Randomized Controlled Trial of E-Counseling for Hypertension

Effectiveness of digital health interventions on adherence and control of hypertension: a systematic review and meta-analysis

BACKGROUND

Hypertension, a risk factor for developing cardiovascular disease, is becoming increasingly prevalent worldwide. Digital health is now widely utilized for hypertension management, and numerous studies have assessed its effectiveness.

OBJECTIVE

The review aims to analyse the effectiveness of digital health (i.e., mobile health (mHealth), telehealth, and the combination of mHealth & telehealth) on hypertensive patients, concerning three key areas: clinical outcomes, medication adherence, and adherence to lifestyle changes, as compared to standard care.

METHODS

The review followed the PRISMA framework. Eight electronic databases were scanned for randomized control trials focusing on the effects of mHealth or telehealth on hypertensive patients, published between 2010 and 2023. All processes were conducted by the first two authors independently. A meta-analysis was conducted for quantitative data, while a narrative synthesis was conducted for qualitative data.

RESULTS

In total, 74 studies involving 92 686 participants were identified. The meta-analysis favoured the interventions, revealing a significant decrease in systolic blood pressure and diastolic blood pressure for mHealth, telehealth and mHealth & telehealth groups. Nevertheless, medication adherence showed improvement only in the mHealth group, while blood pressure control showed improvement in both mHealth and mHealth & telehealth groups, and BMI showed improvement only in the mHealth group. Evidence for adherence to physical activity and DASH diet/salt intake remained inconclusive.

CONCLUSION

In general, mHealth and telehealth have demonstrated their merits in improving the clinical outcomes of hypertensive patients.

Effectiveness of digital health interventions for telemedicine/telehealth for managing blood pressure in adults: a systematic review and meta-analysis

This systematic review and meta-analysis included randomized controlled trials or observational studies that compare digital health interventions (DHIs) for telemedicine/telehealth versus usual care for managing blood pressure (BP) in adults. We searched PubMed, Cochrane CENTRAL, and IchuShi-Web, and used a random-effects meta-analysis of the weighted mean difference (MD) between the comparison groups to pool data from the included studies. The outcome included the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 117 studies with 68677 participants as eligible. The 3-month intervention period reduced office systolic BP (SBP) compared with usual care in 38 studies (MD: -3.21 mmHg [95% confidence interval: -4.51 to -1.90]), with evidence of heterogeneity. Office SBP across intervention periods demonstrated comparable effects (3-, 6- [54 studies], 12- [43 studies], and >12-month periods [9 studies]). The benefits for office diastolic BP were similar to those for office SBP. Additionally, the interventions significantly reduced the office SBP compared with the control, regardless of the mode of intervention delivery (smartphone apps [38 studies], text messages [35 studies], and websites [34 studies]) or type of facility (medical [74 studies] vs. non-medical [33 studies]). The interventions were more effective in 41 hypertension cohorts compared with 66 non-hypertension cohorts (-4.81 mmHg [-6.33, -3.29] vs. -2.17 mmHg [-3.15, -1.19], P = 0.006 for heterogeneity). In conclusion, DHIs for telemedicine/telehealth improved BP management compared with usual care. The effectiveness with heterogeneity should be considered, as prudent for implementing evidence-based medicine. This meta-analysis considered 117 studies with 68677 participants eligible. The DHIs for telemedicine/telehealth reduced office BP compared with usual care, regardless of intervention duration, intervention delivery mode, facility type, and cohort type. Additionally, the DHIs reduced the risk of uncontrolled BP compared with usual care, regardless of intervention duration, intervention delivery mode, and facility type. BP blood pressure, DHI digital health intervention, MD mean difference, RR risk ratio, SBP systolic blood pressure.

