Cost-Effectiveness of Telemonitoring and Self-Monitoring of Blood Pressure for Antihypertensive Titration in Primary Care (TASMINH4)

Rapid implementation of blood pressure self-monitoring in pregnancy at a UK NHS Trust during the COVID-19 pandemic: a quality improvement evaluation

BACKGROUND

This service evaluation describes the rapid implementation of self-monitoring of blood pressure (SMBP) into maternity care at a tertiary referral centre during the COVID-19 pandemic. It summarises findings, identifies knowledge gaps and provides recommendations for further research and practice.

INTERVENTION

Pregnant and postpartum women monitored their blood pressure (BP) at home, with instructions on actions to take if their BP exceeded pre-determined thresholds. Some also conducted proteinuria self-testing.

DATA COLLECTION AND ANALYSIS

Maternity records, app data and staff feedback were used in interim evaluations to assess process effectiveness and guide adjustments, employing a Plan-Do-Study-Act and root cause analysis approach.

RESULTS

Between March 2020 and August 2021, a total of 605 women agreed to self-monitor their BP, including 10 women with limited English. 491 registered for telemonitoring (81.2%). 21 (3.5%) took part in urine self-testing. Engagement was high and increased over time with no safety issues. Biggest concerns related to monitor supply and postnatal monitoring. In December 2020, SMBP was integrated into the standard maternity care pathway.

CONCLUSIONS

This project demonstrated successful integration of SMBP into maternity care. Early stakeholder engagement and clear guidance were crucial and community midwifery support essential. Supplying BP monitors throughout pregnancy and post partum could improve the service and fully digitised maternity records would aid data collection. More research is needed on SMBP in the postnatal period and among non-English speakers. These findings support efforts to implement app-supported self-monitoring and guide future research.

Cost-Effectiveness of Routine Monitoring of Long-Term Conditions in Primary Care: Informing Decision Modelling with a Systematic Review in Hypertension, Type 2 Diabetes and Chronic Kidney Disease

BACKGROUND

Long-term conditions (LTCs) are major public health problems with a considerable health-related and economic burden. Modelling is key in assessing costs and benefits of different disease management strategies, including routine monitoring, in the conditions of hypertension, type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) in primary care.

OBJECTIVE

This review aimed to identify published model-based cost-effectiveness studies of routine laboratory testing strategies in these LTCs to inform a model evaluating the cost effectiveness of testing strategies in the UK.

METHODS

We searched the Medline and Embase databases from inception to July 2023; the National Institute for Health and Care Institute (NICE) website was also searched. Studies were included if they were model-based economic evaluations, evaluated testing strategies, assessed regular testing, and considered adults aged >16 years. Studies identified were summarised by testing strategies, model type, structure, inputs, assessment of uncertainty, and conclusions drawn.

RESULTS

Five studies were included in the review, i.e. Markov (n = 3) and microsimulation (n = 2) models. Models were applied within T2DM (n = 2), hypertension (n = 1), T2DM/hypertension (n = 1) and CKD (n = 1). Comorbidity between all three LTCs was modelled to varying extents. All studies used a lifetime horizon, except for a 10-year horizon T2DM model, and all used quality-adjusted life-years as the effectiveness outcome, except a TD2M model that used glycaemic control. No studies explicitly provided a rationale for their selected modelling approach. UK models were available for diabetes and CKD, but these compared only a limited set of routine monitoring tests and frequencies.

CONCLUSIONS

There were few studies comparing routine testing strategies in the UK, indicating a need to develop a novel model in all three LTCs. Justification for the modelling technique of the identified studies was lacking. Markov and microsimulation models, with and without comorbidities, were used; however, the findings of this review can provide data sources and inform modelling approaches for evaluating the cost effectiveness of testing strategies in all three LTCs.

Detection and Control of Pregnancy Hypertension Using Self-Monitoring of Blood Pressure With Automated Telemonitoring: Cost Analyses of the BUMP Randomized Trials

BACKGROUND

Pregnancy hypertension continues to cause maternal and perinatal morbidity. Two linked UK randomized trials showed adding self-monitoring of blood pressure (SMBP) with automated telemonitoring to usual antenatal care did not result in earlier detection or better control of pregnancy hypertension. This article reports the trials' integrated cost analyses.

METHODS

Two cost analyses. SMBP with usual care was compared with usual care alone in pregnant individuals at risk of hypertension (BUMP 1 trial [Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension], n=2441) and with hypertension (BUMP 2 trial, n=850). Clinical notes review identified participant-level antenatal, intrapartum, and postnatal care and these were costed. Comparisons between trial arms used means and 95% CIs. Within BUMP 2, chronic and gestational hypertension cohorts were analyzed separately. Telemonitoring system costs were reported separately.

RESULTS

In BUMP 1, mean (SE) total costs with SMBP and with usual care were £7200 (£323) and £7063 (£245), respectively, mean difference (95% CI), £151 (-£633 to £936). For the BUMP 2 chronic hypertension cohort, corresponding figures were £13 384 (£1230), £12 614 (£1081), mean difference £323 (-£2904 to £3549) and for the gestational hypertension cohort were £11 456 (£901), £11 145 (£959), mean difference £41 (-£2486 to £2567). The per-person cost of telemonitoring was £6 in BUMP 1 and £29 in BUMP 2.

CONCLUSIONS

SMBP was not associated with changes in the cost of health care contacts for individuals at risk of, or with, pregnancy hypertension. This is reassuring as SMBP in pregnancy is widely prevalent, particularly because of the COVID-19 pandemic.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334149.

Bottom-Up Analysis of Telemonitoring Costs: A Case Study in Slovenian Primary Care

Introduction

Telemonitoring improves clinical outcomes in patients with arterial hypertension (AH) and type 2 diabetes (T2D), however, cost structure analyses are lacking. This study seeks to explore the cost structure of telemonitoring for the elderly with AH and T2D in primary care and identify factors influencing costs for potential future expansions.

Methods

Infrastructure, operational, patient participation, and out-of-pocket costs were determined using a bottom-up approach. Infrastructure costs were determined by dividing equipment and telemonitoring platform expenses by the number of participants. Operational and patient participation costs were determined by considering patient training time, data measurement/review time, and teleconsultation time. The change in out-of-pocket costs was assessed in both groups using a structured questionnaire and 12-month expenditure data. Statistical analysis employed an unpaired sample t-test, Mann-Whitney U test, and chi-square test.

Results

A total of 117 patients aged 71.4±4.7 years were included in the study. The telemonitoring intervention incurred an annual infrastructure costs of €489.4 and operational costs of €97.3 (95% CI 85.7-109.0) per patient. Patient annual participation costs were €215.6 (95% CI 190.9-241.1). Average annual out-of-pocket costs for both groups were €345 (95% CI 221-469). After 12 months the telemonitoring group reported significantly lower out-of-pocket costs (€132 vs. €545, p<0.001), driven by reduced spending on food, dietary supplements, medical equipment, and specialist check-ups compared to the standard care group.

Conclusion

To optimise the cost structure of telemonitoring, strategies like shortening the telemonitoring period, developing a national telemonitoring platform, using patient devices, integrating artificial intelligence into platforms, and involving nurse practitioners as telemedicine centre coordinators should be explored.

Exploring the patient experience of remote hypertension management in Scotland during COVID-19: a qualitative study

OBJECTIVES

The aim of this study was to understand how patients experienced hypertension management, with or without blood pressure (BP) telemonitoring, during the COVID-19 pandemic.

DESIGN, METHODS, PARTICIPANTS AND SETTING

This qualitative study conducted between April and November 2022 consisted of 43 semistructured telephone interviews (23 men and 20 women) from 6 primary care practices in one area of Scotland.

