Hypertension Subtypes among Thai Hypertensives: An Analysis of Telehealth-Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project

May Measurement Month 2021: an analysis of blood pressure screening results from Thailand

Blood pressure (BP) measurement is the mainstay for diagnosing and treating hypertension. Blood pressure screening in the May Measurement Month (MMM) project is helpful for the early detection of hypertension, which is usually asymptomatic. This study aimed to investigate the epidemiology of hypertension from data in the MMM21 project in Thailand. A cross-sectional study was conducted according to the MMM clinical study protocol for MMM21 in all regions of Thailand from August to November 2021. We included adults aged ≥18 years. Baseline characteristics, history of hypertension diagnosis, and treatment were collected through the questionnaires followed by three standardized BP measurements, 1 min apart. We included 10 940 participants with a mean age of 41.3 (SD ± 13.5) years. Only 6% never had their BP measured before. Of all participants, 30.2% had hypertension, and among this hypertensive population, 50.3% were aware, and 46.2% were taking antihypertensive medications. Of participants with hypertension, 31.6% had controlled BP (<140/90 mmHg), and BP control was 68.5% among those taking antihypertensive medication. The proportion of participants who had diabetes, were on aspirin, and were on statin were 6, 7.2, and 11.4%, respectively. Almost all participants (93.7%) had received at least one COVID-19 vaccination, and 8.0% reported a previous COVID-19 positive test. Most of the participants (97.4%) received hypertension care at no cost. Hypertension awareness and overall BP control rate were relatively low, while most subjects had previously had their BP checked. The widespread use of BP measurement may improve the diagnosis and treatment of hypertension to improve the care of those with hypertension in Thailand.

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

Prevalence and Clinical Characteristics including Patterns of Antihypertensive Drug Administration of the Different Home Blood Pressure Phenotypes in Treated Hypertensive Patients

Quality and quantity of home blood pressure (BP) control are important for optimizing hypertensive treatment. The prevalence and associated clinical characteristics of the different home blood pressure phenotypes in treated hypertensive patients were not elucidated. This study was conducted in Siriraj Hospital, Thailand from 2019 to 2020. We included treated hypertensive patients with ≥1 antihypertensive drug and had self-home BP measurement data. Both traditional (office BP < 140/90 mmHg and home BP < 130/80 mmHg) and new BP targets (office and home BP < 130/80 mmHg) were used for the classification of BP phenotypes. Home BP phenotypes consisted of controlled hypertension (all home BPs achieved home BP targets), isolated uncontrolled morning hypertension (MoHT) (only morning BP was above home BP targets), isolated uncontrolled evening hypertension (EHT) (only evening BP was above home BP targets), and combined morning-evening uncontrolled hypertension (MoEHT) (all home BPs were above home BP targets). Our study included 1,406 patients. The total mean age was 62.94 ± 13.97 years. There were 39.40% men. The prevalence of each home BP phenotype (by traditional BP target) was 55.76%, 12.66%, 7.40%, and 24.18% in controlled (home) hypertension, MoHT, EHT, and MoEHT, respectively. Classical BP control status was 35.21% well-controlled hypertension, 30.01% white-coat uncontrolled hypertension, 9.74% masked uncontrolled hypertension, and 25.04% sustained uncontrolled hypertension. The multivariable analysis showed the significantly associated factor of MoHT was the presence of previous cardiovascular disease (adjusted OR 5.54, 95% CI (2.02–15.22); $p$ value = 0.001). Taking once-daily long-acting antihypertensive drugs in the morning were significantly associated with both EHT (adjusted OR 0.20, 95% CI (0.05–0.82); $p$ value = 0.025) and MoEHT (adjusted OR 0.20, 95% CI (0.04–1.00); $p$ value = 0.049). These results were consistent in groups classified by new home BP target <130/80 mmHg.

Validation of Uright model TD 3127AT wireless-portable ambulatory blood pressure monitoring device with timer trigger modification, standard cuff size, in normotensive and mild hypertensive patients of Thailand registry (Thai valid ambulatory blood pressure monitoring)

BACKGROUND

Nowadays, automated blood pressure (BP) monitoring devices are commonly used by patients as a part of standard medical care for hypertension. The timer trigger was modified into a wireless automated home BP monitoring (HBPM) device to expand its potential use as ambulatory BP monitoring. However, the BP measurement accuracy in this modified device remains unknown.