Self-management behavior strategy based on behavioral economics in patients with hypertension: a scoping review

Hypertensive patients often do not make the most favorable choices and behaviors for managing disease. Behavioral economics strategies offer new ideas for guiding patients toward health behavior. The scoping review aimed to summarize behavioral economics strategies designed to improve hypertension self-management behaviors. A literature search was conducted in September 2022 using the following electronic databases: Embase, Medline, CINAHL, PsycINFO, Web of Science, Cochrane Library, CNKI, Wan Fang Database for Chinese Periodicals, and CBM-SinoMed. We screened the literature for experimental studies written in Chinese or English reporting on BE strategies designed to improve self-management behavior in hypertension. We searched 17 820 records and included 18 articles in the final scoping review. We performed qualitative synthesis by the categories of choice architecture. The most common BE strategies were those targeting decision information and decision assistance, such as changing the presentation of information, making information visible, and providing reminders for actions. Most strategies targeted BP, diet, medication adherence, and physical activity behavior. Ten out of 18 studies reported statistically significant improvement in self-management behavior. Further research on BE strategies should focus on addressing the challenges, including changing the decision structure, encompassing a more comprehensive range of target behaviors, and examining the long-term effects of BE strategies.

Cognitive-behavioral therapy for treating hypertension: a systematic review and meta-analysis

The aim of the study is to investigate whether cognitive behavioral therapy (CBT) can help in reducing blood pressure (BP) in patients with hypertension, both systolic blood pressure (SBP) and diastolic blood pressure (DBP), this being the primary outcome. This was a systematic review with a meta-analysis that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The keywords used for the searches were CBT and hypertension and their respective synonyms, and were applied to the Pubmed, EMBASE and Web of Science databases. Eligibility and data extraction were performed by two independent researchers. They assessed the risk of bias using the Cochrane's RoB 2 tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the evidence. The data was pooled on the basis that all the analyses had a random effects model. Twenty-two studies were included in this review. In the meta-analysis, 11 studies were included in the analyses of the BP outcomes (SBP and DBP), five studies were included in the follow-up evaluation, and two studies in the body mass index (BMI) analysis. The searches included a total of 2897 patients. The studies presented a high risk of bias and very low quality of evidence. We observed an effect of -0.65 (95% CI: -0.91; -0.39) for CBT-based interventions on SBP with high heterogeneity (I2 85%) and a higher effect of -0.78% (95% CI: -1.13; -0.43) on DBP with even greater heterogeneity (I2 92%). We observed that CBT did have an effect on reducing BP and BMI in hypertensive adults. However, due to the considerable heterogeneity between the studies, the high risk of bias, and the low overall quality of evidence, confidence in these findings should be limited.

An Exploration of Dietary Strategies for Hypertension Management: A Narrative Review

This review aims to clarify the influence of various nutritional approaches in the management of hypertension. An extensive search of databases, namely, PubMed, Cochrane Library, Scopus, and Web of Science, was performed, covering the period from January 2012 to October 2023. We used keywords, such as "hypertension," "nutrition," "nutritional management," "nutrient intake," "dietary strategies," "DASH diet," "Mediterranean diet," and related terms. Hypertension, a grave global health concern, affects more than one billion people worldwide. Lifestyle modifications, including nutritional strategies, are important in non-pharmacological interventions. Dietary patterns, such as the DASH (Dietary Approaches to Stop Hypertension) and Mediterranean diets, which emphasize fruit and vegetable consumption, have demonstrated efficacy in reducing blood pressure. Certain nutrients, such as potassium, calcium, and magnesium, have significant effects on blood pressure. The mechanisms underlying these dietary strategies include vasodilation, improvement in endothelial function, regulation of sodium balance, and mitigation of oxidative stress. However, successful implementation of these strategies can be hindered by various factors, such as adherence challenges, socioeconomic disparities, and cultural preferences. In conclusion, robust evidence supports the effectiveness of nutritional strategies in the management of hypertension. DASH and Mediterranean diets, along with an increased intake of specific nutrients, contribute to blood pressure reduction. Hence, comprehensive lifestyle modifications, with a focus on nutritional changes, are recommended as primary or complementary treatments for hypertension. Addressing the identified barriers could enhance the efficacy and use of these dietary approaches in clinical practice.

Automated Digital Counseling Program (ODYSSEE-Kidney Health): A Pilot Study on Health-Related Quality of Life

Key Points

Feasibility of implementing an automated, scalable, digital self-care program for patients with CKD was established. The primary outcome of improvement in health-related quality of life improved with the ODYSSEE-Kidney Health program. A dose relationship was shown between program engagement tertile and improvement in 4-month outcomes.

