Abstract
Background and Objective:
Meta-analysis of randomized controlled trials have demonstrated the efficacy of telemedicine in blood pressure (BP) management when compared to conventional care. We initiated a hypertension telehealth clinic in our urban primary care clinic and through this study aim to evaluate the strengths and limitations of telemedicine in hypertension (HTN) control. The primary outcome of the study is to identify the proportion of patients with improved HTN. Secondary outcomes included identifying: predictors for lower BP, predictors of missing telehealth appointments, and comorbid conditions that are more likely to necessitate use of more than 1 antihypertensive medication.
Methods and Analysis:
Patients seen in the HTN telehealth clinic from May 1st, 2022 to October 31st, 2022 were identified. A retrospective chart review was done to compare the BP during in-person visit prior to first telehealth visit, telehealth visit home BP readings and last recorded in-office BP on chart at end of study period. Descriptive statistical analysis, Chi Square test, and multivariable logistic regression was used to analyze data.
Results:
Of the 234 appointments, 83% were conducted and 154 patients were seen. A remarkable decrease in percentage of patients with BP >140/90 was seen when comparing in-office visit BP to first telehealth visit home BP, 72% versus 45% respectively. No remarkable difference was noted in percentage of patients with BP >140/90 when comparing first telehealth visit home BP to last in-office BP recorded on chart, 45% and 41% respectively. Patients with diabetes had lower odds of missing appointments, adjusted odds ratio (aOR): 0.34 ([0.12-0.91], P = .03). Patients with partners were more likely to have lower BP at the telehealth visit, aOR:3.2 ([1.15-9.86], P = .03) while patients with obstructive sleep apnea (OSA) (aOR 0.27 ([0.08-0.77], P = .02) and CAD, aOR 0.24 ([0.06-0.8], P = .03) were less likely to have lower BP.
Conclusion:
The study demonstrated telemedicine as a great tool to prevent overtreatment of hypertension as significant difference between in-office BP and home BP during telehealth visits was noted. We did not see a significant change in blood pressure when comparing home BP at first telehealth visit to the last in-person clinic BP at end of study period.
Keywords
Introduction
As evident from the recent COVID-19 health pandemic, telemedicine has thrived and emerged as an invaluable resource to ensure continuity of care of patients with chronic illnesses. 1 In 2021, 37% of adults in the USA used telemedicine.2,3 Hypertension is one of the most common chronic illnesses in the USA with a prevalence of 47.3% with only 1 in 4 adults having their blood pressure controlled. 4 It is crucial that hypertension is well controlled as uncontrolled blood pressure increases the risk of heart disease and stroke, 2 leading causes of death in the USA. 5
As per the 2017 ACC/AHA guidelines for management of hypertension, telehealth is a class IIa recommendation as a useful adjunct to interventions shown to reduce BP for patients with HTN. 6 As summarized in the international expert position paper on use of telemedicine for HTN management, various randomized controlled studies and meta-analysis have shown that greater BP reductions and a larger proportion of patients achieved BP control when a telemedicine approach was utilized compared with usual care. 7
Telemedicine requires a multidisciplinary healthcare team based approach and its success is dependent on many factors such as the setting/facility managing the telehealth clinic, the availability of electronic solutions (Electronic Medical Records, telemonitoring and tracking abilities, and video and remote consultation platform), availability of devices/tools (video cameras, mic, speakers, and video capable mobile devices), and communication networks and case managers (physicians capable of using telemedicine platforms, social workers, and pharmacists). 7
To improve the blood pressure control of patients at an urban primary care clinic, a hypertension telehealth clinic was established. As outlined above, the success of such a clinic is dependent on multiple factors and as a result we conducted this retrospective study to assess the benefits and limitations of telemedicine in an urban primary care clinic setting. We further aim to identify predictors of improved blood pressure in telemedicine, predictors of missing telehealth visit appointments, and comorbidities that would necessitate use of 1 or multiple antihypertensive medications.
Methods
Study Design
A hypertension telehealth clinic was established to improve blood pressure control. Physicians could refer patients with hypertension (uncontrolled or controlled that needed close follow ups) for further management. Details of the structure of telehealth visit are outlined in the Supplemental Material information. This study was approved by the Institutional Review Board. Patients who were diagnosed with uncontrolled hypertension during traditional office visits were offered telemedicine visit appointments. During that same office visit the physician gave training to the patients on how to accurately measure blood pressure at home as per the American Heart Association guidelines, provided prescription for an automated home blood pressure machine to be picked up at any local pharmacy, provided a blood pressure log for patients to manually record their BP readings and ensured that patient had a video compatible phone. 8
A retrospective cohort study was performed where we queried our electronic medical record (EMR) to obtain a list of patients who were scheduled for a hypertension telehealth visit between May 1st, 2022, and October 31st, 2022, at our primary care clinic. For each patient, we recorded the following information at baseline: demographics [including sex, age, race/ethnicity, marital status, and mean income which was done based on linking zip codes with US census data] and comorbid conditions based on their International Classification of Diseases, 10th Revision (ICD-10) codes.