RESULTS

From the views of 25 participants with experience of using the Connect Me telemonitoring service and 18 participants without such experience, 5 themes were developed. These were: (1) navigating access to services. There were challenges to gaining timely and/or in-person access to services and a reluctance to attend clinical settings because participants were aware of their increased risk of contracting the COVID-19 virus. (2) Adapting National Health Service services. All six practices had adapted care provision in response to potential COVID-19 transmission; however, these adaptations disrupted routine management of in-person primary care hypertension, diabetes and/or asthma checks. (3) Telemonitoring feedback. Telemonitoring reduced the need to attend in-person primary care practices and supported access to remote healthcare monitoring and feedback. (4) Self-management. Many non-telemonitoring participants were motivated to use self-management strategies to track their BP using home monitoring equipment. Also, participants were empowered to self-manage lifestyle and hypertension medication. (5) Experience of having COVID-19. Some participants contracting the COVID-19 virus experienced an immediate increase in their BP while a few experienced ongoing increased BP readings.

CONCLUSIONS

The COVID-19 pandemic disrupted routine in-person care for patients with hypertension. Both telemonitoring and some non-telemonitoring patients were motivated to self-manage hypertension, including self-adjusting medication; however, only those with access to telemonitoring had increased access to hypertension monitoring and feedback. BP telemonitoring permitted routine care to continue for participants in this study and may offer a service useful in pandemic proofing hypertension healthcare in the future.

Economic Evaluation of Blood Pressure Monitoring Techniques in Patients With Hypertension: A Systematic Review

Importance

Blood pressure monitoring is critical to the timely diagnosis and treatment of hypertension. At-home self-monitoring techniques are highly effective in managing high blood pressure; however, evidence regarding the cost-effectiveness of at-home self-monitoring compared with traditional monitoring in clinical settings remains unclear.

Objective

To identify and synthesize published research examining the cost-effectiveness of at-home blood pressure self-monitoring relative to monitoring in a clinical setting among patients with hypertension.

Evidence Review

A systematic literature search of 5 databases (PubMed, MEDLINE, Embase, EconLit, and CINAHL) followed by a backward citation search was conducted in September 2022. Full-text, peer-reviewed articles in English including patients with high blood pressure (systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg) at baseline were included. Data from studies comparing at-home self-monitoring with clinical-setting monitoring alternatives were extracted, and the outcomes of interest included incremental cost-effectiveness and cost-utility ratios. Non-peer-reviewed studies or studies with pregnant women and children were excluded. To ensure accuracy and reliability, 2 authors independently evaluated all articles for eligibility and extracted relevant data from the selected articles.

Findings

Of 1607 articles identified from 5 databases, 16 studies met the inclusion criteria. Most studies were conducted in the US (6 [40%]) and in the UK (6 [40%]), and almost all studies (14 [90%]) used a health care insurance system perspective to determine costs. Nearly half the studies used quality-adjusted life-years gained and cost per 1-mm Hg reduction in blood pressure as outcomes. Overall, at-home blood pressure monitoring (HBPM) was found to be more cost-effective than monitoring in a clinical setting, particularly over a minimum 10-year time horizon. Among studies comparing HBPM alone vs 24-hour ambulatory blood pressure monitoring (ABPM) or HBPM combined with additional support or team-based care, the latter were found to be more cost-effective.

Conclusions and Relevance

In this systematic review, at-home blood pressure self-monitoring, particularly using automatic 24-hour continuous blood pressure measurements or combined with additional support or team-based care, demonstrated the potential to be cost-effective long-term compared with care in the physical clinical setting and could thus be prioritized for patients with hypertension from a cost-effectiveness standpoint.

Telemonitoring for health education and self-management in South Western Sydney

BACKGROUND

Telemonitoring (TM) plays an important role in the self-management of chronic diseases. This study aimed to assess the feasibility of TM in early stages of chronic care for self-management and recognition of signs and symptoms of exacerbation, with a view to completing the TM program in an optimal timeframe to encourage independence and self-management.

METHODS

This study was conducted from 2019 to 2020. Included in the study were patients with chronic conditions at an early stage of their disease residing in the South Western Sydney region. Eligible patients were allocated a TM device for 6months. Their routine tests data were sent in real time to health care professionals. Following assessment by a TM coordinator, suitable patients were off-boarded (deactivation of monitoring device) after 6months. Data on hospitalisation/emergency department presentation and surveys were collected to assess the impact of TM on the level of the patient's understanding of their signs and symptoms of exacerbation, self-care, and quality of life.

RESULTS

Out of 44 patients approached, seven were off-boarded at the 6-month timeframe. The follow-up data on the hospitalisation/emergency department presentation during monitoring and 12months post off-boarding showed a reduction in the frequency of hospitalisation/nil admissions. Patients reported an increased understanding of their health condition and confidence in managing their own health with the support of TM.

CONCLUSION

The result demonstrates the feasibility of TM as a tool for health education and self-management in the coordination of care for chronic disease patients; however, the small sample size was a limitation.

Economics of Team-Based Care for Blood Pressure Control: Updated Community Guide Systematic Review

INTRODUCTION

This paper examined the recent evidence from economic evaluations of team-based care for controlling high blood pressure.

METHODS

The search covered studies published from January 2011 through January 2021 and was limited to those based in the U.S. and other high-income countries. This yielded 35 studies: 23 based in the U.S. and 12 based in other high-income countries. Analyses were conducted from May 2021 through February 2023. All monetary values reported are in 2020 U.S. dollars.

RESULTS

The median intervention cost per patient per year was $438 for U.S. studies and $299 for all studies. The median change in healthcare cost per patient per year after the intervention was -$140 for both U.S. studies and for all studies. The median net cost per patient per year was $439 for U.S. studies and $133 for all studies. The median cost per quality-adjusted life year gained was $12,897 for U.S. studies and $15,202 for all studies, which are below a conservative benchmark of $50,000 for cost-effectiveness.

DISCUSSION

Intervention cost and net cost were higher in the U.S. than in other high-income countries. Healthcare cost averted did not exceed intervention cost in most studies. The evidence shows that team-based care for blood pressure control is cost-effective, reaffirming the favorable cost-effectiveness conclusion reached in the 2015 systematic review.

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.

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.

Person-centered and measured life's simple 7 cardiovascular health concordance and association with incident cardiovascular disease

Person-centered cardiovascular health (CVH) may facilitate cardiovascular disease primordial prevention in low resources settings. The study aims to assess the validity of person-centered CVH compared to gold standard measured CVH by examining the concordance between person-centered vs. measured CVH together with their respective association with incident cardiovascular disease events (CVD). Life's Simple 7 (LS7) CVH metrics, including non-smoking, Body Mass Index, diet, physical activity, blood glycemia, blood pressure, and blood cholesterol were collected from 19,473 adults participating in the e-cohort NutriNet-Santé study from 2011 to 2014 and were followed until September 2020. Clinical examinations and blood analyses defined the measured biological metrics, while diagnoses, medication, or treatment for type 2 diabetes, hypertension, and hypercholesterolemia defined person-centered biological metrics. Declared behavioral metrics were common for both measured and person-centered CVH. The study included 18,714 CVD-free participants (mean age 51 years, 73% women), among whom 16.52% and 38.75% had 5-7 ideal LS7 metrics according to measured and person-centered CVH, respectively. Weighted concordance of person-centered and measured CVH was 0.87 [0.86; 0.88]. Over median follow-up of 8.05 years, 749 CVD events occurred. There was a 7% (HR 0.93 [0.88; 0.99]) and 13% (HR 0.87 [0.83; 0.92]) risk reduction of CVD risk by additional measured and person-centered ideal metrics, respectively. In conclusion, person-centered CVH may represent a reliable alternative to measured CVH.