Background

In-person counseling programs promote self-care behavior and health-related quality of life (HRQoL). ODYSSEE-Kidney Health (prO moting health with D igitallY based counS eling for S elf-care bE havior and quality of lifE ; ODYSSEE-KH) is an automated, scalable, digital counseling program for patients with CKD. This open-label, single-arm pilot study tested the efficacy potential of the ODYSSEE-KH program to improve HRQoL in patients with CKD.

Methods

Adults with categories G3b to 5d CKD were recruited from nephrology clinics in Toronto, Canada. Patients (N =29) received access to the ODYSSEE-KH program in conjunction with usual care. Generalized linear models and pairwise comparisons of mean change scores were conducted to assess the primary outcome: Mental Component Score (MCS) of the Kidney Disease Quality of Life–Short Form instrument. Secondary outcomes included the MCS Mental Health Scale, 36-Item Kidney Disease Quality of Life–Short Form, Generalized Anxiety Disorder Scale, Patient Health Questionnaire for depression, Enhancing Recovery in Coronary Heart Disease Social Support Instrument, and 3-Item Revised University of California, Los Angeles (UCLA) Loneliness Scale.

Results

The mean age of the patients was 53.5 years (SD=18.3); 35% were women; 56% were White; 93% had completed ≥postsecondary education; patients came from the Multi-Care Kidney Clinic (n =9), Home Peritoneal Dialysis Unit (n =12), and Home Hemodialysis Unit (n =8); and 24 participants completed the 4-month end-of-study questionnaires. Outcomes were assessed according to tertiles of program log-on minutes: median (range)=67 (62–108), 212 (119–355), and 500 (359–1573) minutes, respectively. Patients in the highest tertile of engagement showed significant improvements on the MCS versus the moderate tertile group (P = 0.01). Significant dose-response associations were observed for the MCS Mental Health Scale (P < 0.05), KDQoL Burden on Kidney Disease (P < 0.01), KDQoL Effect of Kidney Disease on Everyday Life (P < 0.01), aggregated KDQoL Summary Scale (P < 0.05), Generalized Anxiety Disorder Scale (P < 0.01), Patient Health Questionnaire for Depression (P < 0.05), Enhancing Recovery in Coronary Heart Disease Social Support Instrument (P < 0.01), and 3-Item Revised UCLA Loneliness Scale (P < 0.01).

Conclusion

The ODYSSEE-KH program demonstrated feasibility as an automated, scalable, digital self-care program for patients with CKD. There is evidence of its efficacy potential to improve HRQoL. Further evaluation with a larger sample is warranted.

Educational Program with Text Messaging for Community-Dwelling Patients with Hypertension: A Pilot Randomized Controlled Trial

PURPOSE

Controlling blood pressure minimizes the risk of cardiovascular events among patients with hypertension. Despite regular follow-ups, the hypertension management for patients aged ≥45 years is limited as evidenced from a decreased control rate. This pilot study aimed to test a theory-guided educational program for community-dwelling patients with hypertension.

METHODS

Sixty-nine patients with hypertension aged ≥45 years and having high blood pressure (>130/80 mmHg) were recruited in this two-arm pilot randomized controlled trial. Participants in the intervention group underwent a program guided by the Health Promotion Model, whereas those in the control group received usual care. Data were collected at baseline, week 8, and week 12 and used to assess the blood pressure, pulse pressure, self-efficacy, and adherence to hypertension management. Data were analyzed using a generalized estimating equation based on the intention-to-treat principle. Process evaluation was conducted to assess the feasibility and acceptability of the educational program.

RESULTS

The results obtained using the generalized estimating equation revealed that the educational program led to reduction in the systolic blood pressure (β = -7.12, p = .086) and pulse pressure (β = -8.20, p = .007) and to improve self-efficacy (β = 2.61, p = .269) at week 12. The program had a small-to-moderate effect on the reduction of systolic blood pressure (effect size = -0.45) and pulse pressure (effect size = -0.66) and self-efficacy (effect size = 0.23). The participants were highly satisfied with the educational program.

CONCLUSIONS

The educational program was found to be feasible and acceptable and may be incorporated into current hypertension management practices at the community level.

