Telemonitoring for Hypertension Management: The Time Is Now

Introduction Over the past 2 years, the coronavirus disease 2019 pandemic has challenged our beliefs about the optimal way to deliver health care and has also revealed major deficiencies in the traditional health care model centered around fee-for-service structures (1). The pandemic also led to disruptive innovation by increasing exponentially the use of telemedicine to serve isolated patients. Furthermore, telehealth has indirectly allowed underserved populations, such as patients in rural areas and those with impaired mobility, to have access to services that were not readily available. In that regard, changes in health care delivery have the potential to benefit patients with hypertension, the most common and important risk factor for cardiovascular disease worldwide (2). However, the potential benefits of telehealth strategies for the management of hypertension are not only limited to improving access and accessibility and were highlighted before the pandemic by the 2017 Hypertension Clinical Practice Guidelines, which suggest that telehealth can be a useful adjunct to interventions shown to reduce BP for adults with hypertension (3). In fact, of common chronic conditions, hypertension may be best suited to telemonitoring and telehealth (2). Telemonitoring for Hypertension Telemonitoring for hypertension involves the remote measurement and transmission of BP, heart rate, and weight (2). Telemonitoring is just one aspect of a comprehensive telehealth program. Comprehensive telehealth for hypertension involves the provision of services via information communication technology, including phones, video visits, web-based technology, and email. Telehealth services can be multidisciplinary and include assessment of medication adherence, provision of education regarding diet and exercise, and one-on-one consultations (see Figure 1). Studies of telehealth-based hypertension management report a high average patient adherence and were very well received, with excellent acceptability (4). As discussed below, comprehensive telehealth programs are associated with treatment intensification and improved BP control. Figure 1.: Comprehensive, multidisciplinary hypertension telehealth programs improve blood pressure control. Utility of Out-of-Office BP Measurements and Transmission Using Telemonitoring Telemonitoring is ideally suited for hypertension. The rationale for using BP measurements outside of the traditional clinical setting is highly relevant for both the diagnosis and the management of hypertension as pointed out by the US Preventive Services Task Force, which recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment (5). The limitations of diagnosing hypertension solely in the office setting are well known and include measurement errors, the limited number of measurements that can be made, and the non-negligible prevalence of white-coat hypertension (WCH) and masked hypertension (MH) (6). In an international database of patients with CKD, the prevalence of MH was found to be 16%, whereas that of WCH was 20% (7). Relative to patients with sustained elevation in clinic and out-of-office BP, WCH appears to be a relatively low-risk condition (8). On the other hand, patients with MH are at increased risk for adverse cardiovascular and kidney events. This increased risk is seen in those with and without CKD. Moreover, self-monitoring is important because it empowers patients and promotes patient engagement and commitment to care (9). Beyond the location and the number of measurements, using the correct technique is key (10) and has been described in detail by all of the major bodies issuing hypertension guidelines (3, 11–14). Specific training is therefore important to ensure proper measurement technique and seems to be done so far in a minority of cases (15, 16). Passive measures that include posters, handouts, information booklets, and other educational tools are of limited value (17) ; teaching patients to perform self-measurements properly during office visits could be most effective. Video visits and adequacy of number of readings may be utilized to assess and monitor proper technique (18). The use of validated and calibrated upper-arm devices is critical for obtaining accurate BP measurements both in clinic and at home. Fortunately, several online listings of validated devices issued by national and international scientific societies are freely available and easily accessible (19–22). Timely communication of results with health care providers is important. Transmission of home BP recordings directly into electronic health records is now feasible from some home BP monitors or via mobile smartphone apps. Direct transmission of BPs into the electronic health record simplifies data collection, but whether it is associated with better outcomes is unknown. It is, however, important to note that self-monitoring alone is not associated with meaningful changes in mean clinic or ambulatory BP or the proportion of patients with controlled BP. Co-interventions are required to achieve BP control and include systematic medication titration, education, pharmacist co-management, and lifestyle counseling (23). An illustrative example is the HOME BP randomized trial where a digital intervention comprising self-monitoring of BP with reminders and predetermined drug changes combined with lifestyle change support resulted in better control of systolic BP compared to usual care, with low incremental costs (24). Reorganizing care with integration of allied health professionals for a team-based approach and empowerment of nurses and pharmacists to adjust antihypertensive therapy improves BP control (25). In the Hyperlink study (26, 27), using a cluster randomized trial design, investigators evaluated the effect of a telehealth intervention on BP control. The 12-month telehealth intervention included (1) home BP monitoring with transmission of BP data to a secure website and (2) pharmacist co-management, including hypertension and lifestyle education, medication review, and management of antihypertensive drug therapy. From a baseline of 148 mm Hg, the telehealth intervention resulted in lower BP at 12 months (126 versus 135 mm Hg in the usual care group) and at 18 months (127 versus 133 mm Hg in the usual care group). This improvement in BP in the telehealth arm was achieved through increased number of medication classes and a reduction in the proportion of participants who added salt to their food (27). Key components of the intervention included automated transmission of BP data, co-management by a multidisciplinary team, and a multifaceted intervention, including education and medication review. Moreover, the intervention had sustained effects for up to 12 months after the intervention ended; however, such effects were not sustained at 54 months, suggesting that long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention when needed (27). Finally, despite a cost of 1511 per patient, the Hyperlink telemonitoring intervention ended up with a net cost saving of 1900 per patient over 5 years due to a reduction in cardiovascular events (28). In addition to Hyperlink, a number of other randomized controlled trials have demonstrated that telemonitoring combined with lifestyle interventions and multidisciplinary care improves BP control (24, 29–31). These studies should inform multilevel implementation of telehealth and telemonitoring for BP control in routine clinical practice. Conclusion The expansion of telemonitoring is a welcome adjunct to the multiple strategies already implemented for the control of hypertension. The importance of acquiring longitudinal BP data outside the office for diagnosis and control makes hypertension an ideal candidate for telemonitoring. The plethora of available tools rendering the transmission of data feasible and accessible in a multitude of settings calls for further expansion of this modality. Recent changes in reimbursement policies provide coverage for self-measured BP monitoring (18). Telehealth programs should ensure accurate and reliable BP measurements using techniques adherent to guideline recommendations. Implementation of telehealth and telemonitoring programs need to account for the digital divide and avoid worsening inequities in communities that may not be digitally literate or financially capable of acquiring devices and the required technologies necessary to transmit home BPs. Telemonitoring should by no means replace in-person visits because this modality is not appropriate for all types of encounters. As is the case for any chronic disease, in-person interaction with providers is important for an optimal exchange of emotions and empathy and constitutes an essential therapeutic tool. In the future, determining the ideal ratio of in-person visits to virtual visits, the optimal use of remote device monitoring, and the right mix of health professionals will be important to optimizing hypertension care. Disclosures All authors have nothing to disclose. Funding None.