OBJECTIVE

We aimed to assess the accuracy of Uright model TD 3127AT, which is an automated HBPM device with a timer trigger modification, following an International Organization for Standardization (ISO) 81060-2:2018 guidelines in the Thai population.

METHODS

This cross-sectional study included normotensive and hypertensive Thai participants following the ISO 81060-2:2018 guidelines from August 2021 to February 2022. This study aimed to compare the BP readings from an automated sphygmomanometer, Uright model TD 3127AT, TaiDoc Technology Corporation, with a timer trigger to a standard manual BP measurement.

RESULT

BPs were measured in 85 participants with a mean age ± SD of 38.39 ± 13.91 years, and 69% were females. The mean SBP ± SD (range) was 117.46 ± 18.63 (84-176) mmHg and the mean DBP ± SD (range) was 74.84 ± 10.70 (42-108) mmHg. The mean BP difference between observers and devices was 0.66 ± 6.81 mmHg for SBP and -0.96 ± 6.33 mmHg for DBP. The SD of the averaged pair determination per individual was ±4.45 mmHg for SBP and ±3.46 mmHg for DBP. The accuracy of the timer-triggered device was found to be acceptable when evaluated according to the ISO 81060-2: 2018 guidelines.

CONCLUSION

An automated sphygmomanometer, Uright model TD 3127AT, TaiDoc Technology Corporation, with timer trigger modification passed the ISO 81060-2:2018 guidelines.

2022 Thai Hypertension Society guidelines on home blood pressure monitoring

In 2021, the Universal Health Coverage Payment Scheme of Thailand approved home blood pressure monitoring (HBPM) devices for reimbursement. National utilization of HBPM devices will begin in 2022. This article provides the recommendations for HBPM from the Thai Hypertension Society. In this report, the authors review the benefits of HBPM and recommend confirming the diagnosis of hypertension by HBPM. Devices for HBPM should be the automated and validated upper arm cuff devices. HBPM should be ideally done for seven consecutive days before each clinic visit and take at least two readings (1 min apart) in the morning and before going to bed. The average blood pressure (BP) of 125-134/75-84 mmHg is classified as high normal BP and hypertension is BP of 135/85 mmHg or more. Target BP levels depend on the age of the patients; that is, < 125/75 mmHg for patients aged 18-65 years old, and <135/85 mmHg for patients over 65 years of age.

Comparison of measured blood pressure levels, hypertension history, oral diseases, and associated factors among Thai dental patients

PURPOSE

To compare blood pressure (BP), hypertension (HT) history, oral diseases, and potentially associated factors among dental patients in Thailand and explore the associations among them.

METHODS

This study included 709 patients. Demographic data, BP levels, oral diseases, xerostomia, anxiety, depression, and associated factors were evaluated.

RESULTS

One-third of the patients were male; patients with a history of HT were older than those without (P < 0.001). In total, 53 (7.5%) had such a history, and HT was controlled in 29 (54.7%) of them. Patients with possible HT (BP ≥140/90 mmHg; 94 in total, 13.3%) were five times more likely to have a definitive diagnosis of HT than those without possible HT (odd ratio [OR] = 4.95; 95% confidence interval [CI]: 2.76-8.87; P < 0.001). They also had an increased tendency to be taking antidyslipidemic (OR = 5.54; 95% CI: 2.90-10.60; P = 0.001) or antidiabetic (OR = 4.80; 95% CI: 1.91-12.08; P = 0.001) drugs. Male sex (ß = 0.156, P < 0.001), higher age (ß = 0.299, P < 0.001), higher body mass index (ß = 0.410, P < 0.001), and periapical tissue diseases (ß = 0.073, P = 0.019) were significantly associated with elevated systolic BP. Severe periodontitis (ß = 0.081, P = 0.023) and a comparable association pattern with systolic BP were related to diastolic BP. Multivariate analysis revealed no significant association between BP and tooth loss, xerostomia, smoking, education level, anxiety, or depression.

CONCLUSION

Dentists play an essential role in screening for undiagnosed and uncontrolled HT. Significant associations were noted between oral inflammatory diseases and high BP.

An Implementation Framework for Telemedicine to Address Noncommunicable Diseases in Thailand

To maintain the continuity of noncommunicable disease (NCD) services and ascertain the health outcomes of patients with NCDs during the COVID-19 (coronavirus disease 2019) outbreak in Thailand, various telemedicine services have been developed. To achieve this determination, the implementation framework has been constructed based on recommendations from multidisciplinary experts (Thai NCD Collaboration Group). Within the framework, all key elements are illustrated with their priority and expected collaborations. Ultimately, active collaborations from multi-stakeholders are vitally important to ensure that telemedicine services for NCDs will finally become practical, successful, and sustainable.

