04), reduced long-term mortality (+0.11 life years gained), leading to +0.49 quality-adjusted life years (QALYs) gained as compared with UC. The ICUR was 4 169.4 EUR/QALY gained. Patient-reported experience was higher in the BPTM (+10 PEQ, p = .01). The UC group showed minor changes in MOS SF-36 and PEQ (+1.3; +6, respectively; p n.s.).

CONCLUSIONS

Being cost-effective, BPTM incorporates both clinical benefits and patient-perceived value. Larger randomised studies are needed to confirm our findings.

Digital Management of Hypertension Improves Systolic Blood Pressure Variability

BACKGROUND

Higher systolic blood pressure variability has been shown to be a better predictor of all-cause and cardiovascular disease mortality, stroke, and cardiac disease compared with average systolic blood pressure.

METHODS

We evaluated the impact of a digital hypertension program on systolic blood pressure variability in 803 consecutive patients with long-standing hypertension who had been under the care of a primary care physician for a minimum of 12 months prior to enrollment (mean 4.7 years). Blood pressure readings were transmitted directly from home using a digitally connected blood pressure unit. Medication adjustments and lifestyle coaching was performed virtually via a dedicated team of pharmacists and health coaches. Systolic blood pressure variability was grouped by quartile and measured using the standard deviation (SD) of all systolic blood pressure values per individual.

RESULTS

The mean age was 67 ± 12 years, 41% were male, submitting 3.3 ± 3.7 blood pressures per week. Under usual care, only 30% of patients were in the lowest-risk quartile, and 21% of patients were in the highest risk. After 24 months, the mean systolic blood pressure variability progressively fell from 12.8 ± 4.3 mm Hg to 9.9 ± 5.1 mm Hg (P <0.0001) with 57% of patients achieving the lowest-risk quartile.

CONCLUSIONS

The majority of patients with hypertension under usual care have elevated systolic blood pressure variability exposing them to higher risk of cardiovascular disease events. Digital management of hypertension that includes weekly submission of home readings leads to improvement in average systolic blood pressure as well as systolic blood pressure variability over time, which should improve cardiovascular prognosis.

Clinical inertia in hypertension: a new holistic and practical concept within the cardiovascular continuum and clinical care process

Purpose: Recognition of clinical inertia is essential to improve the control of chronic diseases. Although it is very intuitive, a better interpretation of the concept of clinical inertia is lacking, likely due to its high complexity. Materials and Methods: After a review of the published articles, we propose a practical vision of inertia, contextualized within the clinical process of hypertension care. Results: This new vision enables the integration of previous terms and definitions of clinical inertia, as well as proposing specific strategies for its reduction. Conclusion: Although some concepts should be considered as 'justified inertia' or 'investigator inertia', the idea that inertia may be present throughout the continuum of care gives physicians a holistic view of the problem that is easily applicable to their clinical practice. Measures to overcome inertia are complicated because of the intrinsic complexity of the concept.