key: cord-0774338-nz91ftzo
authors: Khanijahani, Ahmad; Akinci, Nesli; Quitiquit, Eric
title: A Systematic Review of the Role of Telemedicine in Blood Pressure Control: Focus on Patient Engagement
date: 2022-04-12
journal: Curr Hypertens Rep
DOI: 10.1007/s11906-022-01186-5
sha: a8a4c28affc0c0178e4ce770d6ad2d3f9d579eaa
doc_id: 774338
cord_uid: nz91ftzo

PURPOSE OF REVIEW: To systematically review and synthesize the existing evidence on the effects of different telemedicine interventions on improving patient engagement among patients with hypertension. Patient engagement is defined as patients’ knowledge, skills, ability, and willingness to manage their healthcare within the context of interventions designed to promote positive patient behaviors. RECENT FINDINGS: Telemedicine is a rapidly growing method of healthcare services delivery. Telemedicine interventions are mainly used to facilitate communication between the patient and provider, measure, record, and track blood pressure, and educate and train patients about managing their blood pressure. Findings from several studies indicate the evidence of patient engagement, adherence to the care plan, improvement in knowledge about blood pressure, and patient satisfaction with telemedicine interventions for blood pressure. SUMMARY: Telemedicine interventions need to be customized depending on patient demographics and socioeconomic characteristics such as age and education level to ensure optimal patient engagement. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11906-022-01186-5.

Telemedicine is continuously growing as a practical method of healthcare service delivery nationally and globally across various healthcare settings. The advent of the COVID-19 pandemic has brought telemedicine interventions to the forefront of healthcare offerings and highlights more than ever the importance of optimizing telemedicine interventions so they can best serve patients, providers, and healthcare systems [1 ••, 2••]. Though individual telemedicine offerings vary in their structure and organization, telemedicine is broadly defined as the act of delivering healthcare services over a distance using information and communication technologies to aid in the diagnosis, treatment and prevention, research and evaluation, and the continuing education of healthcare providers [3] . Despite potential challenges in implementing telemedicine interventions, such as protecting the privacy of patient data, technological costs, and the heterogeneity of these interventions, the use of telemedicine has increased substantially over time. In 2010, 35% of hospitals in the USA were fully or partially implementing a computerized telehealth system and, by 2017, this percentage rose to 76% [4] . A 2016 World Health Organization (WHO) survey found that 87% of countries (n = 109) reported implementing at least one mobile health (e.g., telemedicine through mobile phones and patient monitoring devices) program and that 57% of the responding countries (n = 70) recognized telehealth at a national policy level [5] .

This article is part of the Topical Collection on Telemedicine and Technology * Ahmad Khanijahani khanijahania@duq.edu Telemedicine is becoming increasingly popular to manage patients with chronic conditions such as diabetes, heart disease, and hypertension. Blood pressure (BP) monitoring and control through telemedicine is particularly of interest as nearly 50% of US adults have hypertension, and only about 24% of them have their hypertension under control [6] . In 2017, over 472,000 individuals' primary or contributing cause of death in the USA was hypertension, and hypertension cost the USA approximately $131 billion each year between 2003 and 2014 [7, 8] . Healthcare systems must develop and implement efficient hypertension management methods to lower the disease burden nationally and globally. Previous studies, including randomized controlled trials, suggest that home blood pressure telemonitoring (HBPT) improves blood pressure control in patients with hypertension. Additional studies have demonstrated a significant reduction in BP through regular HBPT than usual care [9] . Telemedicine, therefore, presents a promising method of facilitating the care and management of patients with hypertension.

