Home blood pressure telemonitoring in the 21st century (2025)

Abstract

Blood pressure telemonitoring (BPT) is a telehealth strategy that allows remote data transmission of blood pressure and additional information on patients’ health status from their dwellings or from a community setting to the doctor's office or the hospital. There is sufficiently strong evidence from several randomized controlled trials that the regular and prolonged use of BPT combined with telecounseling and case management under the supervision of a team of healthcare professionals is associated with a significant blood pressure reduction compared with usual care, particularly in cases of patients at high risk. However, most current evidence is based on studies of relatively short duration (<12months), and in the few studies that have investigated longer‐term outcomes, no evidence of better or sustained effect could be provided. In addition, no definition of the optimal BPT‐based healthcare delivery model could be derived from the studies performed so far, because of the heterogeneity of interventions, technologies, and study designs. BPT can also be provided in the context of “mobile health” (m‐health) wireless solutions, together with educational support, medication reminders, and teleconsultation. When BPT is integrated in an m‐health solution, it has the potential to promote patient's self‐management, as a complement to the doctor's intervention, and encourage greater participation in medical decision‐making. In conclusion, BPT has a potential key role in the management of patients with hypertension, since it seems to improve the quality of delivered care and allow for more effective prevention of the cardiovascular consequences of hypertension.

1. INTRODUCTION

Progress in technology has offered novel approaches to telemonitoring (ie, remote monitoring) of blood pressure (BP) values measured at a patient's home. Among them is eHealth, which represents an emerging field where a complex interaction among medical informatics, public health, and business occurs, through which health services and health‐related information are delivered or enhanced by means of the Internet, aimed at improving health care locally, regionally, and worldwide by using information and communication technology. Until a few years ago, web‐based computer‐tailored interventions were almost exclusively delivered via computer (eHealth). Currently, however, interventions delivered via mobile phones (mHealth) are an interesting alternative for health promotion, as they may more easily reach people. A growing number of e‐health strategies have been developed in recent years in order to provide more efficient healthcare services and to improve the quality of hypertension management.1 Among all of the possible e‐health services, the most popular and widely distributed among healthcare professionals and general public are those based on telemedicine and telemonitoring. Telemedicine is the exchange of medical information (eg, health parameters, biological signals, and diagnostic images) from one site to another via electronic communications in order to provide diagnosis and care at a distance.2 When mobile communication devices, such as smartphones are used to communicate between doctors and patients, the specific term “mobile health” or m‐health is used.3

e‐Health solutions may empower patients with hypertension, facilitate the relationship with their physician, and help improve BP and cardiovascular risk control. e‐Health services offer patients with hypertension access to diagnostic procedures that might not be available otherwise, without the need to travel long distances. Because of telemedicine solutions, healthcare professionals can reach patients outside their office, track their health status, and easily and quickly communicate with them—a feature particularly important in cases of acute symptoms or sudden BP rises.

Given the wide range of e‐health solutions for hypertension management, in this review we will focus specifically on available technologies for BP telemonitoring (BPT) where the best current evidence on clinical effectiveness exists.

2. BPT TECHNOLOGIES

BPT is a particular application of telemedicine. It consists of automatic data transmission of BP and additional nonvital parameters from the patient's living site (home or workplace BPT) or from a professional healthcare environment (eg, primary care clinic or community pharmacy) to the doctor's office or a hospital.1 BP measurement is usually based on automated upper‐arm BP monitors, which may collect casual readings in surgery or multiple readings over 24 hours, in ambulatory conditions, or during several days at home.

Several BPT systems are available on the market, which are characterized by the different modalities of data collection, transmission, and reporting, and by additional features such as reminding facilities of BP measurement to be performed and/or for medication intake and automatic data reporting. A list of available technologies for BP measurement, collection, and transmission to telemedicine providing centers is presented in Table1.

In BPT solutions, BP measurements are stored in the device memory and then forwarded, immediately or periodically, to a remote computer host. Data transmission is usually achieved through a landline broadband or mobile network and through the web by applying encryption transmission protocols that ensure data integrity and security. Once data are received at the central telemedicine server they are stored and analyzed. Reports are automatically generated and then reviewed by case managers (usually a healthcare technician, a nurse, or a pharmacist) before they are submitted to the reporting physician, although, in some instances, reports are directly sent to the family doctor in charge. At the end of this process a medical report is forwarded to the patient and referring primary physician through a website, via e‐mail, or through dedicated smartphone apps. During all of these processes, the case manager may also interact with the patient in order to obtain feedback on his/her health status and adjust treatment according to the indications of the managing physician (cointervention or additional support).