We also collected the following telemedicine specific information: was patient present for telehealth visit?, patient’s BP during the in-person office visit prior to the first telehealth visit, patient’s self-reported home blood pressure reading recorded in EMR by physicians during each telehealth visit (an average calculated by the physician of the daily home BP over past 1 week), and patient’s blood pressure at the last in-person clinic visit on EMR during end of study period.
Furthermore, we noted the number of antihypertensive medications patients were taking at the first telehealth visit (if on combination pill, separate classes were recorded), number of telehealth visits conducted for each patient, and information about antihypertensive medication changes at each telehealth visit. If no medication changes were made during telehealth visit, we reviewed the telehealth visit physician note to identify the reason. The blood pressure readings were categorized as per the ACC/AHA 2017 guidelines into <120/<80, 120 to 129/<80, 130 to 139/80 to 89, ≥140/>90, and >180/>120 mmHg for data analysis purposes. 6
Primary and Secondary Outcomes
The primary outcome was the improvement in blood pressure on comparing in-person clinic BP to telehealth visit home BP to the last BP recorded on EMR at end of study period. Improvement in blood pressure was defined as blood pressure change to a lower blood pressure category.
Secondary outcomes included identifying, (a) predictors of lower and higher blood pressure, (b) predictors of missing telehealth visit appointments, (c) comorbid conditions that would more likely necessitate use of more than 1 antihypertensive medication, (d) the most common antihypertensive medication, and (e) percentage of diabetic patients on Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).
Statistical Analysis
All patients that were not present for their telehealth visit appointment were excluded from all data analysis, except for analysis that involved identifying predictors of missing telehealth appointments.
For each of these 3 groups; in person clinic BP prior to telehealth visit, home BP, and last recorded BP on EMR at end of study period, descriptive statistics were calculated for the proportion of patients in each blood pressure category. Descriptive statistics were also calculated for demographics, comorbid conditions, common blood pressure medications, and proportion of diabetic patients on ACEI/ARBs. Furthermore, descriptive statistics were also used to assess how many patients had medication changes done during telehealth visit and if not done then what were the reasons behind it.
The last BP on EMR at end of study period and in-person clinic BP were further grouped into controlled (BP ≤139/89) and uncontrolled HTN (BP≥140/90) and Chi Square test was used to assess for any statistical difference in number of patients with uncontrolled HTN when comparing in-person clinic BP to last recorded BP on EMR (after hypertension telehealth visits as the intervention). Patients were grouped into 3 groups: improved, same, and worse BP (where their last known BP was lower, same, or worse than the in-person clinic visit BP respectively), and then a multivariable logistic regression model was used to determine demographic and comorbidities predictors of having lower or worse BP during telemedicine. Similar analysis was also done to identify predictors of lower odds of missing telehealth visit appointments. All statistical analyses were performed using R software (R Core Team, 2021), a freely available language and environment for statistical computing. 12
Results
Of the 234 appointments scheduled, 83% were conducted and 17% missed their appointments. A total of 154 patients were seen with 75% patients having 1, 20% having 2, and 5% having 3 or more telehealth visits. Baseline characteristics are outlined in Table 1. Women (56%) had more telehealth visits as compared to men and 87% patients identified as Black.
Baseline Characteristics (n = 154)—no. (%).
The antihypertensive medications patients were taking at the start of their first telehealth visit are outlined in Table 2. Calcium channel blockers were the most used medication (26%).
Most Common Antihypertensive Medications Used by Patients in the Study.
About 72% of patients had BP >140/90 and 13% had BP >180/120 during their in-office visits which decreased to 45% and 2% during home BP on their first tele-visit respectively (Figure 1). Reflecting on this improvement in blood pressure, we noted that patients with BP 120 to 129/<80 increased from 6% during in-office visit to 18% at first telehealth visit (Figure 1). Similarly, patients with BP 130 to 139/80 to 89 increased from 6% during in-office visit to 29% at first telehealth visit (Figure 1). About 45% patients had BP >140/90 at their first telehealth visit and this only improved to 41% on the last recorded BP after their telehealth visits (Figure 1).