Although previous studies demonstrate improvements in BP control and reductions in BP through telemedicine interventions, less is known about the effects of telemedicine on patient engagement among patients with hypertension. In this review, we define patient engagement as patients' knowledge, skills, ability, and willingness to manage their healthcare within interventions designed to promote positive patient behaviors [10] . Increasing and improving patient engagement may be a strategy whereby healthcare systems, providers, and patients observe improved health outcomes, lower costs, and better patient care [10] . Optimizing patient engagement may also contribute to achieving a more patient-centered approach to healthcare, which is increasingly valued in the current healthcare climate [11] . Therefore, assessing the effects of telemedicine on improving patient engagement among patients with hypertension can offer essential insights to enhance the care of hypertensive patients. Insufficient patient adherence to treatment and clinical inertia (the inability of healthcare providers to initiate or intensify therapy appropriately) are the two major causes of inadequate BP control [12] . Telemedicine offers a unique approach to target such concerns and can potentially improve outcomes for patients. To our knowledge, to date, there is no comprehensive review of empirical studies on the effects of telemedicine on improving patient engagement in patients with hypertension. The purpose of this systematic review was to compile and assess the existing relevant literature, fill current knowledge gaps by providing comparative evidence about the impact of telemedicine on improving patient engagement in patients with hypertension, and inform future research and policy development on this topic.

We searched PubMed, Wiley Online Library, Scopus, and Embase for relevant studies until July 2020. After restricting our search terms to include different variations of telemedicine, patient engagement, and hypertension, the initial search yielded 775 results. Table 1 includes the search terms and the general search strategy.

Only original research articles published in peer-reviewed journals were included in this review. Other formats, such as book chapters, viewpoints, and comments, were excluded. If possible, we restricted the results to journal articles in the search process. Otherwise, we eliminated the other publication formats during the review of the search results. Only articles published in English were included in this review. Table 2 details the study selection and inclusion criteria.

The flow diagram in Fig. 1 demonstrates the study selection process for this systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) [13] . A total of 775 studies were initially identified through database searching (PubMed, Wiley Online Library, Scopus, and Embase). After removing duplicated "e-Health" OR "eHealth" OR "telemedicine" OR "telehealth" OR "tele-health" OR "telecare" OR "health information technology" OR mhealth OR "mobile health" "patient involvement" OR "patient empowerment" OR "patient participation" OR "patient activation" OR "patient engagement" OR adherence "blood pressure" OR hypertension results, 580 studies remained. Of those studies, 560 studies were deemed irrelevant and excluded from further analysis after reviewing the title of the studies. Twenty studies remained and were assessed for eligibility. Another seven studies were excluded after a complete review of these studies with relevant reasons listed in Fig. 1 . Ultimately, thirteen studies were included in this systematic review. Table 3 summarizes the sample sizes, study designs, interventions, and primary findings for the thirteen studies included in this systematic review. The publication dates for the included articles ranged from 2012 to 2019. Seven studies were from North America (six from the USA and one from Canada), one from South America (Bolivia), three from Western Europe (two from Sweden and one from England), one from East Asia (China), and one study location could not be identified.

A variety of telemedicine platforms and technologies were utilized in the reviewed studies. In most studies (n = 10), patient communication was predominantly achieved through mobile phones [14-21, 22•, 23] . The communication strategies utilized in these nine studies included a smartphone application [15] [16] [17] [18] [19] 23 ], text messaging [22•], interactive voice response (IVR) calls [21] , and a mobilefriendly website [20] . In one study, patients uploaded their BP data to an online portal via a home computer or clinic kiosk [14] . Another study employed an online portal that could be accessed by mobile phone or computer [24] . In two studies, the telemedicine intervention primarily targeted healthcare providers and included a teleconference system [25] and the electronic medical record [26] . Seven studies included a component of the telemedicine intervention that sent reminders to patients. These reminders were sent to remind patients about taking medications [16, 18] , recording and submitting BP readings [14, 15, 19] , and about their upcoming appointments [17, 24] .

