Hypertension in Urban Underserved Subjects Using Telemedicine
Hypertension in Urban Underserved Subjects Using Telemedicine
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/m, 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.
Reduction in cardiovascular disease (CVD) mortality, which began during the 1960s, has slowed and may be leveling off. Estimates from National Health and Nutrition Examination Survey suggest that one-third of the US population is at risk for CVD caused by hypertension, diabetes, hyperlipidemia, or cigarette smoking. Cardiovascular disease mortality has declined less for African Americans and for people from lower socioeconomic classes than for other groups. Half of the disparity in CVD mortality rates between African Americans and whites is attributable to hypertension.
Screening and managing 60 to 80 million patients with hypertension is an impossible task for the current heath care system. Systems of care that are efficient, convenient, and inexpensive are needed to address the problem. Prior studies have shown the benefits of telephone communication systems for hypertension management. Other studies support the value of a telephonic communication system for communicating self-measured blood pressure (BP) to a care provider, and telemedicine studies have shown benefit in subjects using home measurements and telemedicine communication with a physician. These studies have not addressed underserved subjects who present a unique challenge because of a higher incidence of hypertension and diabetes, limited access to care, and higher levels of poverty.
In a previously study, we found trends toward improved BP in underserved subjects who participated in a telemedicine study aimed at reducing cardiovascular risk based on Framingham score.
In the present study, we evaluated a telephone and Internet-based system for delivering a patient-centered self-monitoring program for hypertension management in an underserved, urban community with a high incidence of hypertension and diabetes. Because patients with diabetes typically use self-measure of blood glucose and frequent reporting, we hypothesized that subjects with diabetes would respond differently to the program because of their established system of care that involves frequent self-monitoring of their health status, compared with nondiabetic subjects who are often asymptomatic and not exposed to frequent self-monitoring.
Abstract and Introduction
Abstract
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/m, 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.
Introduction
Reduction in cardiovascular disease (CVD) mortality, which began during the 1960s, has slowed and may be leveling off. Estimates from National Health and Nutrition Examination Survey suggest that one-third of the US population is at risk for CVD caused by hypertension, diabetes, hyperlipidemia, or cigarette smoking. Cardiovascular disease mortality has declined less for African Americans and for people from lower socioeconomic classes than for other groups. Half of the disparity in CVD mortality rates between African Americans and whites is attributable to hypertension.
Screening and managing 60 to 80 million patients with hypertension is an impossible task for the current heath care system. Systems of care that are efficient, convenient, and inexpensive are needed to address the problem. Prior studies have shown the benefits of telephone communication systems for hypertension management. Other studies support the value of a telephonic communication system for communicating self-measured blood pressure (BP) to a care provider, and telemedicine studies have shown benefit in subjects using home measurements and telemedicine communication with a physician. These studies have not addressed underserved subjects who present a unique challenge because of a higher incidence of hypertension and diabetes, limited access to care, and higher levels of poverty.
In a previously study, we found trends toward improved BP in underserved subjects who participated in a telemedicine study aimed at reducing cardiovascular risk based on Framingham score.
In the present study, we evaluated a telephone and Internet-based system for delivering a patient-centered self-monitoring program for hypertension management in an underserved, urban community with a high incidence of hypertension and diabetes. Because patients with diabetes typically use self-measure of blood glucose and frequent reporting, we hypothesized that subjects with diabetes would respond differently to the program because of their established system of care that involves frequent self-monitoring of their health status, compared with nondiabetic subjects who are often asymptomatic and not exposed to frequent self-monitoring.
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