M. Anderson C. Healthcare Provider’s Perspectives on Home Blood Pressure Management in Peru and Cameroon: Findings from the BPMONITOR Study

Home blood pressure management, including self-monitoring and medication self-titration, is an efficient and cost-effective tool. Although its use is increasing globally, little is known about the feasibility of such interventions in low and middle-income countries. Further, the perspectives and experiences of healthcare providers who play a big role in ensuring the success of home blood pressure management interventions have not been documented. This qualitative study was conducted with a total of 35 healthcare providers (60% female, mean [SD] age = 37.3 [6.9 years] years), through 4 in-depth interviews from Peru, and 8 in-depth interviews and 4 focus groups from Cameroon. Study participants (healthcare providers) include physicians (primary care physicians), specialists (cardiologists and geriatricians), and nurses that were purposively recruited from two hospitals in two of the largest cities in both countries. Results were thematically analyzed by two researchers. Themes derived were related to feasibility and acceptability, and largely reflected providers in both countries endorsing home blood pressure management. Providers' concerns were in three main areas; 1) safety of patients when they self-titrate medications, 2) resources such as healthcare financing, local hospital policies that support communications with patients for home blood pressure management, and 3) sustainability through patient adherence, incorporating home blood pressure management within clinical guidelines and hospital policies, and complementing with continued health education and lifestyle modifications. According to providers, home blood pressure management may be feasible and acceptable if tailored multi-faceted protocols were introduced bearing in mind local contexts.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions have shown promising results for the management of type 2 diabetes, but a comparison of the effectiveness and implementation of the different modes is not currently available. Therefore, this study aimed to compare the effectiveness of SMS, smartphone application, and website-based interventions on improving glycaemia in adults with type 2 diabetes and report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis, we searched CINAHL, Cochrane Central, Embase, MEDLINE, and PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) that examined the effectiveness of digital health interventions in reducing glycated haemoglobin A1c (HbA1c) in adults with type 2 diabetes, published in English from Jan 1, 2009. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint assessed was the change in the mean (and 95% CI) plasma concentration of HbA1c at 3 months or more. Cochrane risk of bias 2 was used to assess risk of bias. Data on reach, uptake, and feasibility were summarised narratively and data on HbA1c reduction were synthesised in a meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation criteria was used to evaluate the level of evidence. The study was registered with PROSPERO, CRD42021247845.

FINDINGS

Of the 3236 records identified, 56 RCTs from 24 regions (n=11 486 participants), were included in the narrative synthesis, and 26 studies (n=4546 participants) in the meta-analysis. 20 studies used SMS as the primary mode of delivery of the digital health intervention, 25 used smartphone applications, and 11 implemented interventions via websites. Smartphone application interventions reported higher reach compared with SMS and website-based interventions, but website-based interventions reported higher uptake compared with SMS and smartphone application interventions. Effective interventions, in general, included people with greater severity of their condition at baseline (ie, higher HbA1c) and administration of a higher dose intensity of the intervention, such as more frequent use of smartphone applications. Overall, digital health intervention group participants had a -0·30 (95% CI -0·42 to -0·19) percentage point greater reduction in HbA1c, compared with control group participants. The difference in HbA1c reduction between groups was statistically significant when interventions were delivered through smartphone applications (-0·42% [-0·63 to -0·20]) and via SMS (-0·37% [-0·57 to -0·17]), but not when delivered via websites (-0·09% [-0·64 to 0·46]). Due to the considerable heterogeneity between included studies, the level of evidence was moderate overall.

INTERPRETATION

Smartphone application and SMS interventions, but not website-based interventions, were associated with better glycaemic control. However, the studies' heterogeneity should be recognised. Considering that both smartphone application and SMS interventions are effective for diabetes management, clinicians should consider factors such as reach, uptake, patient preference, and context of the intervention when deciding on the mode of delivery of the intervention. Nine in ten people worldwide own a feature phone and can receive SMS and four in five people have access to a smartphone, with numerous smartphone applications being available for diabetes management. Clinicians should familiarise themselves with this modality of programme delivery and encourage people with type 2 diabetes to use evidence-based applications for improving their self-management of diabetes. Future research needs to describe in detail the mediators and moderators of the effectiveness and implementation of SMS and smartphone application interventions, such as the optimal dose, frequency, timing, user interface, and communication mode to both further improve their effectiveness and to increase their reach, uptake, and feasibility.

FUNDING

EU's Horizon 2020 Research and Innovation Programme.

Nurse-led telehealth intervention effectiveness on reducing hypertension: a systematic review

BACKGROUND

Hypertension is a public health concern for many countries. The World Health Organization has established a global objective to reduce the prevalence of non-communicable diseases, including hypertension, which is associated with cardiovascular disease. Remote nursing interventions can potentially lessen the burden on the healthcare system and promote a healthier population. This systematic review aims to synthesize available evidence on the effectiveness of nursing-led telehealth interventions in reducing blood pressure in hypertensive patients.

METHODS

A systematic review was conducted. The search was performed from May to June 2021, in the databases: PubMed, Scopus, Cochrane Library, Web of Science, CINAHL, and ProQuest within 2010-2021 in English, Spanish and Portuguese. Randomized controlled trials and Quasi-experimental studies were considered. This systematic review followed the criteria of the Cochrane Handbook for Systematic Reviews of Interventions, with the support of the PRISMA guidelines and registered in PROSPERO. For critical analysis, the tools of the Joanna Briggs Institute were used.

RESULTS

Of the 942 articles found, six controlled clinical trials and one quasi-experimental study were selected. Different nurse-led interventions (telehealth devices, remote video consultation, calls and email alerts) have demonstrated a significant decrease in blood pressure (especially systolic blood pressure) in the intervention groups. Nurse-led interventions also effect hypertension awareness, self-efficacy, and self-control. Positive effects on lowering cholesterol, consumption of fruits and vegetables, physical activity and adherence to medication were also described.

CONCLUSION

Nurse-led interventions delivered remotely have a positive effect in lowering the blood pressure of patients with hypertension. Further research is required to support strategies that will deliver the best continuous, quality, and cost-effective nursing care.

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

Background

Digital interventions offer a potentially cost-effective means to support patient self-management in primary care, but evidence for the feasibility, acceptability and cost-effectiveness of digital interventions remains mixed. This programme focused on the potential for self-management digital interventions to improve outcomes in two common, contrasting conditions (i.e. hypertension and asthma) for which care is currently suboptimal, leading to excess deaths, illness, disability and costs for the NHS.

Objectives

The overall purpose was to address the question of how digital interventions can best provide cost-effective support for patient self-management in primary care. Our aims were to develop and trial digital interventions to support patient self-management of hypertension and asthma. Through the process of planning, developing and evaluating these interventions, we also aimed to generate a better understanding of what features and methods for implementing digital interventions could make digital interventions acceptable, feasible, effective and cost-effective to integrate into primary care.

Design

For the hypertension strand, we carried out systematic reviews of quantitative and qualitative evidence, intervention planning, development and optimisation, and an unmasked randomised controlled trial comparing digital intervention with usual care, with a health economic analysis and nested process evaluation. For the asthma strand, we carried out a systematic review of quantitative evidence, intervention planning, development and optimisation, and a feasibility randomised controlled trial comparing digital intervention with usual care, with nested process evaluation.

Setting

General practices (hypertension, n = 76; asthma, n = 7) across Wessex and Thames Valley regions in Southern England.