The studies varied in terms of how BP was measured and recorded. In eight studies [14, 15, 18, 19, 21] , BP was self-recorded by patients. In two studies [16, 22 •] , BP was recorded in a clinical setting. Feedback provided to patients included automated email or text messages to reinforce monitoring in patients who were actively monitoring BP [14] , tailored text messages to patients who were not providing enough BP recordings [14] , a five-star rating system to rate the patient's adherence to BP monitoring [14] , automated responses that described actions patients should take if BP readings were outside of an acceptable range [15] , graphs and figures of self-reported data [14, 17, 18] , and immediate feedback after each BP recording that included an enthusiastic animation and positive reinforcement language [19] . Patients' BP data were reviewed by a clinician either periodically [14-16, 18, 20] or as seen fit, and patients could be contacted with further information if needed [15, 16, 20] . Clinician notifications could also be prompted when patients were not taking medications or their BP and glucose level values were worrying [21] .

Nine studies [14-19, 21, 22•, 23] included a patient education or training component. Patients were educated about the benefits of managing their BP on their overall health and well-being, and clinicians identified target levels for patients' systolic BP (SBP) and diastolic BP (DBP) values [14] . Patients were also sent text messages containing educational information [15, 22•] and received training on measuring their BP [15, 16] . In two studies, the smartphone [17, 19] . Patients also received education about disease self-management based on their responses to IVR call questions [21] .

Three studies demonstrated improvements in patient engagement upon implementing a telemedicine intervention [19, 21, 23] . Patients were actively involved in their medical care by self-monitoring their heart rates and blood pressures. They experienced significantly better drug therapy adherence and significantly improved quality of life scores [17] .

In addition, through self-monitoring and self-reporting BP and other health data, patients could contextualize their BP values within their daily lives and participate more equally in their follow-up consultations with their providers [23] .

Patients who regularly used online health portals had a significantly greater interest in using websites and mobile phone apps to monitor and record their BP, weight, exercise, and medication usage data [24] . Patients with the most significant clinical need showed the highest engagement levels, and higher engagement levels were associated with a more significant BP reduction [19] . Additionally, the presence of an informal caregiver who received health information regarding the patient was found to increase patient engagement significantly [21] . In one study, patient engagement was promising for the first month but then fell off sharply during the next 2 months [15] .

Compared to the usual care group, patient knowledge was significantly improved (p < 0.05) in patients using a telemedicine intervention [17] . Patients felt a greater sense of responsibility in monitoring their health and felt greater motivation to make and maintain lifestyle changes [18] . In older patients, e-Health literacy was positively associated with online portal usage and an interest in using healthtracking tools [18] . e-Health literacy scores were also positively associated with higher education and negatively associated with age [24] . Full-text articles assessed for eligibility n = 20

Full-text articles excluded, with reasons (n = 7) 

In studies that assessed patient satisfaction with the telemedicine intervention [15-18, 23, 24] , patients generally viewed the intervention positively. In one study, over 90% of the patients reported that the app was user-friendly and helpful [17] . In another study, patients reported that the intervention was a user-friendly tool and could enable healthcare providers to better understand the patient perspective [18] . Some suggestions that patients and healthcare workers had for improving the telemedicine-based intervention were making graphs easier to understand and tailoring the system according to personal preferences [18] . When comparing patients who used an online health portal with portal non-users, a significantly greater proportion of the portal users rated viewing lab results, checking health records for accuracy, and receiving test reminders as useful [24] . Some concerns among portal non-users about portal use were the privacy and security of their health data, not seeing the need for using the portal to manage their health and the lack of personalization in using technology [24] . Concerns about computer literacy, the difficulty of remembering passwords and logging into portal accounts, lack of technical support, provider availability for online appointment scheduling, and response times to medical messages were expressed by portal users [24] . In one study, the majority of patients who responded to a survey about the telemedicine intervention reported feeling more confident understanding their BP and taking their own BP measurements upon using the intervention [15] .

Three studies reported statistically significant reductions in blood pressure levels upon using a telemedicine intervention [14, 16, 19] . In one study, statistically significant decreases in both average SBP and DBP readings were observed upon 30 days (p < 0.01) and 180 days of study enrollment (p < 0.05) [14] . In another study, the intervention group had a greater reduction in SBP at weeks 4 and 12 compared with the usual care group. However, the decline in SBP in week 4 was the only statistically significant finding [16] . In the third study, a statistically and clinically significant reduction in SBP was observed in less than 4 weeks, where 10% of the participants experienced a drop of at least 10 mm Hg in SBP (p < 0.001) [19] . On the other hand, two studies did not report significant differences in blood pressure levels upon using a telemedicine intervention [20, 22 •] (Table 4 ).

