Clinical Investigation
Hypertension
Managing hypertension in urban underserved subjects using telemedicine—A clinical trial

https://doi.org/10.1016/j.ahj.2013.01.004Get rights and content

Background

We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension.

Methods

A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months.

Results

Average age was 59.6 years, average body mass index was 33.7 kg/m2, 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: −13.9 mm Hg, T: −18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: −19 ± 20 mm Hg, C: −12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes.

Conclusion

In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

Section snippets

Methods

We conducted a randomized, controlled trial to test the hypothesis that self-monitoring of BP and an Internet- and telephone-based communication system will allow more patients to reach goal BP compared with usual care. We studied an urban population comprised mainly of African Americans with a high incidence of both hypertension and diabetes. Subjects were recruited from Temple University Medical Center in Philadelphia, Pennsylvania, and Christiana Health Care Center in Wilmington, Delaware,

Results

The study was conducted over a 4-year period. We recruited 241 subjects, of which 206 completed the 6-month study. Figure shows a flow diagram of the recruiting process. After screening, 241 patients were randomized into 121 controls and 120 telemedicine subjects. Table I shows the demographic characteristics of the subjects. African American subjects represented about 80% of the study population. Sixty-five percent were female, more than 50% had family incomes at or near the poverty level, and

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

Summary

In asymptomatic hypertensive individuals, engagement with a health care system was successful in reducing BP. Telemedicine appears to have little advantage, except in nondiabetic patients who showed a substantial improvement in BP control compared with control subjects. The increased number of antihypertensive medications noted in the telemedicine subjects suggests that physician reminders are an important part of hypertension management. The observation that BP was also reduced in the control,

Conclusion

In a community of low-income, underserved urban subjects with a high incidence of hypertension, we demonstrated that minimal engagement with a system of care resulted in a significant reduction of BP. Internet- and telephone-based communications coupled with self-measured BP and physician reminders showed a distinct advantage over usual care in asymptomatic nondiabetic subjects.

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