Participants

For the hypertension strand, people with uncontrolled hypertension taking one, two or three antihypertensive medications. For the asthma strand, adults with asthma and impaired asthma-related quality of life.

Interventions

Our hypertension intervention (i.e. HOME BP) was a digital intervention that included motivational training for patients to self-monitor blood pressure, as well as health-care professionals to support self-management; a digital interface to send monthly readings to the health-care professional and to prompt planned medication changes when patients’ readings exceeded recommended targets for 2 consecutive months; and support for optional patient healthy behaviour change (e.g. healthy diet/weight loss, increased physical activity and reduced alcohol and salt consumption). The control group were provided with a Blood Pressure UK (London, UK) leaflet for hypertension and received routine hypertension care. Our asthma intervention (i.e. My Breathing Matters) was a digital intervention to improve the functional quality of life of primary care patients with asthma by supporting illness self-management. Motivational content intended to facilitate use of pharmacological self-management strategies (e.g. medication adherence and appropriate health-care service use) and non-pharmacological self-management strategies (e.g. breathing retraining, stress reduction and healthy behaviour change). The control group were given an Asthma UK (London, UK) information booklet on asthma self-management and received routine asthma care.

Main outcome measures

The primary outcome for the hypertension randomised controlled trial was difference between intervention and usual-care groups in mean systolic blood pressure (mmHg) at 12 months, adjusted for baseline blood pressure, blood pressure target (i.e. standard, diabetic or aged > 80 years), age and general practice. The primary outcome for the asthma feasibility study was the feasibility of the trial design, including recruitment, adherence, intervention engagement and retention at follow-up. Health-care utilisation data were collected via notes review.

Review methods

The quantitative reviews included a meta-analysis. The qualitative review comprised a meta-ethnography.

Results

A total of 622 hypertensive patients were recruited to the randomised controlled trial, and 552 (89%) were followed up at 12 months. Systolic blood pressure was significantly lower in the intervention group at 12 months, with a difference of –3.4 mmHg (95% confidence interval –6.1 to –0.8 mmHg), and this gave an incremental cost per unit of systolic blood pressure reduction of £11 (95% confidence interval £5 to £29). Owing to a cost difference of £402 and a quality-adjusted life-year (QALY) difference of 0.044, long-term modelling puts the incremental cost per QALY at just over £9000. The probability of being cost-effective was 66% at willingness to pay £20,000 per quality-adjusted life-year, and this was higher at higher thresholds. A total of 88 patients were recruited to the asthma feasibility trial (target n = 80; n = 44 in each arm). At 3-month follow-up, two patients withdrew and six patients did not complete outcome measures. At 12 months, two patients withdrew and four patients did not complete outcome measures. A total of 36 out of 44 patients in the intervention group engaged with My Breathing Matters [with a median of four (range 0–25) logins].

Limitations

Although the interventions were designed to be as accessible as was feasible, most trial participants were white and participants of lower socioeconomic status were less likely to take part and complete follow-up measures. Challenges remain in terms of integrating digital interventions with clinical records.

Conclusions

A digital intervention using self-monitored blood pressure to inform medication titration led to significantly lower blood pressure in participants than usual care. The observed reduction in blood pressure would be expected to lead to a reduction of 10–15% in patients suffering a stroke. The feasibility trial of My Breathing Matters suggests that a fully powered randomised controlled trial of the intervention is warranted. The theory-, evidence- and person-based approaches to intervention development refined through this programme enabled us to identify and address important contextual barriers to and facilitators of engagement with the interventions.

Future work

This research justifies consideration of further implementation of the hypertension intervention, a fully powered randomised controlled trial of the asthma intervention and wide dissemination of our methods for intervention development. Our interventions can also be adapted for a range of other health conditions.

Trial and study registration

The trials are registered as ISRCTN13790648 (hypertension) and ISRCTN15698435 (asthma). The studies are registered as PROSPERO CRD42013004773 (hypertension review) and PROSPERO CRD42014013455 (asthma review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 11. See the NIHR Journals Library website for further information.

Telemonitoring of elderly with hypertension and type 2 diabetes at the primary care level: Protocol for a multicentric randomized controlled pilot study

Introduction

Arterial hypertension (AH) and type 2 diabetes (T2D) represent a significant burden for the public health system, with an exceptionally high prevalence in patients aged ≥65 years. This study aims to test the acceptability, clinical effectiveness, and cost-effectiveness of telemonitoring in elderly patients with AH and T2D at the primary care level.

Methods

A m ulti-centre, prospective, randomized, controlled t rial w ill be conducted. Patients a ged ≥ 65 y ears with AH and T2D will be randomized in a 1:1 proportion to a mHealth intervention or standard care group. Patients in the intervention group will measure their blood pressure (BP) twice weekly and blood glucose (BG) once monthly. The readings will be synchronously transmitted via a mobile application to the telemonitoring platform, where they will be reviewed by a general practitioner who will indicate changes in measurement regimen or carry out a teleconsultation. The primary endpoint will be a change in systolic BP (SBP) and glycated haemoglobin (HbA1c) relative to standard care up to 12 months after inclusion. Secondary endpoints will be a change in other observed clinical variables, quality-of-life indexes, and costs.

Expected results

Telemonitoring will be an acceptable method of care associated with significant reductions in SBP and HbA1c levels and an increase in quality-of-life indexes in the intervention group. However, the cost-effectiveness threshold (incremental cost-effectiveness ratio below €25,000/quality-adjusted life year) might not be reached.

Conclusion

This study will provide new evidence for scaling up telemonitoring network at the primary care level and modifying telemonitoring protocols to achieve the best clinical and cost-effective outcomes.

An Integrated Community-Based Blood Pressure Telemonitoring Program - A Population-Based Observational Study

BACKGROUND

Home blood pressure telemonitoring (BPT) has been shown to improve blood pressure control. A community-based BPT program (the Health+ program) was launched in 2015 in an urban area around a medical center.

OBJECTIVES

To examine the impact of the BPT program on the use of medical resources.

METHODS

We conducted a retrospective propensity-score (PS)-matched observational cohort study using the National Health Insurance Research Database (NHIRD) 2013-2016 in Taiwan. A total of 9,546 adults with a high risk of cardiovascular disease participated in the integrated BPT program, and 19,082 PS-matched controls were identified from the NHIRD. The primary and secondary outcome measures were changes in 1-year emergency department visit rate, hospitalization rate, duration of hospital stay, and healthcare costs.

RESULTS

The number of emergency department visits in the Health+ group significantly reduced (0.8 to 0.6 per year vs. 0.8 to 0.9 per year, p < 0.0001) along with a significant decrease in hospitalization rate (43.7% to 21.3% vs. 42.7% to 35.3%, p < 0.001). The duration of hospital stay was also lower in the Health+ group (4.3 to 3.3 days vs. 5.3 to 6.5 days, p < 0.0001). The annual healthcare costs decreased more in the Health+ group (USD 1642 to 1169 vs. 1466 to 1393 per year, p < 0.001), compared with the controls. Subgroup analysis of the Health+ group revealed that the improvements in outcomes were significantly greater among those who were younger and had fewer comorbidities, especially without diabetes or hypertension.

CONCLUSIONS

A community-based integrated BPT program may improve patients' health outcomes and reduce healthcare costs.

Impact of Home Telemonitoring and Management Support on Blood Pressure Control in Nondialysis CKD: A Systematic Review and Meta-Analysis

Background:

Hypertension is a major cause of cardiovascular disease, chronic kidney disease (CKD), and death. Several studies have demonstrated the efficacy of home blood pressure telemonitoring (HBPT) for blood pressure (BP) control and outcomes, but the effects of this intervention remain unclear in patients with CKD.

