Heart Disease and Stroke Prevention: Interactive Digital Interventions for Blood Pressure Self-Management

The Community Preventive Services Task Force (CPSTF) uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

McLean G, Band R, Saunderson K, Hanlon P, Murray E, et al. Digital interventions to promote self-management in adults with hypertension: systematic review and meta-analysis. Journal of Hypertension 2016;34(4):600-12.

The review included seven randomized controlled trials (search period through 2014). The team examined each of the studies included in the systematic review and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included seven studies.

• Among recruited patients who had high blood pressure, interventions led to the following outcomes:
  • Systolic blood pressure decreased by a mean of 3.7 mmHg (6 studies)
  • Diastolic blood pressure decreased by a mean of 2.4 mmHg (5 studies)
  • One study reported patients in the intervention group were significantly more likely to have their blood pressure under control after 24 months.

A systematic review of economic evidence has not been conducted.

While additional research is warranted, the CPSTF finding should be applicable to the use of interactive digital interventions in U.S. healthcare settings for adults who have high blood pressure.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Are interventions effective in helping patients control their blood pressure over longer periods of time (1-2 years)?
• Are these interventions effective in reducing morbidity, mortality, and health care utilization associated with hypertension?
• What factors influence intervention effectiveness?
  • Use with or without self-measured blood pressure monitoring?
  • Use with or without additional counseling or interpersonal contact?
  • Setting (i.e. workplaces or community)?
  • Patients’ race, ethnicity, or socioeconomic status?
  • Length of time since hypertension diagnosis?
  • Level of blood pressure control at enrollment?
  • Use with novel or existing smartphone applications?

• All of the included studies were randomized controlled trials.
• Studies were conducted in the United States (3 studies), Canada (1 study), Finland (1 study), Korea (1 study), and Honduras and Mexico (1).
• Patients were recruited in healthcare settings (6 studies) and workplaces (1 study).
• Two U.S. studies included clinics that served urban, low-income communities. In one of these studies, recruited patients were primarily African-American (72%) or Hispanic (14%).
• Evaluated interventions were of short duration (median 6 months).
• Interventions used mobile phones (3 studies), web-based programs (3 studies), or telephones (1 study).
• While limited information was provided about the digital content, all of the interventions included health education related to blood pressure self-management.
• Patients interacted with digital components daily (3 studies) or weekly (3 studies); interactions were variable in the remaining study.
• In five of the studies, digital components were part of self-measured blood pressure monitoring (SMBP) interventions.
• Three studies offered contact or appropriate follow-up with a health professional or community health worker.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

McLean G, Band R, Saunderson K, Hanlon P, Murray E, et al. Digital interventions to promote self-management in adults with hypertension: systematic review and meta-analysis. Journal of Hypertension 2016;34(4):600-12.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Bennett GG, Warner ET, Glasgow RE, Askew S, Goldman J, Ritzwoller DP, et al., Be Fit, Be Well Study Investigators. Obesity treatment for socioeconomically disadvantaged patients in primary care practice. Arch Intern Med 2012;172:565 74.

Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Torgerson J, Carey K. A telecommunications system for monitoring and counselling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens 1996;9 (4 Pt 1):285 92.

Nolan RP, Liu S, Shoemaker JK, Hachinski V, Lynn H, Mikulis DJ, et al. Therapeutic benefit of internet-based lifestyle counselling for hypertension. Can J Cardiol 2012;28:390 6.

Orsama AL, La hteenma ki J, Harno K. Active assistance technology reduces glycosylated hemoglobin and weight in individuals with type 2 diabetes: results of a theory-based randomized trial. Diab Technol Therapeut 2013;15:662 9.

Piette JD, Datwani H, Gaudioso S, Foster SM, Westphal J, Perry W, et al. Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Telemed J EHealth 2012;18:613 20.

Watson AJ, Singh K, Myint UK, Grant RW, Jethwani K, Murachver E. Evaluating a web-based self-management program for employees with hypertension and prehypertension: a randomized clinical trial. Am Heart J 2012;164:625 31.

Yoo HJ, Park MS, Kim TN, Yang SJ, Cho GJ, Hwang TG, et al. A ubiquitous chronic disease care system using cellular phones and the internet. Diabet Med 2009;26:628 35.

Implementation Resources

• CDC’s Division for Heart Disease and Stroke Prevention developed an implementation resource to help communities and health systems implement telehealth interventions to improve chronic diseases, including cardiovascular disease.

Refer to the existing systematic review for information about the search strategy:

McLean G, Band R, Saunderson K, Hanlon P, Murray E, et al. Digital interventions to promote self-management in adults with hypertension: systematic review and meta-analysis. Journal of Hypertension 2016;34(4):600-12.

McLean G, Band R, Saunderson K, Hanlon P, Murray E, et al. Digital interventions to promote self-management in adults with hypertension: systematic review and meta-analysis. Journal of Hypertension 2016;34(4):600-12.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• The CPSTF recommends self-measured blood pressure (SMBP) monitoring interventions when used alone or with additional support based on evidence of effectiveness for patients with high blood pressure. Interactive digital interventions can be a central component of SMBP monitoring or provide additional support for patients.
• The Million Hearts Initiative includes tools and resources to help organize health system and public health improvement strategies for blood pressure management. Strategies may include the use of interactive digital interventions:
  • Self-Measured Blood Pressure Monitoring
  • Medication Adherence
• Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to electronic communications with patients.
• Use of digital interventions might reduce the number of in-person clinic visits needed to encourage patient self-management and achieve blood pressure control.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce coronary heart disease deaths — HDS-02
• Reduce stroke deaths — HDS-03
• Reduce the proportion of adults with high blood pressure — HDS-04
• Increase control of high blood pressure in adults — HDS-05