Previous studies that have examined the effects of telemedicine interventions on the management of hypertensive patients have primarily focused on changes in SBP and Thirteen studies out of the 775 initially identified studies were included in this systematic review. This systematic review aimed to synthesize the existing evidence on telemedicine's effects on improving patient engagement among patients with hypertension.

In the reviewed studies, communication with patients mainly took place through a mobile platform, specifically through smartphones, with nine out of thirteen studies utilizing some form of smartphone communication. The ubiquitous use of smartphones and the increasing number of health-monitoring apps, in particular, may hold promise for expanding the scope of telemedicine interventions. Mobile health (mHealth) allows for faster transmission of patient health data to healthcare providers, offers convenience to both patients and healthcare providers, and has beneficial impacts on chronic disease management [27] . Although more evidence for the efficacy and costeffectiveness of mHealth interventions is needed, mHealth nonetheless remains very much at the forefront of telemedicine developments and technologies [28] .

BP data in eight of the all included studies were selfreported by patients, and in two other studies were recorded in a clinical setting. When caring for hypertensive patients, BP measurements taken in the clinical setting can often be inadequate or misleading [29] . For this reason, home blood pressure monitoring (HBPM) can be advantageous in improving patient care and prime patients to assume a more active role in managing their condition. One of the included studies explicitly states that patients received training on using an automated sphygmomanometer [15] . It is unclear in most studies if patients were adequately trained on how to record their BP. Integrating educational modules into blood pressure monitoring apps with videos demonstrating how to adequately take BP measurements can empower patients by increasing their knowledge and self-sufficiency in managing their condition.

Several studies included a feedback mechanism to inform patients of their BP data and encourage them to take BP recordings. One such feedback mechanism was using graphs and figures to display BP data over time. Another was enthusiastic animations with positive reinforcement language immediately upon patient submission of a BP recording. Some of the feedback was in the form of automated responses, while some feedback consisted of tailored messages. These feedback systems are an important method of ensuring patient engagement on a continual basis with the telemedicine intervention. When patients receive reinforcement and confirmation that they are on track with their BP measurements and have access to their BP data over time in a graphical manner, they can evaluate the BP data within the context of their daily lives and adopt a more healthconscious mindset. It is unclear which feedback systems are the most effective in encouraging patients to manage and record their BP. More robust research is needed to gain a complete understanding of the characteristics of the most effective feedback systems for optimal patient engagement.

Three studies demonstrated an apparent increase in patient engagement upon using the telemedicine intervention. In these studies, patients contextualized their BP values within their daily lives and contributed more equally Changes in blood pressure between the telemedicine intervention and the control/standard care/usual care Aberger, 2014 [14] Baseline vs 30 days after intervention: significant decrease in SBP and DBP, 6.0 mm Hg and 3.0 mm Hg, respectively (p values < 0.01). Baseline vs 180 days after intervention: significant decrease in SBP and DBP, 6.6 mm Hg and 5.0 mm Hg, respectively (p values < 0.5) Cottrell, 2015 [15] BP control was achieved by only 5-22% of 1495 patients signed up to one of the three monitoring protocols. No data on exact or average changes in blood pressure Frias, 2017 [16] At week 4, the intervention resulted in a statistically greater SBP reduction than usual care (mean difference − 9.1, 95% CI − 14.0 to − 3.3 mm Hg) and sustained even more reduction at week 12 Kaplan, 2017 [19] Blood pressure reduction was achieved for 22-25% of application users between weeks 4 and 22 compared to the baseline Levine, 2018 [20] There was no significant difference in systolic blood pressure (SBP) change from baseline, comparing the virtual visit and the usual care Tobe, 2019 [22 • ] There was no significant difference in systolic 0.8 (95% CI − 4.2 to 5.8 mm Hg) or diastolic − 1.0 (95% CI − 3.7 to 1.8 mm Hg, p = 0.5) blood pressure between groups from baseline to final stage to conversations with their health providers. Those with the greatest clinical need showed the highest engagement levels. However, one study noted that while engagement was promising for the first month, it fell off sharply during the following 2 months. It is essential to gain a complete understanding of the factors that drive patient engagement and how patient engagement manifests over the long run.