Objective:

To determine the impact of HBPT on cardiovascular–related and kidney disease–related outcomes in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

All studies that met our criteria regardless of country of origin.

Participants:

Patients with chronic kidney disease included in studies using HBPT for BP assessment and control.

Measurements:

Descriptive and quantitative analysis of our primary and secondary outcomes.

Methods:

We searched MEDLINE, Embase, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Web of Science, and gray literature from inception for observational and randomized controlled studies in nondialysis (ND) CKD using HBPT for BP control. We selected studies that used HBPT as intervention (with or without a control arm) for BP control in ND-CKD populations. The primary outcome was change in mean systolic BP (SBP) and mean diastolic BP (DBP).

Results:

We selected 7 studies from 1669 articles that were initially identified. Overall, pooled estimates in the mean difference (MD) for SBP and DBP were −8.8 mm Hg; 95% confidence interval (CI): −16.2 to −1.4; P = .02 and −2.4 mm Hg; 95% CI: −3.8 to −1.0; P < .001, respectively. For studies comparing intervention with usual care (UC), pooled estimate in MD for SBP was −8.0 mm Hg (P = .02) with no significant reduction for DBP (−2.6 mm Hg; P = .18). In studies without a UC arm, both SBP and DBP were not significantly reduced (P > .05). The pooled estimate in MD for estimated glomerular filtration rate showed a significant improvement (5.4 mL/min/1.73 m²; P < .001).

Limitations:

Heterogeneity and few available studies for inclusion limited our ability to identify a robust link between HBPT use and BP and kidney function improvement.

Conclusion:

Home blood pressure telemonitoring is associated with mild lowering of BP and moderately improved kidney function in patients with CKD. However, larger studies with improved designs and prolonged interventions are still needed to assess the effects of HBPT on patients’ outcomes.

PROSPERO registration ID

CRD42020190705

Economic Evaluations of Remote Patient Monitoring for Chronic Disease: A Systematic Review

OBJECTIVES

This study aimed to systematically review and summarize economic evaluations of noninvasive remote patient monitoring (RPM) for chronic diseases compared with usual care.

METHODS

A systematic literature search identified economic evaluations of RPM for chronic diseases, compared with usual care. Searches of PubMed, Embase, CINAHL, and EconLit using keyword synonyms for RPM and economics identified articles published from up until September 2021. Title, abstract, and full-text reviews were conducted. Data extraction of study characteristics and health economic findings was performed. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

This review demonstrated that the cost-effectiveness of RPM was dependent on clinical context, capital investment, organizational processes, and willingness to pay in each specific setting. RPM was found to be highly cost-effective for hypertension and may be cost-effective for heart failure and chronic obstructive pulmonary disease. There were few studies that investigated RPM for diabetes or other chronic diseases. Studies were of high reporting quality, with an average Consolidated Health Economic Evaluation Reporting Standards score of 81%. Of the final 34 included studies, most were conducted from the healthcare system perspective. Eighteen studies used cost-utility analysis, 4 used cost-effectiveness analysis, 2 combined cost-utility analysis and a cost-effectiveness analysis, 1 used cost-consequence analysis, 1 used cost-benefit analysis, and 8 used cost-minimization analysis.

CONCLUSIONS

RPM was highly cost-effective for hypertension and may achieve greater long-term cost savings from the prevention of high-cost health events. For chronic obstructive pulmonary disease and heart failure, cost-effectiveness findings differed according to disease severity and there was limited economic evidence for diabetes interventions.

Consumer Devices for Patient-Generated Health Data Using Blood Pressure Monitors for Managing Hypertension: Systematic Review

Background

In the era of digital health information technology, there has been a proliferation of devices that collect patient-generated health data (PGHD), including consumer blood pressure (BP) monitors. Despite their widespread use, it remains unclear whether such devices can improve health outcomes.

Objective

We performed a systematic review of the literature on consumer BP monitors that collect PGHD for managing hypertension to summarize their clinical impact on health and surrogate outcomes. We focused particularly on studies designed to measure the specific effect of using a BP monitor independent of cointerventions. We have also summarized the process and consumer experience outcomes.

Methods

An information specialist searched PubMed, MEDLINE, and Embase for controlled studies on consumer BP monitors published up to May 12, 2020. We assessed the risk of bias using an adapted 9-item appraisal tool and performed a narrative synthesis of the results.

Results

We identified 41 different types of BP monitors used in 49 studies included for review. Device engineers judged that 38 (92%) of those devices were similar to the currently available consumer BP monitors. The median sample size was 222 (IQR 101-416) participants, and the median length of follow-up was 6 (IQR 3-12) months. Of the included studies, 18 (36%) were designed to isolate the clinical effects of BP monitors; 6 of the 18 (33%) studies evaluated health outcomes (eg, mortality, hospitalizations, and quality of life), and data on those outcomes were unclear. The lack of clarity was due to low event rates, short follow-up duration, and risk of bias. All 18 studies that isolated the effect of BP monitors measured both systolic and diastolic BP and generally demonstrated a decrease of 2 to 4 mm Hg in systolic BP and 1 to 3 mm Hg in diastolic BP compared with non–BP monitor groups. Adherence to using consumer BP monitors ranged from 38% to 89%, and ease of use and satisfaction ratings were generally high. Adverse events were infrequent, but there were a few technical problems with devices (eg, incorrect device alerts).

Conclusions

Overall, BP monitors offer small benefits in terms of BP reduction; however, the health impact of these devices continues to remain unclear. Future studies are needed to examine the effectiveness of BP monitors that transmit data to health care providers. Additional data from implementation studies may help determine which components are critical for sustained BP improvement, which in turn may improve prescription decisions by clinicians and coverage decisions by policy makers.

Improving Blood Pressure Control Using Digital Communication Methods in Serbia

Background: The purpose of this study was to compare home and office BP in the adjustment of antihypertensive treatment. Methods: This study was an open, prospective, noninterventional, multicenter clinical trial that occurred between July 2019 and February 2020, in 34 cities in the territory of the Republic of Serbia, which monitored 1581 participants for 6 months. Depending on the used blood pressure monitoring method used, all patients were divided into control (office BP monitoring) and experimental (home BP telemonitoring) groups. We collected anamnestic data and data about systolic blood pressure (SP), in mmHg, diastolic blood pressure (DP), in mmHg, and heart rate (HR), in beats/minute, from all patients. Results: SP values were significantly different at baseline, and at the second, third, and fourth visits between the two tested groups. Home and office BP decreased significantly (p < 0.000) during the 6-month follow-up. We observed a statistically significant influence of the presence of diabetes mellitus and dyslipidemia on the dynamics of differences between SP monitoring values. Conclusions: Our study suggests that novel technologies in BP monitoring can be excellent alternatives for BP assessment in hypertensive patients with other cardiovascular risk factors such as diabetes and dyslipidemia.

Cost-Effectiveness of Antihypertensive Deprescribing in Primary Care: a Markov Modelling Study Using Data From the OPTiMISE Trial

BACKGROUND

Deprescribing of antihypertensive medications for older patients with normal blood pressure is recommended by some clinical guidelines, where the potential harms of treatment may outweigh the benefits. This study aimed to assess the cost-effectiveness of this approach.

METHODS

A Markov patient-level simulation was undertaken to model the effect of withdrawing one antihypertensive compared with usual care, over a life-time horizon. Model population characteristics were estimated using data from the OPTiMISE antihypertensive deprescribing trial, and the effects of blood pressure changes on outcomes were derived from the literature. Health-related quality of life was modeled in Quality-Adjusted Life Years (QALYs) and presented as costs per QALY gained.

