Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland

How Is Telehealth Currently Being Utilized to Help in Hypertension Management within Primary Healthcare Settings? A Scoping Review

Telehealth has improved patient access to healthcare services and has been shown to have a positive impact in various healthcare settings. In any case, little is understood regarding the utilization of telehealth in hypertension management in primary healthcare (PHC) settings. This study aimed to identify and classify information about the types of interventions and types of telehealth technology in hypertension management in primary healthcare. A scoping review based on PRISMA-ScR was used in this study. We searched for articles in four databases: Pubmed, Scopus, Science Direct, and Embase in English. The selected articles were published in 2013-2023. The data were extracted, categorized, and analyzed using thematic analysis. There were 1142 articles identified and 42 articles included in this study. Regarding the proportions of studies showing varying trends in the last ten years, most studies came from the United States (US) (23.8%), were conducted in urban locations (33.3%), and had a quantitative study approach (69%). Telehealth interventions in hypertension management are dominated by telemonitoring followed by teleconsultation. Asynchronous telehealth is becoming the most widely used technology in managing hypertension in primary care settings. Telehealth in primary care hypertension management involves the use of telecommunications technology to monitor and manage blood pressure and provide medical advice and counselling remotely.

Qualitative evaluation of rapid implementation of remote blood pressure self-monitoring in pregnancy during Covid-19

In March 2020, the World Health Organisation named the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2), which causes corona virus disease 2019 (COVID -19), as a pandemic. Pregnant women were considered at increased risk of developing severe COVID-19 after viral infection. In response maternity services reduced face-to-face consultations with high-risk pregnant women by supplying blood pressure monitors for supported self-monitoring. This paper explores the experiences of patients and clinicians of the rapid roll-out of supported self-monitoring programme in Scotland during the first and second wave of the COVID-19 pandemic. We conducted semi-structured telephone interviews with high-risk women and healthcare professionals who were using supported self-monitoring of blood pressure (BP) In four case studies during the COVID-19 pandemic. 20 women, 15 midwives and 4 obstetricians took part in the interviews. Interviews with healthcare professionals showed that while implementation occurred at pace and at scale across the National Health Service (NHS) in Scotland, implementation differed locally, resulting in mixed experiences. Study Participants observed several barriers and facilitators to implementation. Women value the simplicity of use and convenience of the digital communications platforms while health professionals were more interested in their impact on reducing workload for both women and health professionals largely found self-monitoring acceptable, with only a few exceptions. These results show that rapid change can occur in the NHS at a national level when there is a shared motivation. While self-monitoring is acceptable to most women, decisions regarding self-monitoring should be made jointly and on an individual basis.

Blood Pressure and Chronic Kidney Disease Progression: An Updated Review

Hypertension (HTN) is common in chronic kidney disease (CKD), and it may aggravate CKD progression. The optimal blood pressure (BP) value in CKD patients is not established yet, although systolic BP ≤130 mmHg is acceptable as a target. Continuous BP monitoring is essential to detect the different variants of high BP and monitor the treatment response. Various methods of BP measurement in the clinic office and at home are currently used. One of these methods is ambulatory BP monitoring (ABPM), by which BP can be closely assessed for even diurnal changes.

We conducted a non-systematic literature review to explore and update the association between high BP and the course of CKD and to review various BP monitoring methods to determine the optimal method for BP recording in CKD patients. PubMed, EMBASE, Google, Google Scholar, and Web Science were searched for published reviews and original articles on BP and CKD by using various phrases and keywords such as "hypertension and CKD", "CKD progression and hypertension", "CKD stage and hypertension", "BP control in CKD", "BP measurement methods", "diurnal BP variation effect on CKD progression", and "types of hypertension." We evaluated and discussed published articles relevant to the review objective. Before preparing the final draft of this article, each author was assigned a section of the topic to read, research deeply, and write a summary about the assigned section. Then a summary of each author's contribution was collected and discussed in several group sessions.

Early detection of high BP is essential to prevent CKD development and progression. Although the latest Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest that a systolic BP ≤120 mmHg is the target toprevent CKD progression, systolic BP ≤130 mmHg is universally recommended.ABPM is a promising method to diagnose and follow up on BP control; however, the high cost of the new devices and patient unfamiliarity with them have proven to be major disadvantages with regard to this method.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Examining the effectiveness of telemonitoring with routinely acquired blood pressure data in primary care: challenges in the statistical analysis

Background

Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data.

Methods

Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6–12 months follow-up prior to analysis. The fourth analysis used linear mixed modelling based on all available data.

Results

The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6–12 months follow-up (-4.06, 95% CI -6.30 to -1.82, p < 0.001) for patients with systolic BP below 135 at baseline. For the standardisation with matching and regression adjustment for propensity score analyses, systolic BP was significantly lower overall (− 5.96, 95% CI -8.36 to − 3.55 , p < 0.001) and (− 3.73, 95% CI− 5.34 to − 2.13, p < 0.001) respectively, even after assuming that − 5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -3.37 (95% CI -5.41 to -1.33 , p < 0.001) after 1 year.

Conclusions

The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01219-8.

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.

