Benefits of Home-Based Blood Pressure Telemonitoring Services in the Management of Hypertension (Research Proposal Sample)

Running Head: HYPERTENSION AND TELEMONITORING
Title: Benefits of Home-Based Blood Pressure Telemonitoring Services in the Management of Hypertension
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Abstract
Hypertension is a disease that affects a significant number of adults in the United States. The use of technology to monitor blood pressures at home, also known as telemonitoring services, help patients and physicians monitor and manage hypertension. The drive of this literature review is to find articles that test the hypothesis that complementing telemonitoring services with the usual care of pharmacological and or non-pharmacological anti-hypertensive treatments, will improve blood pressure control in adults. In testing the hypothesis, a structured literature review got performed. Reviews considered explored home-based telemonitoring in hypertension and published between 2010 and 2015. Furthermore, the articles met the inclusion criteria. The quality of evidence got rated using the National Guideline Clearinghouse rating scheme. Fourteen articles got inclusion in this review and among which four randomized controlled trials that reported blood pressure outcomes of 1,922 participants. Findings suggested that telemonitoring contributed to statistically significant reductions in blood pressure or improved control in blood pressure. Cost analysis studies (n=3) showed mixed results with two suggesting cost savings while the third had inconclusive results. Patient’s adherence, ease of using telemonitoring technology, improved patient-physician relationships and increased patient autonomy resulted from other studies. The telemonitoring technology provides health-care professionals an aggregate and a mean blood pressure measurement. Data obtained from the measurements allows physicians, and other health-care professionals make decisions to change hypertension treatment and care. Incorporating telemonitoring services in the management of hypertension helps to improve blood pressure control.
Keywords
Hypertension, blood pressure, telemonitoring, telemedicine, telehealth
Introduction
About 80 million adults in the United States got diagnosed with hypertension according to the American Heart Association or AHA ("Statistical Fact Sheet," 2013). The cost of treating hypertension in 2009 was $51.0 billion. Although hypertension is modifiable with pharmacological and non-pharmacological treatments, the death rate from hypertension increased by 17.1 percent from 1999 to 2009. The AHA categorize hypertension into stage 1 and stages 2. AHA considers systolic blood pressure readings of 140-159 mm Hg or diastolic blood pressure readings of 80-89 mm Hg as stage 1. Stage 2 hypertension is a systolic blood pressure reading of >160 mm Hg or a diastolic blood pressure of >100 mm Hg. A hypertensive crisis is a blood pressure reading of >180/110.
Hypertension does not present any symptoms, and affected patients are unaware that they have it and do not seek treatment. Inadequate blood pressure control or failure to reduce blood pressure is a problem in hypertension management. The sequelae of hypertension in patients with uncontrolled blood pressures are aneurysms, metabolic syndrome, kidney failure, cerebrovascular accidents, and myocardial infarction. These sequelae can get prevented if blood pressure can get controlled properly. The Eighth Joint National Committee (JNC) on the management of hypertension in adults recommends starting pharmacological treatment in all adults diagnosed with hypertension (James et al., 2014). The JNC recommends initiating thiazide diuretics, ACE Inhibitors (ACEI), Angiotensin Receptor Blockers (ARB), or Calcium Channel Blockers (CCB), alone or in combination to non-black populations. The JNC recommends the use of thiazide diuretics or CCB for the African American population. However, for hypertensive patients regardless of their race, with chronic kidney disease, the JNC recommends the use of ACEI or ARB.
The goal blood pressure is a systolic blood pressure of <140 mm Hg and diastolic blood pressure of <90 mm Hg for hypertensive patients aged 60 years and younger. Patients older than 60 years old, the goal blood pressure is a systolic blood pressure of <150 mm Hg and a diastolic blood pressure of <90 mm Hg.