RESULTS

In the base-case analysis, medication reduction resulted in lower costs than usual care (mean difference £185), but also lower QALYs (mean difference 0.062) per patient over a life-time horizon. Usual care was cost-effective at £2975 per QALY gained (more costly, but more effective). Medication reduction resulted more heart failure and stroke/TIA events but fewer adverse events. Medication reduction may be the preferred strategy at a willingness-to-pay of £20 000/QALY, where the baseline absolute risk of serious drug-related adverse events was ≥7.7% a year (compared with 1.7% in the base-case).

CONCLUSIONS

Although there was uncertainty around many of the assumptions underpinning this model, these findings suggest that antihypertensive medication reduction should not be attempted in many older patients with controlled systolic blood pressure. For populations at high risk of adverse effects, deprescribing may be beneficial, but a targeted approach would be required in routine practice.

Home Telemonitoring of Arterial Hypertension With Antihypertensive Treatment Titration: Protocol for a Randomized Controlled Prospective Trial (HOROSCOPE Study)

Background

Despite the availability of effective treatment, the control of hypertension remains insufficient. Telemonitoring in the management of hypertension would be an effective way to improve blood pressure control.

Objective

The aim of our study will be to evaluate the effects of telemonitoring with antihypertensive treatment titration on blood pressure control in Tunisian patients with hypertension.

Methods

Our trial will be a prospective, rater-blinded randomized controlled trial carried out with primary care physicians in the Sahel region of Tunisia. Patients will be eligible for enrollment if they are aged over 35 years, are newly diagnosed with hypertension, or are known to be poorly controlled on antihypertensive therapy. Participants will be randomly assigned in a 1:1 ratio to the telemonitoring arm or usual care arm. The telemonitoring arm will involve a weekly telephone call for the collection of the home blood pressure measurements, therapeutic education, and treatment compliance assessment as well as a monthly call for treatment titration and a side effect check. Randomization will be done via the use of an interactive web responsive system, and patients will be stratified by investigation center. Neither participants nor investigators will be masked to the group assignments. The primary outcome will be the change in mean 24-hour systolic blood pressure from baseline to the 6-month follow-up in the 2 groups. All randomized patients who attend the follow-up visit at 6 months and have no missing data for the primary outcome will be included in the analysis.

Results

Recruitment to the trial started in July 2020. The study was initiated with 17 primary care physicians. We expect the inclusion period to last for approximately 6 months. We expect to complete data collection by the end of 2021 and plan to disseminate the results subsequently.

Conclusions

The HOROSCOPE (Home Telemonitoring of Arterial Hypertension With Antihypertensive Treatment Titration: Randomized Controlled Prospective Trial) study will provide important new evidence that could shed some light on the feasibility and impact of telemonitoring and self-monitoring in a Tunisian population of patients with hypertension who consult primary care physicians.

Trial Registration

ClinicalTrials.gov NCT04607239; https://clinicaltrials.gov/ct2/show/NCT04607239

International Registered Report Identifier (IRRID)

DERR1-10.2196/26184

Prospects for developing and implementing remote blood pressure monitoring in patients under dispensary follow-up

Recently, the use of telemedicine technologies (TMT) in the healthcare has gained great importance. TMT is one of the ways to increase the healthcare availability, including in patients with high blood pressure (BP). Office BP measurement and 24-hour BP monitoring are not accurate enough to study natural or induced BP changes over long periods of time. For the selection of antihypertensive drugs and the diagnosis of hypertension (HTN) in patients with an emotionally unstable personality type, as well as in the differential diagnosis of normotension, preHTN, BP selfmonitoring comes first. The use of BP self-monitoring for the diagnosis, selection of therapy, assessment of adherence and effectiveness of treatment of HTN is more effective with remote, socalled telemetric, dynamic BP monitoring. The article presents world experience in the effective use of dynamic remote BP monitoring using TMT.

 

Systematic Review of Self-Measured Blood Pressure Monitoring With Support: Intervention Effectiveness and Cost

INTRODUCTION

Self-measured blood pressure monitoring with support is an evidence-based intervention that helps patients control their blood pressure. This systematic economic review describes how certain intervention aspects contribute to effectiveness, intervention cost, and intervention cost per unit of the effectiveness of self-measured blood pressure monitoring with support.

METHODS

Papers published between data inception and March 2021 were identified from a database search and manual searches. Papers were included if they focused on self-measured blood pressure monitoring with support and reported blood pressure change and intervention cost. Papers focused on preeclampsia, kidney disease, or drug efficacy were excluded. Quality of estimates was assessed for effectiveness, cost, and cost per unit of effectiveness. Patient characteristics and intervention features were analyzed in 2021 to determine how they impacted effectiveness, intervention cost, and intervention cost per unit of effectiveness.

RESULTS

A total of 22 studies were included in this review from papers identified in the search. Type of support was not associated with differences in cost and cost per unit of effectiveness. Lower cost and cost per unit of effectiveness were achieved with simple technologies such as interactive phone systems, smartphones, and websites and where providers interacted with patients only as needed.

DISCUSSION

Some of the included studies provided only limited information on key outcomes of interest to this review. However, the strength of this review is the systematic collection and synthesis of evidence that revealed the associations between the characteristics of implemented interventions and their patients and the interventions' effectiveness and cost, a useful contribution to the fields of both research and implementation.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).

Implementation of a self-measured blood pressure program in a community pharmacy: A pilot study

BACKGROUND

Hypertension is a leading cause of cardiovascular disease in the United States and is costing the health care system billions of dollars annually. A health program that combines education, empowerment, and monitoring has shown to improve clinical outcomes and decrease overall health care costs.

OBJECTIVE

To describe the implementation and effectiveness of a self-measured blood pressure (SMBP) program in a community pharmacy.

PRACTICE DESCRIPTION

An independent community pharmacy located within rural Southeast Missouri. On-site community pharmacists provide medication therapy management, adherence monitoring, immunizations, and reimbursed clinical services.

PRACTICE INNOVATION

Patients were eligible if they were older than 18 years of age and fell into one of the following categories: self-reported a new hypertension diagnosis, self-reported a desire to SMBP, were referred by a provider, or had a medication change within the 3 months before enrollment. The program consisted of 4 patient sessions. The first session obtained an initial blood pressure and provided patient education and behavior counseling. Follow-up sessions obtained average SMBP readings and reinforced previously learned concepts.

EVALUATION METHODS

Implementation was evaluated using time and patient satisfaction. Effectiveness was evaluated using number and type of clinical problems identified, BP measurements, and test scores.

RESULTS

A total of 20 patients enrolled and completed the study. The program took 63 minutes (SD ± 18) of staff time per patient for recruitment, sessions, reminder calls, and documentation. All patients received education and monitoring and 11 additional clinical problems were documented. Systolic BP decreased an average of 17 mm Hg (P = 0.002), and diastolic BP decreased an average of 12 mm Hg (P < 0.001). Patient confidence scores increased by 14%, and 7 more patients correctly answered the post-test knowledge question. All patients reported overall satisfaction with the program as "satisfied" or "very satisfied."

CONCLUSION

This standardized SMBP program effectively improved hypertension control and patient confidence in managing BP.