3. CLINICAL EFFICACY OF BPT

Several randomized controlled trials performed in the past 2 decades have tested the effectiveness of home BPT for improvement of hypertension control and associated healthcare outcomes. In most studies, a high degree of acceptance of technologies by doctors and patients and of adherence to telemonitoring programs have been documented.1

In one of the largest meta‐analyses of randomized controlled studies including 7037 hypertensive (23 studies) regular BPT at home with a follow‐up of 6months was associated with greater reductions in both office (average, 4.7 mm Hg; 95% confidence interval [CI], 6.2–3.2 mm Hg SBP and 2.5 mm Hg; 95% CI, 3.3–1.6 mm Hg DBP [P<.001 for both]) and 24‐hour ambulatory BP (3.5 mm Hg; 95% CI, 5.3–1.6mm Hg SBP [P<.001] and 1.4; 95% CI, 2.9–0.0 mm Hg DBP [P=.051], and with a greater chance of achieving office BP normalization (relative risk, 1.16; 95% CI, 1.04–1.29 [P=.007]) as compared with usual care (based on periodic BP measurements and visits at the doctor's office, with no remote BP monitoring).4 The improved BP control obtained with the BPT intervention resulted in a significantly larger prescription of antihypertensive medications (0.40; 95% CI, 0.17–0.62 [P<.001] but a similar rate of office consultations. Healthcare costs were significantly (P<.0001) larger in the BPT group (+662.92; 95% CI, +540.81 to +785.04 euros per patient], but were similar to those sustained by the patients in the usual care group when costs of the technology were removed and only medical costs were considered (−12.4; 95% CI, −930.52 to +906.23 euros [P=.767]). Use of BPT helped to improve the physical component of quality of life but not the mental component.

Recently, an updated meta‐analysis of 46 randomized controlled trials with 13875 cases confirmed the superiority of BPT on usual care in terms of improvement of BP control,5 although the results of this meta‐analysis should be considered with some caution given the occurrence of many mistakes in the selection and interpretation of the included studies. This meta‐analysis, in the context of its limitations, showed low‐strength evidence of efficacy of BPT for surrogate outcomes, whereas it suggested that longer‐term (6 to 12months vs <6months) home BPT accompanied by counseling support from study personnel may result in lower BP values. Unfortunately, no significant difference could be observed for BP changes between studies of shorter (<12months) and longer (>12months) duration.

In the various studies included in the meta‐analyses, the effect of BPT in conjunction with cointervention (including for instance medication titration by a case manager, education or lifestyle counseling) led to significantly larger and persistent (up to 12months) BP reductions than self–BP monitoring alone without transmission of BP data and counseling, suggesting a possible additional effect of the BPT approach beyond self–BP monitoring.6, 7

An interesting feature of BPT was highlighted in the recent large randomized controlled TASMINH4 (Telemonitoring and/or Self‐Monitoring of Blood Pressure in Hypertension) study, which compared the efficacy of self‐BPT, based on a simple SMS text–based service with self–BP monitoring alone or usual care. The BPT provided automatic prompts to the patient of persistently raised BP (to consult their GP), reminders to monitor BP regularly, and safety warnings for very high or very low readings. In this study, a marginally (P=.322) larger SBP‐lowering effect vs usual care was observed in the BPT group (4.7 mm Hg; 95% CI, 7.0–2.4 mm Hg) than in the self–BP monitoring group (3.5 mm Hg; 95% CI, 5.8–1.2 mm Hg) at 12months.8 However, BPT was able to provide a more rapid decrease in SBP (at 6months), an effect that is likely to further reduce cardiovascular events and might improve longer‐term control. Unfortunately, the aim of the TASMINH4 study was to compare similar intensities of self‐monitoring but with an automated system vs a manual system.

All BPT‐based studies published to date confirm that BPT has the potential to enhance hypertension management, to improve patient outcomes, and to reduce health costs, particularly when considering long‐term follow‐up.9 However, a current limitation of all randomized studies based on BPT is their extremely high level of heterogeneity, which reduces the strength of the evidence provided. Future research needs to explore the specific outcomes of BPT interventions to determine their relative value. It should also determine which BPT provision model best applies to daily clinical practice and gives the maximum benefit. Such studies should particularly focus on high‐risk patients with hypertension, for whom optimal BP control is particularly difficult to attain, and should evaluate whether the benefit of BPT intervention is sustained in the long term.

