Home Blood Pressure Telemonitoring Research Articles

Proceedings of the 2022 IDACO/IDHOCO/IDCARS/UPRIGHT-HTM Consortium Meeting, 1-3 December 2022, Lamot Congress and Heritage Centre, Mechelen, Belgium Meeting Chairpersons: Kei Asayama and Jan A. Staessen.

Background: Home blood pressure telemonitoring (HTM) is recommended by several guidelines in the management of hypertension with its benefits widely documented. HTM enables patients’ active participation in their management and also assists in the diagnoses of white coat and masked hypertension. The feasibility of HTM in poor resource settings such as in Nigeria is unknown. Aim: To determine the feasibility of HTM in Nigeria Methods: We evaluated HTM among Nigerians recruited under the framework of Urinary Proteomics combined with Home Blood Pressure Telemonitoring for Health Care Reforms trial (UPRIGHT-HTM), a multi-centre global clinical trial involving three centres in Nigeria. Eligible patients, aged 55-75 years old with ≥5 cardiovascular diseases risk factors but asymptomatic were trained to collect HTM data using Bluetooth-enabled automated blood pressure (BP) monitors aided with web-based applications that run on android smartphones. Results: Of the 171 patients screened over a 17-month period (May 2021 to September 2022), 1 (0.6%) withdrew consent, 8 (4.8%) without android smart phones, 3 (1.8%) inconsistent with BP measurement over a 5-week run-in period, and 23 (11.3%) who did not meet the inclusion criteria were excluded from this analysis. Of the 136 subjects randomised, 75 (54.4%) were women, 68 (50.0) were obese and 66 (48.5%) had uncontrolled office BP. The time taken to train subjects on HTM averaged at 8.1±3.4 minutes. So far, 44, 236 BP measurements were taken. Overall, the median annual number of BP measurements in the first and second year were 36 and 127 respectively, with monthly median measurements ranging from 12 in August of the first year to 49 measurements in November of the same year. More than 50% of the subjects measured their BP at least 2 times weekly in all but the first quarter of the first year. The average monthly systolic and diastolic BP in each of the 18 months were less than 135mmHg and 85 mmHg respectively. Conclusion: HTM is feasible in clinical trial settings and thus can be integrated into the routine clinical practice in Nigeria.

The potential of blood pressure telemonitoring: experience in the UK and Japan.

Hypertension is the most important and modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality worldwide, and a growing issue as the global population with hypertension increases (estimated to be 626 million women and 652 million men in 2019, almost double the number in 1990). In addition, global control rates for hypertension remain poor: 23% for women and 18% for men in 2019 (Lancet. 2021:957). Measures to reduce the number of poorly controlled hypertensive patients are urgently needed. Remarkable advances in healthcare technology have changed healthcare delivery dramatically in the last decade with out-of-office blood pressure (BP) telemonitoring being widely used in clinical research (Hypertension. 2020:1368). We have demonstrated the efficacy of BP telemonitoring and digital intervention for the management of hypertension in the Telemonitoring And Self-Management IN the control of Hypertension (TASMINH) trials (Lancet. 2010:163, JAMA. 2014:799, Lancet. 2018:949), the Home and Online Management and Evaluation of Blood Pressure (HOME BP) trial (BMJ. 2021:m4858), and the HERB Digital Hypertension 1(HERB-DH1) pivotal trial (Eur Heart J. 2021:4111). A recent meta-analysis found that home BP telemonitoring improved office systolic BP (SBP) by 3.99 mmHg and home BP telemonitoring plus additional support (e.g., counselling and medications management) also showed a reduction of office SBP by 2.44 mmHg versus home BP telemonitoring alone (J Hum Hypertens. 2017:427). This evidence suggests that BP telemonitoring is an optimal tool for reducing BP levels and that combining BP telemonitoring and co-interventions would be the most effective approach for the management of hypertension. There are additional benefits from BP telemonitoring system in clinical practice, including assessment of accurate and reliable out-of-office BP data, and ease of BP measurement and recording by patients without the need for manual systems. Furthermore, such systems can reduce nonadherence of antihypertensive medications and clinical inertia, both of which contribute to a treatment-resistant hypertension (J Hypertens. 2017:2346, J Hypertens. 2021:1238). In practical terms, telemonitoring also facilitates optimal BP management for patients living in geographically remote or poorly medically resourced areas (Hypertension. 2021:1927). In this session, through discussion of the evidence base and clinical experience in the UK and Japan, we will examine the prospects of BP telemonitoring systems for the future management of hypertension. We will examine how BP telemonitoring systems are used and affect BP control in both clinical trials and subsequent implementation. In addition, by comparing such work in the UK and Japan, we will assess the potential of BP telemonitoring systems as a solution to the inadequate BP control status worldwide.