TRIAL REGISTRATION

ClinicalTrials.gov with identifier: NCT04565548.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with hypertension: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions are effective for hypertension self-management, but a comparison of the effectiveness and implementation of the different modes of interventions is not currently available. This study aimed to compare the effectiveness of SMS, smartphone application, and website interventions on improving blood pressure in adults with hypertension, and to report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis we searched CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid MEDLINE, and APA PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) published in English from Jan 1, 2009, that examined the effectiveness of digital health interventions on reducing blood pressure in adults with hypertension. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint was change in the mean of systolic blood pressure. Risk of bias was assessed with Cochrane Risk of Bias 2. Data on systolic and diastolic blood pressure reduction were synthesised in a meta-analysis, and data on reach, uptake and feasibility were summarised narratively. Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to evaluate the level of evidence. The study was registered with PROSPERO CRD42021247845.

FINDINGS

Of the 3235 records identified, 29 RCTs from 13 regions (n=7592 participants) were included in the systematic review, and 28 of these RCTs (n=7092 participants) were included in the meta-analysis. 11 studies used SMS as the primary mode of delivery of the digital health intervention, 13 used smartphone applications, and five used websites. Overall, digital health intervention group participants had a -3·62 mm Hg (95% CI -5·22 to -2·02) greater reduction in systolic blood pressure, and a -2·45 mm Hg (-3·83 to -1·07) greater reduction in diastolic blood pressure, compared with control group participants. No statistically significant differences between the three different modes of delivery were observed for both the systolic (p=0·73) and the diastolic blood pressure (p=0·80) outcomes. Smartphone application interventions had a statistically significant reduction in diastolic blood pressure (-2·45 mm Hg [-4·15 to -0·74]); however, there were no statistically significant reductions for SMS interventions (-1·80 mm Hg [-4·60 to 1·00]) or website interventions (-3·43 mm Hg [-7·24 to 0·38]). Due to the considerable heterogeneity between included studies and the high risk of bias in some, the level of evidence was assigned a low overall score. Interventions were more effective among people with greater severity of hypertension at baseline. SMS interventions reported higher reach and smartphone application studies reported higher uptake, but differences were not statistically significant.

INTERPRETATION

SMS, smartphone application, and website interventions were associated with statistically and clinically significant systolic and diastolic blood pressure reductions, compared with usual care, regardless of the mode of delivery of the intervention. This conclusion is tempered by the considerable heterogeneity of included studies and the high risk of bias in most. Future studies need to describe in detail the mediators and moderators of the effectiveness and implementation of these interventions, to both further improve their effectiveness as well as increase their reach, uptake, and feasibility.

FUNDING

European Union's Horizon 2020 Research and Innovation Programme.

Effectiveness of Telemedicine for Reducing Cardiovascular Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Cardiovascular diseases are the leading cause of death globally. There are six cardiovascular risk factors: diabetes, hypertension, hypercholesterolemia, overweight, sedentary lifestyle and smoking. Due to the low attendance of healthy people in the health system, the use of telemedicine can influence the acquisition of a heart-healthy lifestyle.

OBJECTIVE

this systematic review and meta-analysis aimed to determine the effectiveness of telemedicine and e-health in reducing cardiovascular risk.

METHODS

A systematic review and meta-analysis were carried out using the PubMed, Scopus, Cinhal and WOS databases. Randomized controlled studies between 2017 and 2022 in which telemedicine was used to reduce any of the risk factors were included. The methodological quality was assessed using the "PEDro" scale.

RESULTS

In total, 763 studies were obtained; after the review, 28 target articles were selected and finally grouped as follows: 13 studies on diabetes, six on hypertension, seven on obesity and two on physical activity. For all of the risk factors, a small effect of the intervention was seen.

CONCLUSIONS

although the current evidence is heterogeneous regarding the statistically significant effects of telemedicine on various cardiovascular risk factors, its clinical relevance is undeniable; therefore, its use is recommended as long as the necessary infrastructure exists.