4. POTENTIALS FOR MOBILE TECHNOLOGIES IN HYPERTENSION MANAGEMENT

The growth of mobile computing and communication technologies has led to an exponential increase in the development, diffusion, and use of m‐health applications. A survey of app users performed in the United States showed that 31% of mobile phone owners used their phone to look for health information, with the largest proportion (52%) among smartphone users.10 m‐Health provides wireless diagnostic and clinical decision support tools and is used by consumers or healthcare providers for monitoring health status or improving health outcomes. Smartphone apps can empower patients with accurate medical information, provide tools to promote self‐monitoring and self‐management, and encourage greater participation in medical decision making. A list of potential benefits and drawbacks of m‐health solutions in hypertension management is reported in Table2.

A survey of 107 mobile health applications designed for the management of hypertension found that most hypertension apps help individuals to monitor various physiologic parameters, such as BP and heart rate, prompt changes in their lifestyle through diet and exercise monitoring, and remind them to take their medications.11 Of the 107 apps reviewed, 77 (71.9%) had tracking functions: 74 (69.2%) were capable of monitoring BP and heart rate, 27.1% were capable of recording weight and/or body mass, 2.8% were also capable of tracking salt intake and 4.6% were able to daily track calories consumption daily calories. Concerning the use of the app as a BP‐measuring device, none of the 57 made for the iOS operating system was actually capable of measuring BP, whereas 7 of the 50 (14.0%) made for the Android market could work as a medical device. Unfortunately, only 2.8% of the apps were developed by healthcare professional agencies, none provided any documentation of validation against a gold standard in patients with hypertension, and none formally obtained approval for use as a measuring device by the US Food and Drug Administration or European Commission.

Thus, the smartphone can now be potentially transformed into a mobile health device capable of accurately measuring BP.12 This could make it possible for billions of people to regularly check their BP status and to turn a mobile appliance into an important tool for improving BP control. Even if smartphones are not used as BP‐measuring devices, patients with hypertension might appreciate other app features such as tracking and showing trends in BP data transferred from other devices, providing medication lists and reminders (eg, alarm reminders to take medications to improve adherence to treatment), monitoring physical activity, and sharing data with healthcare providers.

Preliminary evidence from few studies suggests that telehealth strategies based on m‐health may reduce BP and improve adherence to treatment in patients with hypertension, although results are still inconsistent because of large variability in behavioral targets, intervention components, delivery modalities, and patient engagement, as well as heterogeneity of solutions available on the market.13, 14, 15

5. BARRIERS TO THE USE OF BPT IN DAILY PRACTICE

The implementation of BPT solutions in the daily practice of doctors and healthcare professionals may be difficult because of several factors (Table3).16 Poor informatics skill levels of healthcare professionals and patients and lack of adequate knowledge of BP measurement and hypertension guidelines by doctors represent major cultural barriers to the routine use of BPT. The incomplete evidence on the clinical efficacy and economic benefit of BPT provided by randomized studies thus far, technological barriers, high costs of devices, heterogeneity of solutions and technologies, and lack of infrastructures and standards all hinder the dissemination of telehealth strategies. It is unquestionable that the increasing use of m‐health technologies as a result of the large availability of user‐friendly smartphones will circumvent the technical challenge of BPT and provide more flexible and inexpensive platforms to enhance patient care. However, the development and diffusion processes of these solutions need to focus on data integrity, security, and safety, since flaws may occur with data sharing between patients and their health managers.

6. CONCLUSIONS

Current evidence suggests that BPT may be useful in achieving better BP control in patients with hypertension and may help to support doctors in more closely following up with their patients, particularly those who need tighter BP control (eg, those at high cardiovascular risk or with comorbidities) or who require monitoring of multiple vital signs. In general, BPT is well accepted by patients and may help improve patients’ quality of life, optimize antihypertensive treatment, reduce the frequency of face‐to‐face consultations, and decrease healthcare expenditure. The recent introduction of BPT solutions based on m‐health technology has the potential to help facilitate screening and improve control of hypertension but needs robust evaluation. m‐Health will also favor creation of networks between healthcare professionals and thus improve the effectiveness of delivered care to patients with hypertension.

CONFLICT OF INTEREST

S.O. received consultancy fees from Biotechmed Ltd., a provider of telemedicine services. G.P. and E.D. have no conflicts of interest to declare. R.M. has received BP monitors from Omron for research purposes.

Parati G, Dolan E, McManus RJ, Omboni S. Home blood pressure telemonitoring in the 21st century. J Clin Hypertens. 2018;20:1128–1132. 10.1111/jch.13305

REFERENCES