Differentiated Effects and Determinants of Home Blood Pressure Telemonitoring: Three-Year Cohort Study in Jieshou, Anhui, China.

BackgroundHome blood pressure telemonitoring (HBPT) is witnessing rapid diffusion worldwide. Contemporary studies documented mainly short-term (6-12 months) effects of HBPT, and there are limited data about its uptake.ObjectiveThe aim of this study was to explore the 3-year use and determinants of HBPT, and the interactions with systolic and diastolic blood pressure (SBP/DBP) and overall blood pressure (BP) control rate.MethodsHBPT records were obtained from a 3-year cohort of 5658 patients with hypertension in Jieshou, Anhui, China, and data from a structured household survey of a random sample (n=3005) of the cohort. The data analysis comprised (1) timeline trajectories of the rates of monthly active HBPT and mean SBP/DBP for overall and subgroups of patients with varied start-month SBP/DBP; and (2) multivariable linear, logistic, and percentile regression analyses using SBP/DBP, BP control rate, and yearly times of HBPT as the dependent variable, respectively.ResultsHBPT was followed by mixed changes in mean monthly SBP/DBP for varied patient groups. The magnitude of changes ranged from –43 to +39 mmHg for SBP and from –27 to +15 mmHg for DBP. The monthly rates of active HBPT all exhibited a rapid and then gradually slower decline. When controlled for commonly reported confounders, times of HBPT in the last year were found to have decreasing correlation coefficients for SBP/DBP (from 0.16 to –0.35 and from 0.11 to –0.35, respectively) and for BP control rate (from 0.53 to –0.62).ConclusionsHBPT had major and “target-converging” effects on SBP/DBP. The magnitude of changes was much greater than commonly reported. BP, variation in BP, and time were the most important determinants of HBPT uptake. Age, education, duration of hypertension, family history, and diagnosis of hypertension complications were also linked to the uptake but at weaker strength. There is a clear need for differentiated thinking over the application and assessment of HBPT, and for identifying and correcting/leveraging potential outdated/new opportunities or beliefs.

Automatic transmission of home blood pressure data can be effective in managing hypertension: a systematic review and meta-analysis.

Home blood pressure telemonitoring (HBPT) is a useful way to manage BP. Recent advances in digital technology to automatically transmit BP data without the patient input may change the approach to long-term BP treatment and follow-up. The purpose of this review is to summarize the latest data on the HBPT with automatic data transmission. Articles in English from 1980 to 2021 were searched by electronic databases. Randomized controlled trials comparing HBPT with automatic data transmission with usual BP management and including systolic BP (SBP) and/or diastolic BP (DBP) as outcomes in hypertension patients were included in the systematic review. A meta-analysis was conducted. After removing duplicates, 474 papers were included and 23 papers were identified. The HBPT with automatic data transmission had a significant beneficial impact on BP reduction (mean difference for office SBP -6.0 mm Hg; P < 0.001). Subgroup analyses showed that the studies using smartphone applications reduced BP significantly more in the intervention group than in the control group (standardized mean difference for office and home SBP -0.25; P = 0.01) as did the studies using HBPT other than the applications. Longer observation periods showed a sustained effect, and multidisciplinary cooperation was effective. This review suggests that a care path based on HBPT with automatic data transmission can be more effective than classical management of hypertension. In particular, the studies using smartphone applications have shown beneficial effects. The results support the deployment of digital cardiology in the field of hypertension management.