Comparison of blood pressure at in-person clinic visit prior to hypertension telehealth visit versus home BP at first telehealth visit versus last recorded in-office BP at end of study period.
Of note, 3% of patients had initial BP readings of <120/80 mmHg, 6% were 120 to 129/<80 mmHg, and 6% were 130 to 139/80 to 89 mmHg (Figure 1). Although these patients had controlled BP readings at their initial visit, they were seen at the HTN telehealth clinic due to reasons such as high BP at home as compared to office visit, symptoms of hypotension, medication side effects, and patient preference to either decrease dosage or discontinue medications necessitating close follow up.
After dividing the in-person clinic BP and last recorded BP on EMR into controlled (BP ≤ 139/89) and uncontrolled HTN (BP ≥ 140/90), as per Chi-square test, the number of patients with uncontrolled BP after the telehealth visits (as per the last recorded BP) was significantly less as compared to the number of patients with uncontrolled BP during in-office BP readings with a chi-square statistic of 81.26 and P < .001.
Three patients had type 1 and 73 had type 2 diabetes mellitus of which 63% were taking either ACEI or ARB. About 64% of patients were taking more than 1 antihypertensive medication. Table 3 outlines the various comorbid conditions and their associated percentage of patients taking 1 versus 2 or more antihypertensive medication. Notably 100% patients with type 1 diabetes mellitus, atrial fibrillation, end stage kidney disease, and substance use disorder, 95% with CKD, 91% with COPD, 90% with CVA, 89% with cardiomyopathy, 86% with peripheral arterial disease, and 85% with coronary artery disease were taking more than 1 anti-hypertensive medication.
Chronic Medical Conditions and Percentage of Patients on 1 Versus 2 or More Antihypertensive Medications.
Patients with type 2 diabetes mellitus had lower odds of missing appointments, adjusted odds ratio (aOR) 0.34 [95% CI 0.12-0.91; P = .03]. Patients with partners were more likely to have lower BP at the telehealth visit, aOR 3.2 [95% CI 1.15-9.86; P = .03] while patients with Obstructive Sleep Apnea (OSA), aOR 0.27 [95% CI 0.08-0.77; P = .02] and Coronary Artery disease (CAD, aOR 0.24 [95% CI 0.06-0.8; P = .03] were less likely to have lower BP. During the first telehealth visit, 60% of patients had no medication changes done, 18% had dose adjusted and 21% had a new anti-hypertensive medication added (Figure 2).
Pie chart showing what changes were made to patients’ antihypertensive regime during their televisits.
Of the 60% who had no medication changes, 60% of them had their home BP at goal (<140/90), 12% lacked a home BP monitor, 7% physician preference not to change medications, 5% did not record home BP despite having BP machine and 16% due to various other reasons as highlighted in Figure 3.
Pie chart showing reasons behind why patients referred to telehealth clinic did not have any antihypertensive medication changes.
For 76% of telehealth visit encounters, home BP was recorded within the physician’s telehealth visit note and only 14% of patients had these metrics recorded in the appropriate vitals section on the EMR where other providers could also see them.
Discussion
Telemedicine has the potential to revolutionize healthcare by improving access to care, increasing patient convenience, and reducing healthcare costs. Despite these potential benefits, telemedicine remains underutilized in the United States, with only 37% of adults having used telemedicine services in 2021. 2
Our study highlights the potential benefits of telemedicine for hypertension management, including the lower blood pressure readings obtained at home at first telehealth visit compared to in-office visit prior to the first telehealth visit. This finding may be explained by several factors such as antihypertensive medication initiation/changes during in-office visit, white coat hypertension and inaccurate measurement of in-office BP (eg, not in accordance with the AHA guidelines where patient should not have exercised for 30 min, completely relaxed for 5 min before measurement, using correct cuff size, and incorrect arm placement). This is also reflected in the data that patients who did not have medication changes done during first telehealth visit, 60% was due to patient already being at goal BP (<140/90). From this data we can conclude that through telemedicine we can certainly prevent unnecessary overtreatment of hypertension and thus reducing patients’ risk of hypotension and any associated complications.
