Hypertension in Urban Underserved Subjects Using Telemedicine
We tested a telephone- and Internet- based hypertension self-monitoring intervention for BP control in an urban underserved population. Although more than 50% of subjects in the telemedicine group achieved the goal BP of <140 mm Hg, the control group demonstrated a similar proportion of patients reaching the goal BP. Although the primary end point was not achieved because of improved BP in the control group, the magnitude of the BP change was greater in the telemedicine group. This finding suggests that telemedicine subjects received more intensive therapy for hypertension, a finding supported by the greater number of medications prescribed in the telemedicine group. Improvements were accomplished in a population of which half are at or below the poverty level, and about 20% are insured by Medicaid or are without health insurance. The findings indicate that urban underserved subjects with hypertension can be managed in a fashion already demonstrated to be successful in more affluent populations.
Subgroup analysis comparing nondiabetic to diabetic patients showed striking differences in response. Nondiabetic telemedicine subjects had a greater reduction in systolic BP at 6 months compared with control subjects and a greater proportion of telemedicine subjects reaching goal compared with diabetic patients. Control and telemedicine diabetic subjects showed similar reductions in systolic BP over the 6-month study.
Patients in both the telemedicine and the control groups reported a high level of medication adherence. The data were obtained from individual questionnaires. There was a significant increase in the number of hypertension medications in the telemedicine group that was not seen in the controls. Because these are prescription medications, it is evident that the telemedicine system also encouraged better BP management by the care providers who received a monthly report with BP and medication information for patients in the telemedicine group. Similar findings were reported by Crowley et al, who notified providers when elevated BP was reported via a nurse-managed telemedicine system.
Two-thirds of telemedicine subjects used the telephone system instead of the Internet system, likely reflecting the lack of access to computers in the underserved neighborhoods. On the other hand, cell phone use is ubiquitous and therefore the communication choice for most subjects. Telephone systems have been used successfully to improve outcome in chronic disease. Subjects not achieving BP control for more than 1 year used a telephone monitoring device to communicate with their care provider. Within 1 month, systolic and diastolic BPs were significantly reduced compared with usual care. Other studies support the value of a telephonic system for communicating self-measured BP to a care provider. In a prior study, we demonstrated that a telemedicine system coupled with self-measured health status can reduce CVD risk.
The study by Wakefield et al showed a greater BP reduction in telemedicine subjects with diabetes and hypertension. In the present study, our diabetic subjects showed reductions in BP in the telemedicine and control groups. This finding suggests that diabetic patients, already educated on glucose monitoring and self-management, when made aware of their BP, apply the same behavior to BP control. On the other hand, nondiabetic hypertensive subjects showed a significant difference in BP reduction when comparing telemedicine and control groups. The telemedicine subjects achieved their goal BP, performing an average of 1.8 measures per week. Evaluation of usage in this study suggests that 3 measures per month are adequate to achieve the needed adherence for BP control.
It is unclear why the control group showed a significant reduction in BP. Although no intervention was provided to the controls, they had their BP measured, were informed of the elevated value, and were advised to seek care from their care provider and to report to the research center in 6 months for follow-up. This much intervention, particularly in nondiabetic patients with no other incentive for seeking health care, appears to be effective in encouraging positive health behavior. These results are similar to the results of McManus et al, who found a 12.2-mm reduction in systolic BP in their controls compared with a 17.6-mm reduction in the telemedicine intervention group.
Although mortality from CVD in the United States has declined over the past 30 years, it has increased in underserved communities because of hypertension, diabetes, and obesity. The African American community has a higher incidence of hypertension that adds considerable risk for CVD. Population studies indicate that about 100 million US adults have increased cardiovascular risk, and recent federal initiatives have targeted reduction in CVD risk as a major policy. Managing this large at-risk population based only on physician office encounters is likely to fail because of the shortage of physicians, the high cost, and the inconvenience of repeated office visits for care. Patient-centered care principles where the individual becomes a part of the care team, electronic bidirectional communication with a care team, and readily accessible health measures would allow large-scale screening and management through a care team. Although we did not measure CVD events, it is likely that the system used in this study can be sustained as a reminder and reporting system over a longer term to reduce acute CVD event rates. The demonstrated improvement in both the control and the intervention groups suggests that minimal engagement would be needed to improve BP control. The telemedicine system provides a component of automation to the program, thus expanding the capability of the care providers to handle larger numbers of patients.
This is a clinical trial in a specific group of urban underserved subjects, most of whom are African American. The results therefore may not be generalizable to different ethnic or socioeconomic groups. We did not collect economic data and therefore cannot comment on relative costs to maintain the communication system or the savings associated with improved cardiovascular risk. The telemedicine system costs would be less than $50.00 per year, whereas the care team cost would be justified by the reduced cost of care for acute events (stroke, myocardial infarction, heart failure, renal failure). Economic reviews of telemedicine systems for BP management are generally favorable.
