The choice of home blood pressure result reporting method is essential: Results mailed to physicians did not improve hypertension control compared with ordinary office-based blood pressure treatment

An Updated Meta-Analysis of Remote Blood Pressure Monitoring in Urban-Dwelling Patients with Hypertension

Following the coronavirus disease-2019 pandemic, this study aimed to evaluate the overall effects of remote blood pressure monitoring (RBPM) for urban-dwelling patients with hypertension and high accessibility to healthcare and provide updated quantitative summary data. Of 2721 database-searched articles from RBPM’s inception to November 2020, 32 high-quality studies (48 comparisons) were selected as primary data for synthesis. A meta-analysis was undertaken using a random effects model. Primary outcomes were changes in office systolic blood pressure (SBP) and diastolic blood pressure (DBP) following RBPM. The secondary outcome was the BP control rate. Compared with a usual care group, there was a decrease in SBP and DBP in the RBPM group (standardized mean difference 0.507 (95% confidence interval [CI] 0.339–0.675, p < 0.001; weighted mean difference [WMD] 4.464 mmHg, p < 0.001) and 0.315 (CI 0.209–0.422, p < 0.001; WMD 2.075 mmHg, p < 0.001), respectively). The RBPM group had a higher BP control rate based on a relative ratio (RR) of 1.226 (1.107–1.358, p < 0.001). RBPM effects increased with increases in city size and frequent monitoring, with decreases in intervention duration, and in cities without medically underserved areas. RBPM is effective in reducing BP and in achieving target BP levels for urban-dwelling patients with hypertension.

Comparative effect of eHealth interventions on hypertension management-related outcomes: A network meta-analysis

BACKGROUND

Increasingly, health professionals and patients have begun to be involved in eHealth interventions to assist in the self-management of hypertension. Therefore, this study was aimed at comparing the effect of different types of eHealth interventions (phone calls, blood pressure telemonitoring, emails, web-site, smartphone-app, short message service (SMS) and more than two eHealth interventions) on reducing systolic and diastolic blood pressure, increasing adherence to medication treatment, improving physical activity compliance, controlling blood pressure, and improving quality of life (QoL).

METHODS

A systematic search in MEDLINE (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted to identify experimental studies addressing the effect of eHealth interventions on the self-management of hypertension. Comparative evaluation of the eHealth interventions effect were performed by conducting a standard pairwise meta-analysis and a network meta-analysis for direct and indirect comparisons between eHealth interventions and control/non-intervention.

RESULTS

Fifty-one studies were included in the analysis showing a moderate effect size for more than two types of eHealth interventions (-0.46; 95%CI: -0.64, -0.27, p < 0.001 and -0.29; 95%CI: -0.46, -0.13, p < 0.001), phone calls (-0.37; 95%CI: -0.57, -0.17, p < 0.001 and -0.29; 95%CI: -0.52, -0.07, p = 0.011) and smartphone-app (-0.26; 95%CI: -0.50, -0.01, p = 0.040 and -0.40; 95%CI: -0.70, -0.10, p = 0.010) on reducing both systolic and diastolic blood pressure, respectively. Additionally, i) smartphone-app improved medication adherence by 45%; ii) more than two types of eHealth interventions and emails improved physical activity compliance by 18% and 57% respectively; ii) more than two types of eHealth interventions, phone calls, blood pressure telemonitoring, website and SMS improved blood pressure control between 16% and 30%; and iv) blood pressure telemonitoring showed a week effect on QoL CONCLUSIONS: Our study reported eHealth to be a suitable intervention for the self-management of hypertension. Considering our results and the population's accessibility to eHealth devices, eHealth could be a useful and largely scalable tool for the self-management of hypertension.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187468.

Understanding Moderators of Home Blood Pressure Telemonitoring Systems in Urban Hypertensive Patients: A Systematic Review and Meta-Analysis

Background: Factors affecting the effectiveness of telemonitoring in home blood pressure telemonitoring (HBPT) must be examined in an integrated analysis in urban hypertensive patients. Materials and Methods: In a systematic review of electronic databases, we retrieved 1,433 citations and selected 34 comparisons. Specified moderators were the duration of the intervention, the frequency of remote transmission of blood pressure (BP) data, the additional intervention, and the intervention pathway. Results: For the duration of follow-up of HBPT, the weighted mean difference (WMD) in systolic blood pressure (SBP) between two groups was 11.900 mmHg (p-value <0.001) at 2 months and 3.024 mmHg (p = 0.002) at 12 months. The WMD in SBP was 5.512 mmHg (p < 0.001) in cases where data were transmitted daily and 1.818 mmHg (p = 0.084) for monthly transmission. For the group in which further interventions with HBPT were conducted, the WMD in SBP was 3.813 mmHg (p < 0.001). For patients who did not receive additional interventions, the WMD was 2.747 mmHg (p = 0.005). For the pathway of HBPT, the WMD was 6.800 mmHg (p = 0.053) when BP values were remote transmitted through letter, 3.041 mmHg (p = 0.001) through mobile phone/web, 2.224 mmHg (p = 0.043) through telephone-linked computer system, and 4.352 mmHg (p < 0.001) through telephone. Conclusions: The effects of moderators of HBPT systems utilized with urban hypertensive patients differ from those in interventions that did not distinguish urban from rural areas. Results for duration of implementation and frequency of data transmission were significant. Among the interventions using telecommunications, the telephone was the most effective in comparison to other channels.