Our study did not see a significant change in blood pressure when comparing home BP at first telehealth visit to the last BP on EMR at the end of the study periods (45% and 41% with BP >140/90 group respectively) indicating that 41% patients did not achieve better blood pressure control with telemedicine within the study period. This may be due to these patients having difficult to treat HTN. Another factor that may explain this would be that we recorded the last in-office BP in EMR at the end of the study period which may have been falsely elevated due to the multiple reasons outlined above. For our outcomes, the last telehealth home BP would have been the ideal comparison point, however this was not a good option for the study as only 25% patients had 2 or more telehealth visits.
The gender inequality in telemedicine utilization has been noted in several studies. As per the 2021 CDC-National Center for Health Statistics report, telemedicine use was higher in women compared to men (42% vs 31.7%), findings consistent with our study. 2 The ACC/AHA 2017 BP management guidelines have noted psychosocial stressors as risk factors for high BP and having good social support is beneficial to hypertension control. This is probably the reason as to why our study found that patients who have partners were more likely to have a lower blood pressure on tele-visit. This observation highlights the benefits of social support in the effective management of hypertension via telemedicine.
Most patients in the study were Black adults and the most common antihypertensive medication used was CCB (Calcium Channel Blocker). This is in accordance with the 2017 ACC/AHA hypertension guidelines where CCB or thiazides are class 1 recommendation for initial antihypertensive treatment in black adults without HF (Heart Failure) and CKD. 6 Regarding hypertension management in patients with diabetes, the use of ACEIs or ARBs is recommended for patients with diabetes and albuminuria to slow the progression of diabetic kidney disease. 9 We noted that 37% of patients with DM were not on ACEI/ARB and these patients should be investigated further for albuminuria and indications for these medications.
We also found that patients with diabetes were less likely to miss their telehealth appointments and this may be attributed to their increased health literacy and more frequent requirements of medical care. Patients with OSA and CAD were more likely to have higher blood pressure at the tele-visit and thus need closer follow-up, which can also be achieved via telemedicine. These findings are consistent with previous studies that have demonstrated the potential benefits of telemedicine for patients with chronic conditions.10,11
One challenge of telemedicine is patient non-attendance of scheduled appointments with 17% no-show rate in our study. Further research is needed to identify the reasons behind missing telehealth visit appointments. Few possibilities could be that patients became unexpectedly busy with their daily lives (at work or at home), family/work emergencies, lack of internet connectivity, forgetting appointments, and lack of home BP machine. To maximize the benefits of telemedicine for hypertension management, it is imperative that patients have home blood pressure monitoring devices. When prescribing these devices, insurance and associated out-of-pocket costs must be considered.
To ensure the effective management of hypertension via telemedicine, it is important to document home BP in the appropriate sections in EMR for future tracking and for other physicians to see. We found that for 76% of tele-visit encounters, the home blood pressure readings were documented within the provider’s office note and not in the vitals sections, which is the most preferred area to see patient’s vital trends. This data may not be seen by other physicians in the hospital system who also manage HTN and therefore may result in unnecessary medication changes leading to patient harm. This highlights the need for a more streamlined platform where patients can automatically transmit data to their EMR.
Limitations
The results of this study should be interpreted considering its limitations. The sample size was small, and the study was conducted at a single institution, which may limit the generalizability of the findings. This telemedicine model depends on the patient’s ability to measure blood pressure accurately at home, and the physician must trust the accuracy of the readings reported. Only 25% of patients had ≥2 telehealth visits which limits the evaluation of the effect of multiple telehealth visits on blood pressure control. Also due to this, instead of ideally using last known home BP reading we used the last known in person clinic visit BP for comparison to the other blood pressure groups.
In conclusion, telemedicine represents a useful approach for accurate management of hypertension as it can prevent overtreatment of hypertension. Patients with partners are likely to have lower BP on telemedicine and patients with diabetes are less likely to miss their telehealth visit appointments. The success of telemedicine is multifactorial, and the next step would be to get a better understanding of patients who did not achieve blood pressure control with telemedicine and identify factors as to why this was the case.
Supplemental Material
sj-docx-1-jpc-10.1177_21501319231199014 – Supplemental material for The Use of Telemedicine to Improve Hypertension in an Urban Primary Care Clinic and Predictors of Improved Blood Pressure
Supplemental material, sj-docx-1-jpc-10.1177_21501319231199014 for The Use of Telemedicine to Improve Hypertension in an Urban Primary Care Clinic and Predictors of Improved Blood Pressure by Ajay Kerai, Namratha Meda, Khushboo Agarwal, Mohil Garg, Brototo Deb, Pooja Singh, Puneet Singla, Tareq Arar, Godwin Darko and Nnenna Oluigbo in Journal of Primary Care & Community Health
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