Abstract P223: Hypertension Telemonitoring And Protocolized Case Management For Community-Dwelling Older Adults: A Randomized Controlled Trial

Background: Home blood pressure (BP) telemonitoring combined with case management leads can reduce BP in adults with hypertension. However, the benefits of telemonitoring and case management for hypertension are not well established in older (age &gt;= 65 years) adults. Interventions that can safely improve BP control in this distinct group will be critically important, particularly given recent trials showing cardiovascular benefits of intensive BP lowering in this group, and their increased vulnerability to over-treatment-related side effects. Methods: Twelve-month, open-label, randomized controlled trial of community-dwelling older adults comparing home BP telemonitoring (HBPM) with pharmacist-led case management versus enhanced usual care with HBPM alone. The primary outcome was the proportion achieving age-specific systolic BP targets on 24-hour ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regression were used for analyses, with adjustment for baseline BP. Results: Subjects randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age of 79.5 years. The adjusted odds ratio (aOR) for ABPM BP target achievement was 1.48 (95% CI 0.87-2.52, p = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (p-value 0.26 for systolic and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (p-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group subjects had a higher rate of systolic BP &lt; 110 (21% vs 5%, p = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or ED visits. Adherence to HBPM declined by 12 months, with 65% of trial-completers providing all 4 of the study-driven 3-monthly HBPM series. Conclusions: Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It was not associated with major adverse consequences. Further trials will be necessary to refine HBPM interventions, improve adherence, and determine effectiveness in older individuals more conclusively.

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

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. To examine the impact of the BPT program on the use of medical resources. 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. 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. A community-based integrated BPT program may improve patients' health outcomes and reduce healthcare costs.

Telemonitoring and protocolized case management for hypertensive community dwelling older adults (TECHNOMED): a randomized controlled trial.

Home blood pressure (BP) telemonitoring combined with case management leads to BP reductions in individuals with hypertension. However, its benefits are less clear in older (age ≥ 65 years) adults. Twelve-month, open-label, randomized trial of community-dwelling older adults comparing the combination of home BP telemonitoring (HBPM) and pharmacist-led case management, vs. enhanced usual care with HBPM alone. The primary outcome was the proportion achieving systolic BP targets on 24-h ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regressions were used for analyses, adjusted for baseline BP. Enrollment was stopped early due to coronavirus disease 2019. Participants randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age 79.5 years. The adjusted odds ratio for ABPM BP target achievement was 1.48 (95% confidence interval 0.87-2.52, P = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (P-value 0.26 for systolic BP and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (P-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group participants had hypotension (systolic BP < 110) more frequently (21% vs. 5%, P = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or emergency department visits. Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It did not result in major adverse consequences.

Telemonitoring and Case Management for Hypertensive and Remote-Dwelling Patients With Chronic Kidney Disease-The Telemonitoring for Improved Kidney Outcomes Study (TIKO): A Clinical Research Protocol.

Background:Hypertension, together with poorly controlled blood pressure (BP) are known risk factors for kidney disease and progression to kidney failure as well as increased cardiovascular (CV) morbidity and mortality. Several studies in patients without kidney disease have demonstrated the efficacy of home BP telemonitoring (HBPT) for BP control.Objective:The primary aim of this study is to assess the mean difference in systolic BP (SBP) at 12 months, from baseline in remote dwelling patients with hypertension and chronic kidney disease (CKD) in Northern Alberta, Canada, comparing HBPT + usual care versus HBPT + a case manager. Other secondary objectives, including cost-effectiveness and acceptability of HBPT as well as occurrence of adverse events will also be assessed.MethodsDesign:This study is designed as a pragmatic randomized controlled trial (RCT) of HBPT plus clinical case management compared to HBPT with usual care.Setting:Peace River region in Northern Alberta Region, Canada.Patients:Primary care patients with CKD and hypertension.Measurements:Eligible patients will be randomized 1:1 to HBPT + BP case management versus HBPT + usual care. In the intervention arm, BP will be measured 4 times daily for 1 week, with medications titrated up or down by the study case manager until guideline targets (systolic BP [SBP]: <130 mmHg) are achieved. Once BP is controlled, (ie, to guideline-concordant targets), this 1-week protocol will be repeated every 3 months for 1 year. Patients in the control arm will also follow the same BP measurement protocol; however, there will be no interactions with the case manager; they will share their BP readings with their primary care physicians or nurse practitioners at scheduled visits.Limitations:Potential limitations of this study include the relatively short duration of follow-up, possible technological pitfalls, and need for patients to own a smartphone and have access to the internet to participate.Conclusions:As this study will focus on a high-risk population that has been characterized by a large care gap, it will generate important evidence that would allow targeted and effective population-level strategies to be implemented to improve health outcomes for high-risk hypertensive CKD patients in Canada’s remote communities.Trial Registration:www.clinicaltrials.gov (NCT number: NCT04098354)