Deliver Cardiac Virtual Care (CVC) - A Primer for Cardiovascular Professionals in Canada

The COVID-19 pandemic, with its need for distancing, has necessitated the use of virtual care in never-before-seen volumes. This review article aims to provide a primer on virtual care for cardiovascular professionals in Canada. The technology to facilitate remote patient interactions is already available, but barriers exist. Adequate and effective cardiac virtual care must be further developed given the need for rapid evaluation and close ongoing follow-up of patients, as seen in the areas of management of heart failure, cardiac rehabilitation, electrophysiology, and hypertension. Many Canadian organizations have published resources to assist health care providers and patients navigate the unfamiliar virtual care landscape. Although there are concerns surrounding issues such as patient privacy, access to technology, language discrepancies, and billing, these deficits provide opportunities for growth by health care organizations and technology companies. The integration of virtual care, home-based devices, and disruptive technologies emphasize the trend toward virtualization of health care, with the potential for greater personalization of health care interactions and continuity of care. Funding models were rapidly developed at the beginning of the COVID-19 pandemic, and although some provinces have deemed these changes as permanent, the status from other provinces remains unknown. The foundations to support virtual care as a key modality for health care delivery in Canada have been built, and further developments may strengthen its viability as a long-term option.

2021 Spanish Society of Hypertension position statement about telemedicine

The pandemic caused by coronavirus SARS-CoV-2 (COVID-19) has forced, in many cases, to replace face-to-face consultation with the telematic consultation, in order to reduce the risk of contagion associated with the presence of patients in health centres. This change may represent an opportunity for a different and more effective communication between professionals and patients, allowing better accessibility to medical care and more systematic and comprehensive approach to patients with hypertension and cardiovascular risk. However, organisational tools are needed to facilitate communication between patients and professionals, specifically with the exchange of clinical data by remote monitoring of variables associated with hypertension and cardiovascular risk (blood pressure, weight, height, blood tests…), and allow monitoring of adherence to treatments, lifestyles and risk factors. It would be desirable for this to be carried out by multidisciplinary teams, both from primary care, hospital and community pharmacy, with an adequate coordination of care. This document of the Spanish Society of Hypertension (SEH-LELHA) tries to give the keys to improve the quality of care of telematic consultations of patients with hypertension and cardiovascular risk, provide basic criteria of telematic or face to face attention and systematise their content. Likewise, the follow-up criteria are proposed by the different professionals.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Home blood pressure telemonitoring for improving blood pressure control in middle-aged and elderly patients with hypertension

The blood pressure (BP) control rate among treated hypertensives in China remains low at 37.5%. The relationship between home blood pressure telemonitoring (HBPT) and BP control is controversial. The authors aimed to investigate the relationship between HBPT and BP control in middle‐aged and elderly hypertensives. In total, 252 hypertension patients aged between 60 and 79 years were enrolled. The patients were given either HBPT through interactive platforms between physicians and patients (telemonitoring group, n = 126) or conventional management (routine management group, n = 126). All patients were followed‐up for 15 months. BP control was defined as home systolic blood pressure < 135 mm Hg and home diastolic blood pressure < 85 mm Hg. At baseline, there were no significant differences in the baseline BP control rate (p = .083). However, after 15 months, the BP control rate improved in both groups, and the telemonitoring group (71.3%) had a significantly higher BP control than the routine management group (49.8%) (p < .001). The change of BP control rate from baseline in the routine management group increased by 26.1%, and that of the telemonitoring group increased by 35.4%. The results of the fully adjusted binary logistic regression showed that HBPT was positively associated with BP control after adjusting for confounders (OR = 4.15, 95% CI 2.05–8.39). Similar results were observed after 3, 9, and 12 months. The association of HBPT with BP control was similar in subgroups. In conclusions, HBPT is recommended for BP control in middle‐aged and elderly hypertensives in the community setting.

Nurse-Coordinated Blood Pressure Telemonitoring for Urban Hypertensive Patients: A Systematic Review and Meta-Analysis

Coronavirus disease 2019 (COVID-19) has put hypertensive patients in densely populated cities at increased risk. Nurse-coordinated home blood pressure telemonitoring (NC-HBPT) may help address this. We screened studies published in English on three databases, from their inception to 30 November 2020. The effects of NC-HBPT were compared with in-person treatment. Outcomes included changes in blood pressure (BP) following the intervention and rate of BP target achievements before and during COVID-19. Of the 1916 articles identified, 27 comparisons were included in this review. In the intervention group, reductions of 5.731 mmHg (95% confidence interval: 4.120-7.341; p < 0.001) in systolic blood pressure (SBP) and 2.342 mmHg (1.482-3.202; p < 0.001) in diastolic blood pressure (DBP) were identified. The rate of target BP achievement was significant in the intervention group (risk ratio, RR = 1.261, 1.154-1.378; p < 0.001). The effects of intervention over time showed an SBP reduction of 3.000 mmHg (-5.999-11.999) before 2000 and 8.755 mmHg (5.177-12.334) in 2020. DBP reduced by 2.000 mmHg (-2.724-6.724) before 2000 and by 3.529 mmHg (1.221-5.838) in 2020. Analysis of the target BP ratio before 2010 (RR = 1.101, 1.013-1.198) and in 2020 (RR = 1.906, 1.462-2.487) suggested improved BP control during the pandemic. NC-HBPT more significantly improves office blood pressure than UC among urban hypertensive patients.

Smartphone-based remote monitoring of vision in macular disease enables early detection of worsening pathology and need for intravitreal therapy

Background/aims

To assess the outcomes of home monitoring of distortion caused by macular diseases using a smartphone-based application (app), and to examine them with hospital-based assessments of visual acuity (VA), optical coherence tomography-derived central macular thickness (CMT) and the requirement of intravitreal injection therapy.

Design

Observational study with retrospective analysis of data.

Methods

Participants were trained in the correct use of the app (Alleye, Oculocare, Zurich, Switzerland) in person or by using video and telephone consultations. Automated threshold-based alerts were communicated based on a traffic light system. A ‘threshold alarm’ was defined as three consecutive ‘red’ scores, and turned into a ‘persistent alarm’ if present for greater than a 7-day period. Changes of VA and CMT, and the requirement for intravitreal therapy after an alarm were examined.

Results

245 patients performing a total of 11 592 tests (mean 46.9 tests per user) were included and 85 eyes (164 alarms) examined. Mean drop in VA from baseline was −4.23 letters (95% CI: −6.24 to −2.22; p<0.001) and mean increase in CMT was 29.5 µm (95% CI: −0.08 to 59.13; p=0.051). Sixty-six eyes (78.5%) producing alarms either had a drop in VA, increase in CMT or both and 60.0% received an injection. Eyes with persistent alarms had a greater loss of VA, −4.79 letters (95% CI: −6.73 to −2.85; p<0.001) or greater increase in CMT, +87.8 µm (95% CI: 5.2 to 170.4; p=0.038).

Conclusion

Smartphone-based self-tests for macular disease may serve as reliable indicators for the worsening of pathology and the need for treatment.

Impact of home telemonitoring and management support on blood pressure control in non-dialysis CKD: a systematic review protocol

INTRODUCTION

Hypertension is a common public health problem and a key modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD). Home blood pressure (BP) telemonitoring (HBPT) and management is associated with improved BP control, accelerated delivery of care and decision-making strategies that can reduce adverse outcomes associated with hypertension. The aim of this paper is to describe the protocol for a systematic review to assess the impact of HBPT interventions used for improving BP control and reducing CV and kidney outcomes in non-dialysis CKD patients.

METHODS

We developed this protocol using the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015. We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science and PsycINFO and grey literature for studies conducted in non-dialysis CKD patients on interventions using HBPT and reporting outcomes related to BP control and other outcomes such as CV events and kidney disease progression. All studies meeting these criteria, in adults and published from inception until 2020 with no language barrier will be included.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this review as the data used will be extracted from already published studies with publicly accessible data. As this study will assess the impact of HBPT on BP control in non-dialysis CKD patients, evidence gathered through it will be disseminated using traditional approaches that includes open-access peer-reviewed publication, scientific presentations and a report. We will also disseminate our findings to appropriate government agencies.