Discussion
We tested a telephone- and Internet- based hypertension self-monitoring intervention for BP control in an urban underserved population. Although more than 50% of subjects in the telemedicine group achieved the goal BP of <140 mm Hg, the control group demonstrated a similar proportion of patients reaching the goal BP. Although the primary end point was not achieved because of improved BP in the control group, the magnitude of the BP change was greater in the telemedicine group. This finding suggests that telemedicine subjects received more intensive therapy for hypertension, a finding supported by the greater number of medications prescribed in the telemedicine group. Improvements were accomplished in a population of which half are at or below the poverty level, and about 20% are insured by Medicaid or are without health insurance. The findings indicate that urban underserved subjects with hypertension can be managed in a fashion already demonstrated to be successful in more affluent populations.
Subgroup analysis comparing nondiabetic to diabetic patients showed striking differences in response. Nondiabetic telemedicine subjects had a greater reduction in systolic BP at 6 months compared with control subjects and a greater proportion of telemedicine subjects reaching goal compared with diabetic patients. Control and telemedicine diabetic subjects showed similar reductions in systolic BP over the 6-month study.
Patients in both the telemedicine and the control groups reported a high level of medication adherence. The data were obtained from individual questionnaires. There was a significant increase in the number of hypertension medications in the telemedicine group that was not seen in the controls. Because these are prescription medications, it is evident that the telemedicine system also encouraged better BP management by the care providers who received a monthly report with BP and medication information for patients in the telemedicine group. Similar findings were reported by Crowley et al, who notified providers when elevated BP was reported via a nurse-managed telemedicine system.
Two-thirds of telemedicine subjects used the telephone system instead of the Internet system, likely reflecting the lack of access to computers in the underserved neighborhoods. On the other hand, cell phone use is ubiquitous and therefore the communication choice for most subjects. Telephone systems have been used successfully to improve outcome in chronic disease. Subjects not achieving BP control for more than 1 year used a telephone monitoring device to communicate with their care provider. Within 1 month, systolic and diastolic BPs were significantly reduced compared with usual care. Other studies support the value of a telephonic system for communicating self-measured BP to a care provider. In a prior study, we demonstrated that a telemedicine system coupled with self-measured health status can reduce CVD risk.
The study by Wakefield et al showed a greater BP reduction in telemedicine subjects with diabetes and hypertension. In the present study, our diabetic subjects showed reductions in BP in the telemedicine and control groups. This finding suggests that diabetic patients, already educated on glucose monitoring and self-management, when made aware of their BP, apply the same behavior to BP control. On the other hand, nondiabetic hypertensive subjects showed a significant difference in BP reduction when comparing telemedicine and control groups. The telemedicine subjects achieved their goal BP, performing an average of 1.8 measures per week. Evaluation of usage in this study suggests that 3 measures per month are adequate to achieve the needed adherence for BP control.
It is unclear why the control group showed a significant reduction in BP. Although no intervention was provided to the controls, they had their BP measured, were informed of the elevated value, and were advised to seek care from their care provider and to report to the research center in 6 months for follow-up. This much intervention, particularly in nondiabetic patients with no other incentive for seeking health care, appears to be effective in encouraging positive health behavior. These results are similar to the results of McManus et al, who found a 12.2-mm reduction in systolic BP in their controls compared with a 17.6-mm reduction in the telemedicine intervention group.
Although mortality from CVD in the United States has declined over the past 30 years, it has increased in underserved communities because of hypertension, diabetes, and obesity. The African American community has a higher incidence of hypertension that adds considerable risk for CVD. Population studies indicate that about 100 million US adults have increased cardiovascular risk, and recent federal initiatives have targeted reduction in CVD risk as a major policy. Managing this large at-risk population based only on physician office encounters is likely to fail because of the shortage of physicians, the high cost, and the inconvenience of repeated office visits for care. Patient-centered care principles where the individual becomes a part of the care team, electronic bidirectional communication with a care team, and readily accessible health measures would allow large-scale screening and management through a care team. Although we did not measure CVD events, it is likely that the system used in this study can be sustained as a reminder and reporting system over a longer term to reduce acute CVD event rates. The demonstrated improvement in both the control and the intervention groups suggests that minimal engagement would be needed to improve BP control. The telemedicine system provides a component of automation to the program, thus expanding the capability of the care providers to handle larger numbers of patients.
Limitations
This is a clinical trial in a specific group of urban underserved subjects, most of whom are African American. The results therefore may not be generalizable to different ethnic or socioeconomic groups. We did not collect economic data and therefore cannot comment on relative costs to maintain the communication system or the savings associated with improved cardiovascular risk. The telemedicine system costs would be less than $50.00 per year, whereas the care team cost would be justified by the reduced cost of care for acute events (stroke, myocardial infarction, heart failure, renal failure). Economic reviews of telemedicine systems for BP management are generally favorable.
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