Impact of telehealth on the current and future practice of lipidology: a scoping review

Telehealth services have been implemented to deliver care for patients living with many chronic conditions and have expanded greatly during the COVID-19 pandemic. Little is known about the current or future impacts of telehealth on lipid management practices. The PubMed database was searched from inception to June 25, 2021, with the keywords "lipids or cholesterol" and "telehealth," which yielded 376 published articles. Telehealth was defined as a synchronous visit between a patient and clinician that replaced an in-office appointment. Studies that solely used remote monitoring, mobile health technologies, or callbacks of results, were excluded. Articles must have measured lipid values. Review articles and protocol papers were not included. After evaluation, 128 abstracts were included for full text evaluation, with 55 full-text articles eventually included. Of the articles, 29 were randomized clinical trials, 15 were pre-post evaluations, and 11 were other study designs. Telehealth had positive to neutral impacts on lipid management. Reported facilitators include easier implementation of multidisciplinary approaches to care, and utilization of patient-centered programs. Reported barriers to telehealth services include technological barriers, such as various skill levels with technology; systems barriers, such as cost and reimbursement; patient-related barriers, including patient non-adherence; and clinician-related barriers, such as difficulty standardizing care. Clinicians reported improved satisfaction among patients but had mixed feelings regarding their ability to deliver quality care. Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID-19 pandemic, but more research is needed to determine its potential as a sustainable tool for lipid management.

A web-based self-care program to promote healthy lifestyles and control blood pressure in patients with primary hypertension: A randomized controlled trial

BACKGROUND

Hypertension is a major risk factor for cardiovascular diseases, which contributes to the worldwide mortality rate. Successful blood pressure control requires adherence to medications and lifestyle modifications. However, motivating patients with primary hypertension to change and sustain behaviors long-term is challenging. A web-based self-care program centered on self-efficacy theory could provide feedback for effective control of blood pressure.

PURPOSE

To examine the effect of a web-based self-care program for patients with primary hypertension on cardiovascular risk-factors (pulse pressure and lipids), self-efficacy, and self-care behaviors (medication adherence and lifestyle).

DESIGN

A two-armed randomized controlled trial with 3-month and 6-month follow-ups.

SETTING AND PARTICIPANTS

A total of 222 patients with primary hypertension were recruited between February 2017 and August 2018 at a cardiology clinic of a medical center in Taipei, Taiwan.

METHODS

Eligible patients were randomized by permuted block randomization into the intervention group (n = 111) and control group (n = 111). Patients in the intervention group received a 6-month web-based self-care program, based on the theory of self-efficacy, while patients in the control group received usual care. Baseline and outcome measures (3 and 6 months) included self-efficacy, evaluated with the Chinese version of the 6-item Self-Efficacy for Managing Chronic Diseases (SEMC6), self-care, using subscales of the Hypertension Self-Care Activity Level Effects Scale (H-SCALE) for lifestyle and medication adherence, and blood pressure and serum lipid data, collected through web-based self-reports and chart review. Generalized estimating equations evaluated the effects of the intervention.

FINDINGS

At baseline, the control group had higher scores on the SEMC6, and lower cholesterol (HDL) compared with the intervention group (t = -2.70, p < 0.05; and t = 1.76, p < 0.05, respectively). Pulse pressure decreased significantly (β = -20.30, 95% CI -23.76, -16.83), and serum triglycerides and low-density lipoprotein cholesterol levels were significantly lower compared with controls at 6 months (all p < 0.001). At 6 months, the intervention group had significantly higher mean scores for the SEMC6 compared with the control group (β = 21.84, 95% confidence interval [CI] 19.25, 24.42) and H-SCALE subscale for medication adherence, diet, weight management, and physical activity compared with controls at 6 months (all, p < 0.001).

CONCLUSIONS AND CLINICAL RELEVANCE

The greatest benefit of this program was allowing participants to immediately consult with the researchers about self-care issues via the website. Lifestyles vary from person to person; therefore, the individuality of each participant was considered when providing feedback. We provided devising interventions for participants that would increase their confidence in self-care for hypertension and ultimately achieve home blood pressure control. We encourage incorporating this program into standard clinical care for patients with hypertension.

The Contribution of Exercise in Telemedicine Monitoring in Reducing the Modifiable Factors of Hypertension—A Multidisciplinary Approach

The aim of this review was to explore the contribution of physical activity and exercise in the control and reduction of modifiable factors of arterial hypertension in telemedicine programs, assuming a multidisciplinary perspective. Searches were carried out following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses), and the research question defined using the PICOS approach (Population, Intervention, Comparator, Outcomes, Study design). The search strategy applied the following terms: blood pressure OR hypertension AND exercise OR physical activity AND telemedicine. The initial search identified 2190 records, but only 19 studies were considered eligible after checking for the inclusion and exclusion criteria. The following training variables were generally included: heart rate and heart rate reserve, respiratory rate, rate of perceived exertion and oxygen consumption, but no resistance training variables were found. The significant improvements on blood pressure parameters of participants diagnosed with hypertension tended to be transient. The exercise prescription was commonly based on general instructions and recommendations for exercise and hypertension. On the other hand, most of the studies including patients in cardiac rehabilitation programs used a personalized training program based on a baseline assessment, particularly following a cardiopulmonary exercise test. The inclusion of exercise professionals in multidisciplinary teams could provide a more person-oriented approach and the long-term maintenance of a healthy lifestyle.