A limitation of some of these studies was that the study duration was not very long. Although patient engagement increased during the study period, it is impossible to say if this increase in engagement would be sustainable over time.

Overall, in those studies which assessed patient satisfaction with the telemedicine intervention, patient satisfaction was generally high. Patients viewed the intervention as user-friendly. However, patients did have concerns about health data privacy and ease of use of the system. Concerns about the ease of use of the system were of note among the elderly population. It has been shown that eHealth literacy score is usually negatively associated with patient age [30] . However, many times, elderly patients have more morbidities and, because of issues such as poor mobility, have a greater need for what these telemedicine interventions can offer [31] . The simplification of telemedicine and mHealth interventions can potentially improve elderly engagement in the process of receiving care and providing feedback to healthcare providers.

Telemedicine interventions targeted at healthcare providers may also contribute to better outcomes in the treatment of hypertensive patients. Primary care providers who participated in a 12-session telemedicine-based hypertension education program experienced a statistically significant increase in both hypertension management knowledge and self-assessed competency [25] . Increasing provider knowledge and competency can allow for more nuanced monitoring of patients' BP values and encourage providerdirected education of hypertensive patients.

The studies included in this review come from different patient populations and small settings from different countries. These sociodemographic and cultural heterogeneities threaten the generalizability of the findings from these studies. Besides, in some studies, the sample consisted of welleducated individuals who were more likely to use technology. Additionally, the heterogeneity of the telemedicine and mHealth interventions in different studies makes identifying the most proper and effective intervention more challenging.

Another limitation of this systematic literature review is that only studies published in English were included in the review. It is possible that relevant studies were missed during the screening process due to excluding non-English publications and limiting the search to four databases. Therefore, information and insights about the topic of interest may have been excluded from this review. Despite these limitations, this study provides a comprehensive understanding of the different dimensions of utilizing telemedicine to control BP.

Telemedicine and the use of telemedicine technologies within the current and future healthcare climate remain more relevant than ever, mainly due to the advent of the COVID-19 pandemic. Due to social distancing measures during the pandemic, many services previously offered in-person were offered via a telehealth format, and governments and health providers provided additional expansion of telemedicine options and funding [32•] . For instance, private health providers began providing their telemedicine services to the public free of charge, and medium-to small-sized medtech companies provided their telemedicine platforms to public health providers [32 •] . Telemedicine has proven to be a cost-effective and indispensable tool during the pandemic and will undoubtedly be here to stay in the long run. Interestingly, it seems that previous hesitations in adopting telemedicine offerings are changing, and governments are looking more favorably on the utility of telemedicine interventions. For example, in South Korea, since 2018, there have been many controversies about adopting telemedicine systems. However, during the COVID-19 pandemic, the Seoul National University Hospital began actively offering telemedicine services to COVID-19 patients [32•] .

A concern moving forward with the more widespread adaptation of telemedicine systems is the privacy and security of patient data. As echoed by the findings of studies in this systematic review, patients are indeed concerned about the confidentiality of their health data, which can prevent them from engaging fully with telemedicine interventions. The concern of third-party advertiser access to patient health data is particularly of note. Additionally, during the COVID-19 pandemic, patient consent was overlooked for the sake of public interest and public health in some circumstances [32•] . With the ever-growing use and relevance of telemedicine interventions, it is paramount that patient privacy and confidentiality be strictly protected to offer patients a sense of privacy and security.

