Evidence Based Medicine
Mini-CAT
You’ve just attended a dinner sponsored by a company that makes home blood pressure monitors for telehealth applications. It sounds interesting, but you want more information. What is the evidence that telehealth blood pressure monitoring improves blood pressure control in urban populations?
Clinical Question: Please state this as briefly as possible based on the scenario provided
Does telehealth blood pressure monitoring improve blood pressure control in urban populations?
PICO Question: Identify the PICO elements
P: hypertensive adults living in urban areas
I: home blood pressure monitor
C: office visit blood pressure monitor
O: controlled BP
What type of scenario is this?
□ Therapy/ Prevention □ Diagnosis □ Etiology □ Prognosis □ Screening □ Prevalence □ Harms
Type of study best to answer this question: (think about the level of evidence)
□ Meta-analysis □ Systematic Review □ Randomized Controlled Trial □ Cohort Study □ Case Control Study □ Case Series/Report
PICO Search Terms
| P | I | C | O |
| Urban | Home blood pressure monitoring | In-person visit | Controlled BP |
| Hypertension | Telehealth | Blood pressure monitoring | Stable BP |
| Adults | Health care professional | ||
| City | Office visit |
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on
PubMed: hypertension, telehealth, /Limits: adults, last 10 years → 181 results
PubMed: urban, hypertension, telehealth, /Limits: adults → 82 results
Cochrane: telehealth, blood pressure monitoring, /Limits: adults → 14 results
Articles Chosen for Inclusion (please copy and paste the abstract with link):
Article 1 – Home Blood Pressure Monitoring
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159400/
Hypertension is the most common preventable cause of cardiovascular disease. Home blood pressure monitoring (HBPM) is a self-monitoring tool that can be incorporated into the care for patients with hypertension and is recommended by major guidelines. A growing body of evidence supports the benefits of patient HBPM compared with office-based monitoring: these include improved control of BP, diagnosis of white-coat hypertension and prediction of cardiovascular risk. Furthermore, HBPM is cheaper and easier to perform than 24-hour ambulatory BP monitoring (ABPM). All HBPM devices require validation, however, as inaccurate readings have been found in a high proportion of monitors. New technology features a longer inflatable area within the cuff that wraps all the way round the arm, increasing the ‘acceptable range’ of placement and thus reducing the impact of cuff placement on reading accuracy, thereby overcoming the limitations of current devices.
Article 2 – Home blood pressure monitoring: primary role in hypertension management
https://pubmed.ncbi.nlm.nih.gov/24924993/
In the last two decades, considerable evidence on home blood pressure monitoring has accumulated and current guidelines recommend its wide application in clinical practice. First, several outcome studies have shown that the ability of home blood pressure measurements in predicting preclinical target organ damage and cardiovascular events is superior to that of the conventional office blood pressure measurements and similar to that of 24-hour ambulatory monitoring. Second, cross-sectional studies showed considerable agreement of home blood pressure measurements with ambulatory monitoring in detecting the white-coat and masked hypertension phenomena, in both untreated and treated subjects. Third, studies have shown larger blood pressure decline by using home blood pressure monitoring instead of office measurements for treatment adjustment. Fourth, in treated hypertensives, home blood pressure monitoring has been shown to improve long-term adherence to antihypertensive drug treatment and thus, has improved hypertension control rates. These data suggest that home blood pressure should no longer be regarded as only a screening tool that requires confirmation by ambulatory monitoring. Provided that an unbiased assessment is obtained according to current recommendations, home blood pressure monitoring should have a primary role in diagnosis, treatment adjustment, and long-term follow-up of most cases with hypertension.
Article 3 – Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial https://pubmed.ncbi.nlm.nih.gov/33468518/
The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management. Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded.