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

Efficacy of Telemedicine in Hypertension Care Through Home Blood Pressure Monitoring and Videoconferencing: Randomized Controlled Trial.

BackgroundThe burden of time is often the primary reason why patients discontinue their treatment. Telemedicine may help patients adhere to treatment by offering convenience.ObjectiveThis study examined the efficacy and safety of telemedicine for the management of hypertension in Japan.MethodsPatients with uncomplicated hypertension were recruited through web advertising between November 2015 and February 2017. They were then screened, stratified by office systolic blood pressure (SBP), and randomized into two groups: usual care (UC) and telemedicine. The telemedicine group used a 3G network–attached home blood pressure (BP) monitoring device, consulted hypertension specialists from an academic hospital through web-based video visits, and received prescription medication by mail for 1 year. The UC group used the same BP monitoring device but was managed using self-recorded BP readings, which included their diary entries and office BP taken in a community practice setting.ResultsInitial screening was completed by 99 patients, 54% of whom had untreated hypertension. Baseline BP was similar between the groups, but the weekly average SBP at the end of the 1-year study period was significantly lower in the telemedicine group (125, SD 9 mmHg vs 131, SD 12 mmHg, respectively; P=.02). SBP in the telemedicine group was 3.4 mmHg lower in the morning and 5.8 mmHg lower in the evening. The rate of SBP control (135 mmHg) was better in the telemedicine group (85.3% vs 70.0%; P=.01), and significant adverse events were not observed.ConclusionsWe present evidence suggesting that antihypertensive therapy via home BP telemonitoring and web-based video visits achieve better BP control than conventional care and is a safe treatment alternative that warrants further investigation.Trial RegistrationUMIN-CTR UMIN000025372; https://tinyurl.com/47ejkn4b

Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial: rational and protocol

Background Hypertension and diabetes cause chronic kidney disease (CKD) and diastolic left ventricular dysfunction (DVD) as forerunners of disability and death. Home blood pressure telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling prevention. Methods UPRIGHT-HTM (Urinary Proteomics Combined with Home Blood Pressure Telemonitoring for Health Care Reform [NCT04299529]) is an investigator-initiated 5-year clinical trial with patient-centred design, which will randomise 1148 patients to be recruited in Europe, sub-Saharan Africa and South America. During the whole study, HTM data will be collected and freely accessible for patients and caregivers. The UPP, measured at enrolment only, will be communicated early during follow-up to 50% of patients and their caregivers (intervention), but only at trial closure in 50% (control). The hypothesis is that early knowledge of the UPP risk profile will lead to more rigorous risk factor management and result in benefit. Eligible patients, aged 55–75 years old, are asymptomatic, but have ≥5 CKD- or DVD-related risk factors, preferably including hypertension, type-2 diabetes, or both. The primary endpoint is a composite of new-onset intermediate and hard cardiovascular and renal outcomes. Demonstrating that combining UPP with HTM is feasible in a multicultural context and defining the molecular signatures of early CKD and DVD are secondary endpoints. Expected outcomes The expected outcome is that application of UPP on top of HTM will be superior to HTM alone in the prevention of CKD and DVD and associated complications and that UPP allows shifting emphasis from treating to preventing disease, thereby empowering patients.

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.