Because the majority of the studies reviewed were published less than 10 years ago, it appears that the implementation of telemedicine interventions to improve patient engagement among those with hypertension is relatively new. Although the findings show the significant impact of telemedicine in achieving clinical improvements and patient engagement and communication, more is to be known about the effectiveness of different telemedicine initiatives, especially compared to in-person visits to healthcare providers. Studies on the cost-effectiveness of different telemedicine and mHealth interventions can help understand potential cost savings for patients, healthcare personnel, and healthcare organizations. Given that high BP is more common among the elderly, ensuring the use of user-friendly and simplistic approaches might increase patient engagement and improve communication between healthcare providers and patients. Moreover, additional support such as hotlines and translator services can potentially ensure the telemedicine intervention's acceptability among culturally and linguistically diverse communities.

The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s11906-022-01186-5.

Author Contribution All authors contributed to the research process in various forms, including original draft preparation, summarizing findings, writing, reviewing, and editing. AK conceptualized and designed the study, performed the database search, and outlined the manuscript. EQ and NA reviewed the studies, identified the relevant studies, and performed the data extraction.

Conflict of Interest The authors declare that they have no conflict of interest.

This is a review of publicly available and published research papers. No human subject or identification data is collected or analyzed in this study.

This article highlights the importance of using different telemedicine approaches to minimize in-person interactions between healthcare professionals and patients during the COVID-19 pandemic

2020:1357633X20916567. This article focuses on the use of telehealth during emergencies, highlights several barriers

Report on the second global survey on eHealth: World Health Organization

Fact sheet: telehealth

World Health Organization. Global diffusion of eHealth: making universal health coverage achievable: report of the third global survey on eHealth

Hypertension cascade: hypertension prevalence, treatment and control estimates among US adults aged 18 years and older applying the criteria from the American College of Cardiology and American Heart Association's 2017 hypertension guideline-NHANES

Facts about hypertension

Trends in healthcare expenditures among US adults with hypertension: national estimates

The role of telemedicine in hypertension management: focus on blood pressure telemonitoring

Health Affairs Health Policy Brief

Patient-centred care is a way of doing things: how healthcare employees conceptualize patient-centred care

Clinical inertia

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

Enhancing patient engagement and blood pressure management for renal transplant recipients via home electronic monitoring and web-enabled collaborative care

Implementation of simple telehealth to manage hypertension in general practice: a service evaluation

Effectiveness of digital medicines to improve clinical outcomes in patients with uncontrolled hypertension and type 2 diabetes: prospective, open-label, cluster-randomized pilot clinical trial

Mobile health technology for atrial fibrillation management integrating decision support, education, and patient involvement: mAF app trial

Experiences, expectations and challenges of an interactive mobile phonebased system to support self-management of hypertension: patients' and professionals' perspectives. Patient Prefer Adherence

Improving patient engagement in self-measured blood pressure monitoring using a mobile health technology

Association of structured virtual visits for hypertension follow-up in primary care with blood pressure control and use of clinical services

Structured caregiver feedback enhances engagement and impact of mobile health support: a randomized trial in a lowermiddle-income country

Diagnosing hypertension in Indigenous Canadians (DREAM-GLOBAL): a randomized controlled trial to compare the effectiveness of short message service messaging for management of hypertension: main results

Patient contributions during primary care consultations for hypertension after self-reporting via a mobile phone self-management support system

eHealth literacy: patient engagement in identifying strategies to encourage use of patient portals among older adults

Using an established telehealth model to train urban primary care providers on hypertension management

Changes in disparities following the implementation of a health information technology-supported quality improvement initiative

Mobile technologies and the holistic management of chronic diseases

The impact of mHealth interventions: systematic review of systematic reviews

Call to action on use and reimbursement for home blood pressure monitoring: executive summary

Health literacy in the eHealth era: a systematic review of the literature

Human factors considerations in implementing telemedicine systems to accommodate older adults

Telemedicine in the face of the COVID-19 pandemic

1 Department of Health Administration and Public Health,