Hypertension Management Using Mobile Technology and Home Blood Pressure Monitoring: Results of a Randomized Trial in Two Low/Middle-Income Countries
Telemedicine and e-Health. October 2012, 18(8): 613-620. doi:10.1089/tmj.2011.0271. John D. Piette, Hema Datwani, Sofia Gaudioso, Stephanie M. Foster, Joslyn Westphal, William Perry, Joel Rodríguez-Saldaña, Milton O. Mendoza-Avelares, and Nicolle Marinec. 1Ann Arbor VA Healthcare System, Ann Arbor, Michigan. 2Department of Internal Medicine, Ann Arbor, Michigan. 3Yojoa Community Health Systems, Cortés, Honduras. 4University of Michigan Medical School, Ann Arbor, Michigan. 5Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan. 6Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan. 7Remedi Medical Research and Development, Pachuca, Mexico.
Objective: Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries (LMICs). Mobile health technologies may improve noncommunicable disease outcomes, but LMICs lack resources to provide these services. We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure (BP) monitoring as a strategy for improving systolic BPs (SBPs) and other outcomes of hypertensive patients in two LMICs.
Subjects and Methods: This was a randomized trial with a 6-week follow-up. Participants with high SBPs (≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic) were enrolled from clinics in Honduras and Mexico. Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States, plus a home BP monitor. At baseline, control patients received BP results, hypertension information, and usual healthcare. The primary outcome, SBP, was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs. Secondary outcomes included perceived health status and medication-related problems.
Results: Of the 200 patients recruited, 181 (90%) completed follow-up, and 117 of 181 had low literacy or high hypertension information needs. The median annual income was $2,900 USD, and average educational attainment was 6.5 years. At follow-up intervention patients' SBPs decreased 4.2 mm Hg relative to controls (95% confidence interval −9.1, 0.7; p=0.09). In the subgroup with high information needs, intervention patients' average SBPs decreased 8.8 mm Hg (−14.2, −3.4, p=0.002). Compared with controls, intervention patients at follow-up reported fewer depressive symptoms (p=0.004), fewer medication problems (p<0.0001), better general health (p<0.0001), and greater satisfaction with care (p≤0.004).
Conclusions: Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs. A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support.