Primary care physician perspectives on using team care in clinical practice

BackgroundPrimary care physicians were prompted to refer eligible patients with uncontrolled hypertension (HTN) to a program that offered home blood pressure telemonitoring and pharmacist care management. Understanding attitudes, barriers and facilitators, and use of team care in this program provides insight into how physicians incorporate team care into their practice. ObjectiveTo understand physician attitudes and use of team care in the context of a study intervention that included telehealth care with pharmacist care management. MethodsClinicians who were part of the telehealth intervention arm of the Hyperlink 3 study and had at least 20 opportunities to refer an eligible patient with HTN to a clinical pharmacist were invited to be interviewed. Nine physician interviews were conducted, recorded, and transcribed. Each interview lasted approximately 30 minutes and followed an interview guide, allowing for some variation and deeper dives into content on the basis of the clinician response. Three research staff coded each interview and sorted coded text to identify patterns at the physician level and then identified themes across interviews using a comparative process. ResultsPhysicians had an overall positive attitude about team care. Communication, access, trust, and perceived role competency of team members influenced physician engagement in team care. Individualized practice styles influenced how physicians used team care and which care team members they involved most often. All physicians felt that their individual style best achieved high-quality care. ConclusionFor health care teams to be most effective, an understanding of how a physician’s practice style influences their use of team care is likely to be more successful than a one-size-fits-all approach. Incorporating practice style into the key factors necessary for high-functioning teams, such as communication, access, and trust, is necessary for health care teams to thrive.

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

Background Several interventions have been proposed to improve hypertension control with various outcomes. The home blood pressure (HBP) measurement is widely accepted for assessing the response to medications. However, the enhancement of blood pressure (BP) control with HBP telemonitoring technology has yet to be studied in Thailand. Objective To evaluate the attainment of HBP control and drug prescription patterns in Thai hypertensives at one year after initiating the TeleHealth Assisted Instrument in Home Blood Pressure Monitoring (THAI HBPM) nationwide pilot project. Methods A multicenter, prospective study enrolled treated hypertensive adults without prior regular HBPM to obtain monthly self-measured HBP using the same validated, oscillometric telemonitoring devices. The HBP reading was transferred to the clinic via a cloud-based system, so the physicians can adjust the medications at each follow-up visit on a real-life basis. Controlled HBP is defined as having HBP data at one year of follow-up within the defined target range (<135/85 mmHg). Results A total of 1,177 patients (mean age 58 ± 12.3 years, 59.4% women, 13.1% with diabetes) from 46 hospitals (81.5% primary care centers) were enrolled in the study. The mean clinic BP was 143.9 ± 18.1/84.3 ± 11.9 mmHg while the mean HBP was 134.4 ± 15.3/80.1 ± 9.4 mmHg with 609 (51.8%) patients having HBP reading <135/85 mmHg at enrollment. At one year of follow-up after implementing the HBP telemonitoring, 671 patients (57.0%) achieved HBP control. Patients with uncontrolled HBP had a higher prevalence of dyslipidemia and greater waist circumference than the controlled group. The majority of uncontrolled patients were still prescribed only one (36.0%) or two drugs (34.4%) at the end of the study. The antihypertensive drugs were not uptitrated in 136 (24%) patients with uncontrolled HBP at baseline. Calcium channel blocker was the most prescribed drug class (63.0%) followed by angiotensin-converting enzyme inhibitor (44.8%) while the thiazide-type diuretic was used in 18.9% of patients with controlled HBP and 16.4% in uncontrolled patients. Conclusion With the implementation of HBP telemonitoring, the BP control rate based on HBP analysis was still low. This is possibly attributed to the therapeutic inertia of healthcare physicians. Calcium channel blocker was the most frequently used agent while the diuretic was underutilized. The long-term clinical benefit of overcoming therapeutic inertia alongside HBP telemonitoring needs to be validated in a future study.

POS-339 IMPACT OF HOME TELEMONITORING AND MANAGEMENT SUPPORT ON BLOOD PRESSURE CONTROL IN NON-DIALYSIS CKD: A SYSTEMATIC REVIEW AND META-ANALYSIS