PROSPERO REGISTRATION NUMBER

CRD42020190705).

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society

Supplemental Digital Content is available in the text.

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health (“mHealth”) technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

[Blood pressure telemonitoring and remote counseling in uncontrolled hypertension]

Telehealth is a useful adjunct in hypertension (HTN) management. Despite obvious short-term clinical benefit, long-term social impact and cost-effectiveness have not been fully investigated.

AIM

Predictive modeling of long-term clinical and social outcomes and the cost-effectiveness analysis of blood pressure (BP) telemonitoring and remote counseling (BPTM) in patients with HTN.

MATERIALS AND METHODS

A Markov cohort-based (1000 patients in each study arm) model was developed and adopted a 10-year time horizon with 12-month time cycles. Cost and outcome data collected from the three-month study of 240 patients (160 in BPTM group and 80 controls, 48 y.o.). All patients started at a non-complicated HTN well state with a certain possibility of disease progression in a number of health states over a discrete time period. BPTM was compared with usual care in terms of 10-year healthcare costs, quality adjusted life years (QALY) using a Ministry of Health of Russian Federation perspective.

RESULTS

In the long-term run when compared with usual care BPTM was more effective in terms mortality (67 versus 91 patients lost and 9.6 versus 9.71 life years gained) and costs (cost of illness 102 508 000 RUR versus 145 237 700 RUR). Taking quality of life measures into account, the effect of BPTM was also more pronounced (8.31 versus 7.82 QALYs gained). The resultant incremental cost-utility ratio for BPTM was 275 178.98 RUR/1 QALY gained/1 patient (134 837.70 RUR/0.49 QALY/1 patient).

CONCLUSION

According to the results of predictive modeling, implementation of BPTM into clinical practice is likely lead to reduced cardiovascular morbidity and mortality in a cost-effective way.

The current state and future of internet technology-based hypertension management in Japan

Internet-based information and communication technology is altering our lives. Although medicine is traditionally conservative, it can benefit in many ways from adopting new technology and styles of care. Hypertension is a prime condition for the practical application of digital health management because it is prevalent and undercontrolled, and its primary index, home blood pressure, can be effectively telemonitored. Compared to other conditions that require laboratory measures or the use of drugs with frequent side effects, hypertension can be managed without actual office visits with sufficiently low risk. In this review of hypertension in Japan, we discuss the current and somewhat fragmented state of internet technology and the components and processes necessary for smooth, integrated, and multidisciplinary care in the future. Although further clinical trials are required to show the safety and efficacy of information and communication technology-based care for hypertension, the deployment of telemonitoring and telemedicine in daily practice should be expedited to solve the hypertension paradox. Challenges remain relating to cost, data integration, the redesigning of team-based care, and the improvement of user experience, but information and communication technology-based hypertension management is sure to become pivotal in improving public health.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.

Recent advances in managing primary hypertension

Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.

Evidence and Recommendations on the Use of Telemedicine for the Management of Arterial Hypertension: An International Expert Position Paper

Telemedicine allows the remote exchange of medical data between patients and healthcare professionals. It is used to increase patients' access to care and provide effective healthcare services at a distance. During the recent coronavirus disease 2019 (COVID-19) pandemic, telemedicine has thrived and emerged worldwide as an indispensable resource to improve the management of isolated patients due to lockdown or shielding, including those with hypertension. The best proposed healthcare model for telemedicine in hypertension management should include remote monitoring and transmission of vital signs (notably blood pressure) and medication adherence plus education on lifestyle and risk factors, with video consultation as an option. The use of mixed automated feedback services with supervision of a multidisciplinary clinical team (physician, nurse, or pharmacist) is the ideal approach. The indications include screening for suspected hypertension, management of older adults, medically underserved people, high-risk hypertensive patients, patients with multiple diseases, and those isolated due to pandemics or national emergencies.

Success factors in high-effect, low-cost eHealth programs for patients with hypertension: a systematic review and meta-analysis

Background

eHealth programs can lower blood pressure but also drive healthcare costs. This study aims to review the evidence on the effectiveness and costs of eHealth for hypertension and assess commonalities in programs with high effect and low additional cost.

Results

Overall, the incremental decrease in systolic blood pressure using eHealth, compared to usual care, was 3.87 (95% confidence interval (CI) 2.98–4.77) mmHg at 6 months and 5.68 (95% CI 4.77–6.59) mmHg at 12 months’ follow-up. High intensity interventions were more effective, resulting in a 2.6 (95% CI 0.5–4.7) (at 6 months) and 3.3 (95% CI 1.4–5.1) (at 12 months) lower systolic blood pressure, but were also more costly, resulting in €170 (95% CI 56–284) higher costs at 6 months and €342 (95% CI 128–556) at 12 months. Programs that included a high volume of participants showed €203 (95% CI 99–307) less costs than those with a low volume at 6 months, and €525 (95% CI 299–751) at 12 months without showing a difference in systolic blood pressure. Studies that implemented eHealth as a partial replacement, rather than addition to usual care, were also less costly (€119 (95% CI –38–201 at 6 months) and €346 (95% CI 261–430 at 12 months)) without being less effective. Evidence on eHealth programs for hypertension is ambiguous, heterogeneity on effectiveness and costs is high ( I2 = 56–98%).

Conclusion

Effective eHealth with limited additional costs should focus on high intensity interventions, involve a large number of participants and use eHealth as a partial replacement for usual care.

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

Background

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

Aim

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

Design & setting

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

Method

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

Results

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

Conclusion

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

Changing the Health Behavior of Patients With Cardiovascular Disease Through an Electronic Health Intervention in Three Different Countries: Cost-Effectiveness Study in the Do Cardiac Health: Advanced New Generation Ecosystem (Do CHANGE) 2 Randomized Controlled Trial

BACKGROUND

During the last few decades, preventing the development of cardiovascular disease has become a mainstay for reducing cardiovascular morbidity and mortality. It has been suggested that interventions should focus more on committed approaches of self-care, such as electronic health techniques.

OBJECTIVE

This study aimed to provide evidence to understand the financial consequences of implementing the "Do Cardiac Health: Advanced New Generation Ecosystem" (Do CHANGE 2) intervention, which was evaluated in a multisite randomized controlled trial to change the health behavior of patients with cardiovascular disease.

METHODS

The cost-effectiveness analysis of the Do CHANGE 2 intervention was performed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, based on a Markov model of five health states. The following two types of costs were considered for both study groups: (1) health care costs (ie, costs associated with the time spent by health care professionals on service provision, including consultations, and associated unplanned hospitalizations, etc) and (2) societal costs (ie, costs attributed to the time spent by patients and informal caregivers on care activities).

RESULTS

The Do CHANGE 2 intervention was less costly in Spain (incremental cost was -€2514.90) and more costly in the Netherlands and Taiwan (incremental costs were €1373.59 and €1062.54, respectively). Compared with treatment as usual, the effectiveness of the Do CHANGE 2 program in terms of an increase in quality-adjusted life-year gains was slightly higher in the Netherlands and lower in Spain and Taiwan.

CONCLUSIONS

In general, we found that the incremental cost-effectiveness ratio strongly varied depending on the country where the intervention was applied. The Do CHANGE 2 intervention showed a positive cost-effectiveness ratio only when implemented in Spain, indicating that it saved financial costs in relation to the effect of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03178305; https://clinicaltrials.gov/ct2/show/NCT03178305.