Effects of Remote Monitoring of Blood Pressure in Management of Urban Hypertensive Patients: A Systematic Review and Meta-Analysis

Background: Remote home blood pressure monitoring (RBPM) has been shown as effective in managing hypertension in underserved areas. Effects on urban patients, who are more easily provided with high-quality medical services, are still unclear. We systematically review previously published randomized controlled trials on the effect of RBPM for urban hypertensive patients. Methods: We searched electronic databases for studies published in English up to October 2018. Studies comparing the use of RBPM to face-to-face care were included. Outcome measures were changes in office blood pressure (BP) and the rate of BP control. Results: We identified 1,433 potential references for screening, of which 27 were eligible for review. Substantial heterogeneity was evident for the investigated variables. A significant standardized mean difference (SMD) was observed for RBPM for systolic BP, but the effect size was small compared to face-to-face care and was clinically irrelevant in avoiding cardiovascular events (0.212, 95% confidence interval 0.148-0.275; p < 0.001). For diastolic BP, the SMD between the two groups was small (0.170, p < 0.001) and the effect of RBPM was irrelevant in preventing cardiovascular events. The effect on the rate of BP control was significantly high for the intervention group (relative risk: 1.136; p = 0.018). Conclusions: This review demonstrates that RBPM performed on urban hypertensive patients has limited value and seems not to be superior to ordinary care in avoidance of cardiovascular events. Further studies are needed to provide more reliable information about the effectiveness of RBPM in preventing hypertensive cardiovascular complications.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Objective

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

Methods

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

Results

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (i.e., angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis

BACKGROUND

Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension.

METHODS AND FINDINGS

Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies.

CONCLUSIONS

Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Effectiveness of home blood pressure telemonitoring: a systematic review and meta-analysis of randomised controlled studies

To summarise evidence about the effectiveness of home blood pressure telemonitoring (HBPT) and identify the key components of intervention. We comprehensively searched PubMed, EMBASE and the Cochrane Library for relevant studies. The authors were contacted for additional information. Two authors independently extracted the data and assessed the risk of bias. 46 randomised controlled trials including a total of 13 875 cases were identified. Compared with usual care, HBPT improved office systolic blood pressure (BP) and diastolic BP by 3.99 mm Hg (95% confidence interval (CI): 5.06-2.93; P<0.001) and 1.99 mm Hg (95% CI: -2.60 to -1.39; P<0.001), respectively. A larger proportion of patients achieved BP normalisation in the intervention group (relative risk (RR): 1.16; 95% CI: 1.08-1.25; P<0.001). For HBPT plus additional support (including counselling, education, behavioural management, medication management with decision, adherence contracts and so on) versus HBPT alone (or plus less intense additional support), the mean changes in systolic and diastolic BP were 2.44 mm Hg (95% Cl, 4.88 to 0.00 mm Hg; P=0.05) and 1.12 mm Hg (95% CI, -2.34 to 0.1 mm Hg; P=0.07), respectively. For those surrogate outcomes, low-strength evidence failed to show difference. In subgroup analysis, high strength evidence supported a lower BP with HBPT that lasted for 6 or 12 months and was accompanied with counselling support from study personnel. HBPT can improve BP control in the hypertensive patients. It may be more efficacious when a proactive additional support is provided during the intervention process.

[Prevention of therapeutic inertia in the treatment of arterial hypertension by using a program of home blood pressure monitoring]

OBJECTIVE

To evaluate the efficacy of a program of home blood pressure monitoring (HBPM) on therapeutic Inertia (TI) in mild-to-moderate hypertension (AHT).

DESIGN

Controlled, randomised clinical trial.

SETTING

Forty six clinics in 35 primary care centres. Spain.

PARTICIPANTS

A total of 232 patients with uncontrolled hypertension were included.

INTERVENTION

Two groups with 116 patients were formed: 1) Control group (CG): standard health intervention; 2) Intervention group (IG): patients who were included in the HBPM program.

MAIN MEASUREMENTS

TI was calculated by the ratio: Number of patients whose pharmacological treatment was not changed in each visit/Number of patients with an average BP 140mmHg and/or 90mmHg in the general population or 130 and/or 90 mmHg in diabetics. The mean BPs and the percentage of controlled patients were calculated. The mean number of people that required an intervention in order to avoid TI was calculated (NI).

RESULTS

A total of 209 patients completed the study, with TI in 35.64% (95% CI=29.85%-41.43%) of the sample, and in 71.63% (95% CI=63.9-79.36%) of the uncontrolled hypertensive patients. The TI was 22.42% (95% CI=24.2-37%) in the IG and 50% (95% CI=37.75-62.25) in the CG (p<.05) in visit 2, and 25.23% (95% CI=14.84-35.62) and 46.07% (95% CI=33.85-58.29) in the final visit for IG and CG, respectively (P<.05). The NI was 4.3.

CONCLUSIONS

TI was very significant among the uncontrolled hypertensive patients. The studied interventions are effective for improving TI.

Home blood pressure for the management of hypertension: will it become the new standard of practice?

Accurate identification of hypertension is crucial for the prevention of cardiovascular disease. Home blood pressure monitoring (HBPM) provides superior prediction of cardiovascular disease, compared with clinic pressures. HBPM can be a valuable resource for the effective treatment of hypertension, when combined with other modalities used to improve patient education, lifestyle enhancement, adherence to medication and reduction of unnecessary clinic visits. In some developed nations, more than half of households with a hypertensive patient have a device for HBPM. The use of HBPM by patients and the acceptance of HBPM measurements by providers is increasing. The long-term effectiveness of HBPM, combined with telemetry for disease prevention, is promising. More research is still needed to establish its full value. It is predicted that HBPM has definite potential for more effective strategies to control hypertension and reduce the need for on-site clinical care.