Commentary

Telemedicine Management of Hypertension vs Clinic-Based Hypertension Care in the United States

Michael J. Bloch, MD
Evan Bloch

Of the approximately 48% of American adults with hypertension, less than 45% have well-controlled blood pressure (BP).1 Most patients receiving hypertension treatment rely on a clinic-based model, which relies on infrequent visits to assess BP control. A reliance on office visits to up-titrate therapy is subject to the availability of clinicians and can increase clinical inertia. Conversely, telemedicine management of hypertension (TM-HTN) relies on patients’ self-measured BP (SMBP) to provide physicians with more frequent data points to assess treatment efficacy and make pharmacotherapeutic and lifestyle adjustments as necessary. SMBP has also been associated with increased hypertension knowledge in patients and greater treatment adherence.2 Although TM-HTN shows promise as a more effective treatment approach, large-scale data to support this notion is limited.2

To investigate the optimal approach to managing patients with hypertension in the United States, a systematic review and meta-analysis of 13 clinical trials occurring between 1992 and 2019 in the United States was compiled and found that TM-HTN appears more effective at controlling BP than relying solely on clinic-based care.3

For this meta-analysis, the investigators selected US clinical trials in which SMBP-guided pharmacotherapy was compared with a usual-care group where SMBP was not used for treatment decisions. Trials where SMBP was collected but not used in treatment decisions between visits were excluded. Subgroup analyses were also performed to investigate differences in efficacy of BP management across race (predominately trials among patients who were White vs patients who were not White), diabetic condition (trials among patients who had diabetes vs patients who did not have diabetes), and clinicians leading pharmacotherapy (physicians vs nonphysicians). Primary outcomes of interest investigated were differences between TM-HTN and clinic-based care in systolic BP (SBP), diastolic BP (DBP), and trial-defined BP control rate after 6 months or more.

Of the 6058 clinical trials screened, 13 (n = 5330 patients) met all the necessary criteria to be included in the meta-analysis. All 13 trials were eligible for SBP analysis, of which 11 (n = 4243) and seven (n = 3766) trials were eligible for DBP- and BP-control rate analyses, respectively. The proportion of patients who were not White per trial ranged from 4% to 100% with seven of the 13 trials being mostly patients who were not White. The proportion of patients who were diabetic per trial ranged from 14% to 100% with eight of the 13 trials mainly including patients with diabetes. Of the 13 trials, five mostly included patients who were not White and had diabetes.

Pooled across the 13 trials investigated, SBP difference was -7.3 mm Hg favoring TM-HTN. Additionally, SBP reductions were 4.4 mm Hg greater when pharmacotherapy was led by non-physicians compared with physicians. Further, SBP reduction was 5.0 mm Hg less in trials that mostly included patients who were not White. Differences in effect on DBP—pooled across 11 trials—were smaller, at -2.7 mm Hg favoring TM-HTN with DBP reductions being 2.8 mm Hg greater when pharmacotherapy was led by non-physicians. DBP reduction was 2.7 mm Hg less in trials among mostly patients who were not White. Subgroup analyses of trials among patients who had diabetes vs patients who did not have diabetes showed no significant difference in SBP or DBP reductions. The mean difference in BP control rate was 10.1%, favoring TM-HTN. No subgroup analyses were considered for BP control rates as these data were pulled from only 7 eligible trials. A leave-one-out-analysis was performed to assess the influence each trial had on all pooled effects.

This systematic review and meta-analysis of US-based trials using SMBP-guided pharmacotherapy provides strong evidence that TM-HTN can lower BP by 7.3/2.7 mm Hg in comparison to relying solely on clinic-based care. Importantly, SMBP-guided pharmacotherapy was more effective when led by non-physicians compared with physicians. The benefits appear to differentially affect different racial demographics with TM-HTN reducing BP to a greater degree in trials mostly among patients who were White over trials among patients who were not White, although some of this difference may be attributed to the fact that all of the eligible trials among predominantly patients who were not White had physician-led pharmacotherapy which was shown to be less effective.

These analyses suggest that a team-based approach in which SMBP is implemented and reported so that medication levels can be adjusted algorithmically by non-physicians without needing routine approval may help streamline care delivery. This is consistent with the most recent guidelines from the American College of Cardiology/American Heart Association on the management of blood pressure.4 Relying on allied health professionals, including clinical pharmacists, to up-titrate medications through an algorithmic approach would also allow physicians to use clinic visits to focus on more complex cases. Due to the racial inequity of the effect demonstrated by this study, it is possible that implementation of TM-HTN programs could exacerbate the racial disparities that already exist in hypertension care, necessitating proper support for patients who are not White when implementing TM-HTN programs. Taken together, these results provide insight suggesting that effective TM-HTN should be implemented in the United States with special care that it is done in an equity-conscious manner.

References:

  1. Muntner P, Hardy ST, Fine LJ, et al. Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA. 2020;324(12):1190–1200. doi:10.1001/jama.2020.14545
  2. Byrant KB, Sheppard JP, Ruiz-Negron N, et al. J of American Heart Assoc. 2020;9(15): doi:10.1161/JAHA.120.016174
  3. Acharya S, Neupane G, Seals A, et al. Self-measured blood pressure-guided pharmacotherapy: a systematic review and meta-analysis of US-based telemedicine trials. Hypertension. 2024. doi: 10.1161/HYPERTENSIONAHA.123.22109
  4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines. Hypertension. 2018;71(6):e13-e115. doi: 10.1161/HYP.0000000000000

 

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