Hypertension is a major cause of cardiovascular disease, chronic kidney disease (CKD), and death. Several studies have demonstrated the efficacy of using home blood pressure telemonitoring (HBPT) for BP control and outcomes, but the effects of this intervention remain unclear in patients with CKD. We searched MEDLINE, Embase, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Web of Science, and Dissertations and Theses for studies in non-dialysis CKD using HBPT for BP control as well as evaluation of other outcomes. We analyzed systolic blood pressure (SBP), diastolic blood pressure (DBP), estimated glomerular filtration rate (eGFR), and change in number of anti-hypertensives using a random effects model. We selected seven studies from 1,669 articles that were initially identified. Four studies were included in meta analysis for BP (Figure 1). Overall, pooled estimates in the mean difference (MD) for SBP and DBP was -8.8 mmHg; 95% CI: -16.2, -1.4; P=0.02 and -2.4 mmHg; 95% CI: -3.8, -1.0; P<0.001, respectively. For studies comparing intervention with usual care (UC), pooled estimates in MD for SBP was -7.9 mmHg; P=0.02) with no significant reduction for DBP (-2.6 mmHg; P=0.18). For studies without a UC arm, both SBP and DBP were not significantly reduced (p>0.05) (Figure 2). Two studies with a UC arm and baseline eGFR values that were not significantly different evaluated changes of eGFR after 6 months of follow-up in 79 participants. The pooled results showed a significant difference (MD: 5.35 mL/min/1.73m2; 95% CI: 2.49 to 8.21; I2= 0.0%; P<0.001) (Figure 3). However, sensitivity analysis using the follow-up measurements showed a non-significant difference (MD: 5.66 mL/min/1.73m2; 95% CI: − 1.51 to 12.83; I2= 0.0%; P=0.12) (Figure 2). Only one study reported the changes in number of hypertensive medications after 6 months of follow-up (MD: 2.63; 95% CI: − 6.52 to 1.26; I2= 0.0%). Figure 1: PRIMSA flow chart of study selection and inclusion Figure 2: Forest plot and meta-analysis for the effect of HBPT on SBP, DBP, and eGFR using 6-month follow-up mean values (sensitivity analysis). Figure 3: Forest plot and meta-analysis for the effect of HBPT on SBP, DBP, and eGFR after 6 months of follow-up. Our study shows that HBPT is associated with significant reduction of SBP and a significant improvement of kidney function, likely modulated by HBPT effects on BP. However, larger studies with improved designs and prolonged intervention periods are still needed to assess the effects of HBPT on patients’ outcomes including BP, kidney function and non-fatal and fatal CV events in patients with CKD.

Abstract 15008: Improvement in Patient Ratings of Hypertension Care in a Pragmatic Cluster-randomized Trial of Home Blood Pressure Telemonitoring and Pharmacist Care (Hyperlink 3)

Introduction: Patient ratings of their experience of care are part of the “Triple Aim”. Improvements are highly valued by health care organizations, but are hard to achieve. Hypothesis: We tested the effect of a telehealth intervention on satisfaction with hypertension care. Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072 patients with uncontrolled hypertension in 21 primary care clinics in HealthPartners, an integrated health system in Minnesota and Wisconsin. Clinics were randomized to Clinic-based Care (CC, 9 clinics, 1648 patients) or Telehealth Care (TC, 12 clinics, 1424 patients). CC patients received guideline-based hypertension care in face-to-face visits. TC patients were additionally offered home blood pressure (BP) telemonitoring with pharmacist care management. Patients were surveyed at baseline and after 6 months of study enrollment and asked to rate their hypertension care in the previous 6 months on a scale of 0-10. We compared change in the proportion of patients rating their care at the highest level (9 or 10). Results: In the TC group, about 37% of patients attended an intake pharmacist visit and 434 (30%) participated in home BP telemonitoring. Baseline surveys were completed by 1719 (56%) of patients at baseline (goal 50% completion) and 1301 (76%) of those completing the baseline survey completed the 6 month survey (goal 75% completion). Baseline survey respondents’ mean age was 62 y (non-respondents 58 y), 46% were men (non-respondents 48%), 19% were black (non-respondents 20%), and mean BP was 164/93 mm Hg (non-respondents 164/95 mm Hg.) Nearly all patients (over 90%) took antihypertensive medications (median 2). Hypertension care ratings of 9 or 10 were 27.9% at baseline and 30.2% at 6 months in CC, compared with 29.0% at baseline and 39.5% at 6 months in TC. The odds ratio (OR) for change over time in 9 or 10 ratings was 1.11 (95% CI 0.87 - 1.42) in CC, and 1.61 (95% CI 1.26 - 2.07) in TC. The OR for change in 9 or 10 ratings over time in TC vs CC was 1.45 (95% CI 1.03 - 2.06). Conclusions: Home BP telemonitoring with pharmacist care management increased the proportion of patients who highly rated their experience of hypertension care, even though only a minority of the TC patients received the intervention.