Measuring and monitoring blood pressures is important in the management of hypertension. Most blood pressure measurements occur in a health-care setting in the diagnosis of hypertension. These readings could be erroneous to some patients because of the white coat effect phenomenon. The white coat effect manifests when patients have a normal range of blood pressures at home, but get a high blood pressure reading in health-care settings (Reynolds, 2015). JNC recommends at-home blood pressure monitoring (HBPM) in the management of hypertension. Measuring blood pressures at home negates the white coat effect phenomenon and provides more accurate information about the patient, thereby helping physicians provide a proper prognosis.
Schulz, Stahmann, and Neumann (2015) described telemonitoring as a combination of a medical measuring device (e.g. blood pressure unit, weight scale, etc.) and a data transmission unit (e.g. data modems) that enables sending medical telemetry data. Sophisticated encryption techniques enable a tap-proof connection between the patient’s telemonitoring unit and the medical records database. Patients are advised by health professionals to take their blood pressure measurements at an agreed interval within a week. A diagram to illustrate a sample of telemonitoring technology appears below:
Figure 1. The technical architecture of the health coaching system supported with remote patient monitoring. Reprinted from Karhula, T. et al. (2015). Telemonitoring and Mobile Phone-Based Health Coaching Among Finnish Diabetic and Heart Disease Patients: Randomized Controlled Trial. Journal of medical Internet research, 17(6), e153.
Methods
Articles published between 2010 and 2015 found in three databases (EBSCO Host, PubMed, Cochrane Library) and the internet using Google Scholar were used to search for evidence of the efficacy and outcomes of using telemonitoring technology for controlling blood pressure in patients with hypertension. Nevertheless, apart from the databases mentioned, articles included in the reference lists of the studies retrieved from these databases were also reviewed. The research aimed at determining if other studies absent from the databases met the inclusion criteria for this review.  Search words used were "hypertension" or "blood pressure" and "telemonitoring”, "telehealth”, or "telemedicine”. Medical Subject Headings (MeSH) terms used in PubMed were "telemedicine" and "hypertension" as the other search words were not available as MeSH terms in PubMed.
Inclusion criteria used in this literature search comprised: research participants diagnosed with hypertension; randomized controlled trials; cost analysis studies; observational studies and telemonitoring used as an intervention for at least six months. Additionally, the number of participants at least 50; blood pressure measurements done at home without the supervision of a health-care professional and blood pressure readings transmitted by research participants to a personal account and accessed by a health-care professional were included.  Exclusion criteria included: literature reviews; articles written before 2010; blood pressure measurements done by a health-care provider at home; studies paid by companies that develop telemonitoring technology; expert commentaries and studies with participants from the pediatric population.Moreover, studies with nonhuman subjects; and the presence of co-morbidities (e.g. heart failure, chronic kidney disease, diabetes, etc.) got excluded. Studies performed outside the United States got considered.
Research articles got selected based on whether the abstract or the full article met the inclusion criteria previously mentioned.  In total, fourteen published articles found comprised five randomized control trials, three cohort studies, three cost analysis studies, and three qualitative studies. The level of evidence of the published articles chosen for this review got ranked according to the rating scheme from the National Guideline Clearinghouse (See Appendix A)
Results
A total of 206 articles got retrieved from the databases and Google Scholar. Articles retrieved from the reference list of published studies contributed to this number. After the initial search, 180 articles got excluded from the original search. The exclusion entailed: duplicate articles; studies discussed and evaluated other chronic conditions away from hypertension; telemonitoring done inside a health-care facility; lack of a true control group; and use of different technologies to monitor hypertension. Only fourteen articles from the remaining 26 articles met the inclusion criteria and included in this literature review (Figure 2).
Figure 2. Article selection process.
Five of the fourteen items were considered level II on the National Guideline Clearinghouse rating scheme. The remaining articles appeared to be a combination of cost-analysis, observational cohort, and qualitative studies that are considered levels IV to VI in the rating system.
Randomized Controlled Trials that Reported Blood Pressures as a Primary Outcome
The summary of the number of participants and length of study of the four randomized controlled trials appear in Appendix B. The study entailed blood pressure changes as a primary outcome. A fifth randomized controlled trial included in this review focused more on the cost-effectiveness of the telemonitoring intervention, as opposed to measuring blood pressure control discussed later ...