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

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

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

The Association of Health Literacy with High-Quality Home Blood Pressure Monitoring for Hypertensive Patients in Outpatient Settings

Worldwide hypertension (HT) guidelines recommend use of home blood pressure monitoring (HBPM) in patients with persistent suboptimal blood pressure (BP) readings. It is not clear how patients with limited health literacy could perform HBPM to assist BP control. This study aimed at finding the association between HBPM and patients from lower socioeconomic classes, particularly on the effect of health literacy or educational level. Three electronic databases (MEDLINE, EMBASE, and PubMed) were searched for primary studies with keywords including educational level, health literacy, numeracy, home blood pressure monitoring, accuracy, and quality. The PRISMA guideline was followed. The quality of the literature was assessed by the Cochrane tool and modified Newcastle-Ottawa Scale. Nineteen interventional studies and 29 cross-sectional studies were included. Different populations used different cutoffs to report patients' educational level, whereas health literacy was rarely measured. Three studies used psychometric validated tools to assess health literacy. The quality of HBPM could be assessed by the completion of the procedures' checklist or the number of HBPM readings recorded. The association between subjects' health literacy or educational level and the quality of HBPM was variable. The interventional studies showed that increasing professional-patient contact time could improve patients' knowledge, efficacy, and quality of HBPM. Conclusion. Patients' educational level and literacy were not the limiting factors to acquire high-quality HBPM. High-quality HBPM could be achieved by the structured educational intervention. The quality and amount of evidence on this topic are limited. Therefore, further studies are warranted.

Contribution of telemedicine and information technology to hypertension control

Due to fast-paced technological advancements, digital health and telemedicine represent a promising and complex reality, with the potential to change the current management of hypertension and improve its outcomes. New types of health-related strategies are available, ranging from telemonitoring of blood pressure (BP) values to counseling for patients and decisional tools for physicians, thanks to the development of new technology. Even though the strength of available evidence is currently low due to the high heterogeneity of studies and of the proposed interventions, available data suggest a beneficial effect of digital health strategies on BP control and, more generally, on cardiovascular risk reduction. In addition, well-designed randomized controlled trials are needed to further investigate the real impact of these new strategies on clinical outcomes. Furthermore, due to consistent commercial interests in this field, there is a strong need for strict regulations to ensure a safe and secure implementation of this new reality in clinical care.

Effect of different ranges of systolic blood pressure on left ventricular structure and diastolic function in a Chinese population: a cross-sectional population-based Shunyi study

OBJECTIVES

To evaluate the effect of different ranges of systolic blood pressure (SBP) on left ventricular (LV) geometry and diastolic function in Chinese population.

DESIGN

Cross-sectional study.

SETTING

Peking Union Medical College Hospital in Beijing, China.

PARTICIPANTS

All inhabitants aged 35 years or older, living in five villages of Shunyi were invited. Exclusion criteria included individuals who declined participation, presence of moderate to severe valvular heart disease, persistent atrial fibrillation and suboptimal echocardiograms.

INTERVENTIONS

The baseline data of 1051 participants were analysed. The relationship between SBP and LV geometric and diastolic function assessed by echocardiography was analysed after adjusting for conventional cardiac risk factors.

RESULTS

The adjusted value of SBP was independently associated with LV hypertrophy (LVH) and LV diastolic dysfunction (LVDDF) (all p<0.01). Setting individuals with SBP <120 mm Hg as the reference group (group 1), those with SBP between 120 mm Hg and 140 mm Hg (group 2) had higher risk odds of LVH and those with SBP ≥140 mm Hg (group 3) had higher risk odds of LVH and LVDDF (all p<0.01). With the increase of SBP, LV mass index (LVMI) and E/e' stepwise increased and e' stepwise decreased significantly from group 1 to 3 (all p<0.05). In the whole population, SBP was independently correlated with LVMI, LVEDD, Left Atrial Volume Index, e', and E/e' (all p<0.01).

CONCLUSIONS

SBP was independently related to LVH and LVDDF, SBP between 120 and 140 mm Hg was independently related to worse LV remodelling and diastolic function, these findings indicated the potential benefit of intensive SBP control.

Development and Preliminary Feasibility of an Automated Hypertension Self-Management System

BACKGROUND

Uncontrolled hypertension constitutes a significant challenge throughout the world. Blood pressure measurement by patients is informative for both patients and providers but is rarely performed systematically, thereby reducing its utility. Mobile phones can be used to efficiently prompt individuals to measure blood pressure and automate data management while avoiding technology barriers to widespread adoption. Presented is the design and pilot test results of MyBP, an automated texting intervention to support blood pressure self-monitoring and patient self-management.

METHODS

Three sequential phases are described: (1) stakeholders' needs assessment, (2) preliminary design pilot (n = 10), and (3) a 6-week pilot of the redesigned comprehensive program with hypertensive patients (n = 43) recruited from 3 clinical sites (Emergency Department, Primary Care, Hypertension Center). Outcomes of interest included participant adherence, perceived importance of blood pressure monitoring, and healthy behavior change.

RESULTS

Median adherence to MyBP prompts over 6 weeks was 79% (72% emergency department, 84% primary care, and 96% hypertension center, H[2] = 5.56, P = .06). Adherence did not vary by age, sex, education, or baseline use of texting but was lowest among patients recruited from the emergency department (χ[2]2 = 6.66, P = .04). In the exit survey, MyBP was associated with increased importance of blood pressure self-monitoring and particularly motivated primary care and emergency department groups to improve dietary habits, increase daily physical activity, and focus on stress reduction. The majority of participants (88%) indicated interest in using the program for 6 months.

CONCLUSIONS

Automated mobile-phone-based blood pressure self-monitoring using MyBP is feasible, acceptable, and scalable, and may improve self-management and support clinical care.