Abstract P165: Improvement In Self-monitoring Frequency, Electronic Data Sharing, And Medication Changes In A Pragmatic Cluster-randomized Trial Of Home Blood Pressure Telemonitoring And Pharmacist Care (Hyperlink 3)

Introduction: Telehealth and remote monitoring have become critical to patient access to care during the COVID-19 pandemic. We measured the effect of a telehealth care intervention on frequency, sharing methods, and clinical usage of home blood pressure (BP) measurements. Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072 patients with uncontrolled hypertension in 21 primary care clinics in an integrated health system. Clinics were randomized to Clinic-based Care (CC, 9 clinics, 1648 patients) or Telehealth Care (TC, 12 clinics, 1424 patients). TC patients were offered home BP telemonitoring with pharmacist care management. Patients were surveyed at baseline (Nov 2017 - Apr 2019) and after 6 mo of study enrollment. Results: In the TC group, about 37% of patients attended an intake pharmacist visit and 434 (30%) participated in home BP telemonitoring. Baseline surveys were completed by 1719 (56%) of patients at baseline (goal 50%) and 1301 (76%) of those completing the baseline survey completed the 6 mo survey (goal 75%). Baseline survey respondents' mean age was 62, 46% were men, 19% were black, and mean BP was 164/93 mm Hg. Nearly all patients (&gt;90%) took antihypertensive medications (median 2). The odds ratio (OR) for change in measuring BP &gt; 2 times/week vs. less often was 0.97 (95% CI 0.87 - 1.42) in CC, and 2.01 (95% CI 1.56 - 2.59) in TC. The OR for change in frequent measurement in TC vs CC was 2.08 (95% CI 1.45 - 2.97). Conclusions: A telehealth care intervention markedly increased the frequency of home BP self- monitoring, electronic data sharing, and data-driven BP medication changes, even though only a minority of TC patients received the intervention.

Cardiovascular Events and Costs With Home Blood Pressure Telemonitoring and Pharmacist Management for Uncontrolled Hypertension.

Uncontrolled hypertension is a leading contributor to cardiovascular disease. A cluster-randomized trial in 16 primary care clinics showed that 12 months of home blood pressure telemonitoring and pharmacist management lowered blood pressure more than usual care (UC) for 24 months. We report cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, hospitalized heart failure, coronary revascularization, and cardiovascular death) and costs over 5 years of follow-up. In the telemonitoring intervention (TI group, n=228), there were 15 cardiovascular events (5 myocardial infarction, 4 stroke, 5 heart failure, 1 cardiovascular death) among 10 patients. In UC group (n=222), there were 26 events (11 myocardial infarction, 12 stroke, 3 heart failure) among 19 patients. The cardiovascular composite end point incidence was 4.4% in the TI group versus 8.6% in the UC group (odds ratio, 0.49 [95% CI, 0.21-1.13], P=0.09). Including 2 coronary revascularizations in the TI group and 10 in the UC group, the secondary cardiovascular composite end point incidence was 5.3% in the TI group versus 10.4% in the UC group (odds ratio, 0.48 [95% CI, 0.22-1.08], P=0.08). Microsimulation modeling showed the difference in events far exceeded predictions based on observed blood pressure. Intervention costs (in 2017 US dollars) were $1511 per patient. Over 5 years, estimated event costs were $758 000 in the TI group and $1 538 000 in the UC group for a return on investment of 126% and a net cost savings of about $1900 per patient. Telemonitoring with pharmacist management lowered blood pressure and may have reduced costs by avoiding cardiovascular events over 5 years. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781365.

Urinary Proteomics Combined With Home Blood Pressure Telemonitoring for Health Care Reform

Urinary Proteomics Combined With Home Blood Pressure Telemonitoring for Health Care Reform