Article 4 – Integrating Out-Of-Office Blood Pressure in the Diagnosis and Management of Hypertension
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5068246/
Guidelines for the diagnosis and monitoring of hypertension were historically based on in-office blood pressure measurements. However, the United States Preventive Services Task Force recently expanded their recommendations on screening for hypertension to include out-of-office blood pressure measurements to confirm the diagnosis of hypertension. Out-of-office blood pressure monitoring, including ambulatory blood pressure monitoring and home blood pressure monitoring, are important tools in distinguishing between normotension, masked hypertension, white-coat hypertension, and sustained (including uncontrolled or drug-resistant) hypertension. Compared to in-office readings, out-of-office blood pressures are a greater predictor of renal and cardiac morbidity and mortality. There are multiple barriers to the implementation of out-of-office blood pressure monitoring which need to be overcome in order to promote more widespread use of these modalities.
Article 5 – Telehealth interventions: remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD)
Chronic obstructive pulmonary disease (COPD, including bronchitis and emphysema) is a chronic condition causing shortness of breath, cough, and exacerbations leading to poor health outcomes. Face‐to‐face visits with health professionals can be hindered by severity of COPD or frailty, and by people living at a distance from their healthcare provider and having limited access to services. Telehealth technologies aimed at providing health care remotely through monitoring and consultations could help to improve health outcomes of people with COPD. To assess the effectiveness of telehealth interventions that allow remote monitoring and consultation and multi‐component interventions for reducing exacerbations and improving quality of life, while reducing dyspnoea symptoms, hospital service utilisation, and death among people with COPD. Remote monitoring plus usual care provided asynchronously may not be beneficial overall compared to usual care alone. Some benefit is seen in reduction of COPD‐related hospital re‐admissions, but moderate‐certainty evidence is based on one study. We have not found any evidence for dyspnoea symptoms nor harms, and there is no difference in fatalities when remote monitoring is provided in addition to usual care. Remote monitoring interventions alone are no better than usual care overall for health outcomes. Multi‐component interventions with asynchronous remote monitoring are no better than usual care but may provide short‐term benefit for quality of life and may result in fewer re‐admissions to hospital for any cause. We are uncertain whether remote monitoring is responsible for the positive impact on re‐admissions, and we are unable to discern the long‐term benefits of receiving remote monitoring as part of patient care. Owing to paucity of evidence, it is unclear which COPD severity subgroups would benefit from telehealth interventions. Given there is no evidence of harm, telehealth interventions may be beneficial as an additional health resource depending on individual needs based on professional assessment. Larger studies can determine long‐term effects of these interventions.
Summary of the Evidence:
| # | Author (Date) | Level of Evidence | Sample/Setting(# of subjects/ studies, cohort definition etc. ) | Outcome(s) studied | Key Findings | Limitations and Biases |
| 1 | Jacob George and Thomas MacDonald (2015, June) | Systematic Review | RCT = 555 Retrospective analysis #1 = 163 Retro analysis #2 = 133 Prospective cohort | Screening for HTN and the advantages and limitations of HBPM | The use of HBPM devices is cost-effective and has stronger prognostic value in terms of CV risk when compared with clinic BP measurement. | Some automated devices are inaccurate in their readings (upper arm > wrist) Inappropriate cuff size Lack of nocturnal readings |
| 2 | George S Stergiou, Anastasios Kollias, Marilena Zeniodi, Nikos Karpettas, Angeliki Ntineri (2014, Aug) | Systematic review | RCT = 72 studies Sample size = 1350 | Prognostic ability Usefulness in tx adjustment Cost effectiveness | ABPM is expensive, not widely available, and less well-accepted by patients particularly for long-term use. HBPM is accepted widely by pts, low cost, good for long term follow up. | Reliability of the patient data Over and under reporting the BP values Standardization to ensure recommended schedule is being followed |