Home Blood Pressure Control and Drug Prescription Patterns among Thai Hypertensives: A 1-Year Analysis of Telehealth Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project

Background

Several interventions have been proposed to improve hypertension control with various outcomes. The home blood pressure (HBP) measurement is widely accepted for assessing the response to medications. However, the enhancement of blood pressure (BP) control with HBP telemonitoring technology has yet to be studied in Thailand.

Objective

To evaluate the attainment of HBP control and drug prescription patterns in Thai hypertensives at one year after initiating the TeleHealth Assisted Instrument in Home Blood Pressure Monitoring (THAI HBPM) nationwide pilot project.

Methods

A multicenter, prospective study enrolled treated hypertensive adults without prior regular HBPM to obtain monthly self-measured HBP using the same validated, oscillometric telemonitoring devices. The HBP reading was transferred to the clinic via a cloud-based system, so the physicians can adjust the medications at each follow-up visit on a real-life basis. Controlled HBP is defined as having HBP data at one year of follow-up within the defined target range (<135/85 mmHg).

Results

A total of 1,177 patients (mean age 58 ± 12.3 years, 59.4% women, 13.1% with diabetes) from 46 hospitals (81.5% primary care centers) were enrolled in the study. The mean clinic BP was 143.9 ± 18.1/84.3 ± 11.9 mmHg while the mean HBP was 134.4 ± 15.3/80.1 ± 9.4 mmHg with 609 (51.8%) patients having HBP reading <135/85 mmHg at enrollment. At one year of follow-up after implementing the HBP telemonitoring, 671 patients (57.0%) achieved HBP control. Patients with uncontrolled HBP had a higher prevalence of dyslipidemia and greater waist circumference than the controlled group. The majority of uncontrolled patients were still prescribed only one (36.0%) or two drugs (34.4%) at the end of the study. The antihypertensive drugs were not uptitrated in 136 (24%) patients with uncontrolled HBP at baseline. Calcium channel blocker was the most prescribed drug class (63.0%) followed by angiotensin-converting enzyme inhibitor (44.8%) while the thiazide-type diuretic was used in 18.9% of patients with controlled HBP and 16.4% in uncontrolled patients.

Conclusion

With the implementation of HBP telemonitoring, the BP control rate based on HBP analysis was still low. This is possibly attributed to the therapeutic inertia of healthcare physicians. Calcium channel blocker was the most frequently used agent while the diuretic was underutilized. The long-term clinical benefit of overcoming therapeutic inertia alongside HBP telemonitoring needs to be validated in a future study.

READINESS ASSESSMENT OF PATIENTS WITH ARTERIAL HYPERTENSION TO THE APPLICATION OF TELEMEDICAL TECHNOLOGIES

This article presents original data on patients' awareness of arterial hypertension and their readiness to use telemedicine technologies. The aim: to study the factors that may affect the effectiveness of diagnosis and treatment of patients with arterial hypertension (AH) through the use of telemedicine technologies. Materials and methods: this study involves 336 outpatients and indoor patients diagnosed with arterial hypertension. Anonymously, using a questionnaire, were assessed patients' awareness of their diagnosis, access to the Internet, and the ability to remotely control of blood pressure. Results: only about a third of all respondents systematically took the recommended antihypertensive therapy daily. Among them, the vast majority were indoor patients (82 %). We found a direct dependence between the regularity to use the antihypertensive therapy and the interest in the use of telemonitoring of blood pressure (Spearman correlation coefficient +0.59). There is a low awareness of patients about the possibilities of remote monitoring of blood pressure (only 11 %), the vast majority of patients (60 %) for the first time learned about such technologies. Among our respondents, a statistically significant dependence was found between the age of patients and interest in telemonitoring blood pressure at a significance level of p<0.01 (χ2 – 26.119, and the critical value of χ2 significance level p=0.01 is 9.21). Conclusions: the main sources of information for patients with arterial hypertension are primary care physicians (family doctors, therapists) and the Internet. Limited access of patients to the Internet can negatively affect over introduction of telemedicine technologies for the management of arterial hypertension, despite the great interest of patients and society.