| 3 | Richard J McManus, Paul Little, et al. (2020, Oct) | RCT | # of subjects: 622 people with poorly controlled hypertensionParticipants were randomised into intervention group and usual care group Intervention group: self-monitoring of BP with a digital intervention (305 participant) Usual care group: routine HTN care visits (317 participants) Setting: 76 general practices in the United Kingdom | Primary outcome was the difference in systolic blood pressure after one year | Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2mmHg in the intervention group and from 151.6/85.3 to 141.8/79.8mmHg in the usual care group. The Home and Online Management and Evaluation of Blood Pressure (HOME BP) led to better control of systolic blood pressure after one year than usual care. Adverse events were similar to usual care. | Lack of data on drug adherence. The effect size in the trial was slightly smaller compared to another trial in a similar population. |
| 4 | Jordana B. Cohen and Debbie L. Cohen (2016, Nov) | Systematic Review | Not mentioned in the article* | The effectiveness of out-of-office (including ambulatory and home) blood pressure monitoring and how it improves care provided to patient | Out-of-office blood pressure monitoring provides superior prognostication of long-term renal and cardiac risk compared to in-office blood pressures. Additionally, ambulatory blood pressure monitoring and home blood pressure monitoring can have an important role in the verification and management of drug-resistant and pseudo resistant hypertensive patients. | Although the article mentions both automated and manual out-of-office blood pressures, the accuracy of these two methods are not mentioned. An improvement to this study would be to include which method of measuring BP is recommended, so that providers are not steered in the wrong direction. |
| 5 | Sadia Janjua, Deborah Carter, et al. (2021, July) | Systematic Review | 29 studies were included in the review (5654 participants with diagnosed COPD; male proportion 36% to 96%; female proportion 4% to 61%) | Outcomes studied for these populations were COPD‐related hospital re‐admissions. | Asynchronous remote monitoring is no better than usual care but may provide short‐term benefit for quality of life and may result in fewer hospital re‐admissions | Does not separate which COPD sub-groups would benefit from telehealth interventions Uncertain if the monitoring is directly responsible for reduced readmissions Unsure of long-term benefits of monitoring |
Conclusion(s):
Based on the conclusions of all of the articles, telehealth blood pressure monitoring improves blood pressure control in urban populations. It offers several benefits including low cost, convenience, prognostic ability, ease for long term follow-ups, and treatment management.
It has been shown to reduce COPD hospital readmissions and lower the systolic blood pressure in poorly controlled patients. Additionally, home blood pressure improves blood pressure control, as it has been proven to improve long-term renal and cardiac risk. It was also shown to help manage drug-resistant hypertensive patients. While home blood pressure monitoring gains more popularity, there are several limitations that need to be addressed for better accuracy. Further studies should be conducted to evaluate. 2
Clinical Bottom Line: (Please include an assessment of the worth to practice)
Taking at-home blood pressure allows more frequent monitoring, and improves patient autonomy over their well-being. It reduces health care disparities among low-income urban communities caused by the high patient to physician ratio as well as lack of access to a health care provider.
References:
Cohen, J. B., & Cohen, D. L. (2016). Integrating Out-of-Office Blood Pressure in the Diagnosis
and Management of Hypertension. Current cardiology reports, 18(11), 112.
https://doi.org/10.1007/s11886-016-0780-3
Janjua S, Carter D, Threapleton CJD, Prigmore S, Disler RT. Telehealth interventions: remote
monitoring and consultations for people with chronic obstructive pulmonary disease
(COPD). Cochrane Database of Systematic Reviews 2021, Issue 7. Art. No.: CD013196.
DOI: 10.1002/14651858.CD013196.pub2. Accessed 30 November 2021.
Kario K. (2020). Management of Hypertension in the Digital Era: Small Wearable Monitoring
Devices for Remote Blood Pressure Monitoring. Hypertension (Dallas, Tex. : 1979),
76(3), 640–650. https://doi.org/10.1161/HYPERTENSIONAHA.120.14742
McManus, R. J., Little, P., Stuart, B., Morton, K., Raftery, J., Kelly, J., Bradbury, K., Zhang, J.,
Zhu, S., Murray, E., May, C. R., Mair, F. S., Michie, S., Smith, P., Band, R., Ogburn, E., Allen, J., Rice, C., Nuttall, J., Williams, B., … HOME BP investigators (2021). Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial. BMJ (Clinical research ed.), 372, m4858. https://doi.org/10.1136/bmj.m4858
Stergiou GS, Kollias A, Zeniodi M, Karpettas N, Ntineri A. Home blood pressure monitoring:
primary role in hypertension management. Curr Hypertens Rep. 2014 Aug;16(8):462. doi: 10.1007/s11906-014-0462-8. PMID: 24924993. https://pubmed.ncbi.nlm.nih.gov/24924993/