Digital health RCT interventions for cardiovascular disease risk reduction: a systematic review and meta-analysis

Heart disease is a leading cause of UK mortality. Evidence suggests digital health interventions (DHIs), such as smartphone applications, may reduce cardiovascular risk, but no recent reviews are available. This review examined the effect of DHIs on cardiovascular disease (CVD) risk scores in patients with increased CVD risk, compared to usual care alone. PubMed, Cochrane Database, Medline, and Google Scholar were searched for eligible trials published after 01/01/2010, involving populations with at least one CVD risk factor. Primary outcome was change in CVD risk score (e.g. QRISK3) between baseline and follow-up. Meta-analysis was undertaken using Revman5/STATA using random-effects modelling. Cochrane RoB-2 tool determined risk-of-bias. 6 randomised controlled trials from 36 retrieved articles (16.7%) met inclusion criteria, involving 1,157 patients treated with DHIs alongside usual care, and 1,127 patients offered usual care only (control group). Meta-analysis using random-effects model in STATA showed an inconclusive effect for DHIs as effective compared to usual care (Mean Difference, MD -0.76, 95% CI -1.72, 0.20), with moderate certainty (GRADEpro). Sensitivity analysis by DHI modality suggested automated email messaging was the most effective DHI (MD -1.09, 95% Cl -2.15, -0.03), with moderate certainty (GRADEpro). However, substantial study heterogeneity was noted in main and sensitivity analyses (I2 = 66% and 64% respectively). Quality assessment identified risk-of-bias concerns, particularly for outcome measurement. Findings suggest specific DHIs such as automated email messaging may improve CVD risk outcomes, but were inconclusive for DHIs overall. Further research into specific DHI modalities is required, with longer follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12553-022-00651-0.

Effectiveness of multiple combined lifestyle interventions in reducing blood pressure among patients with prehypertension and hypertension: a network meta-analysis

BACKGROUND

Different combinations of lifestyle interventions have been studied with varying results on hypertension control. Hence, this review was done to compare multiple combined lifestyle intervention in reducing blood pressure (BP) among patients with prehypertension or hypertension.

METHODS

We conducted systematic search in the following databases: MEDLINE, PubMed Central, CENTRAL, ScienceDirect, Google Scholar from 1964 until November 2020. Estimates of comparative intervention effect from network meta-analyses (random-effects model) were represented as mean difference (MD) with 95% confidence interval.

RESULTS

In total, 14 studies with 2451 participants were included. Almost all the studies had high risk of bias. Healthy diet (HD) and physical activity (PA) combination showed highest mean reduction in systolic BP (-9.88 mmHg) and diastolic BP (-6.28 mmHg) followed by HD + PA + smoking cessation + alcohol restriction combination (systolic BP = -6.58 mmHg, diastolic BP = -4.09 mmHg) compared with usual care. HD and PA combination had the highest probability of being the best intervention (82.8% for SBP and 81.7% for DBP).

CONCLUSION

We found that HD and PA are the most important combination of lifestyle modifications for prehypertensive and hypertensive patients. Hence, a coordinated approach is required from the clinicians by integrating beneficial effect of these modifications through education, counselling and support.

SUMMARY BOX

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

Therapeutic components of digital counseling for chronic heart failure

BACKGROUND

Task force statements support the use of cognitive behavioral therapy (CBT) and motivational interviewing (MI) to promote self-care in chronic heart failure (CHF) patients. Digital counseling interventions have the potential to complement conventional programs. However, therapeutic components of digital programs associated with improved outcomes are not clearly established.

OBJECTIVE

Identify therapeutic components of the Canadian e-Platform to Promote Behavioral Self-Management in Chronic Heart Failure (CHF-CePPORT) protocol that were associated with improved health-related quality of life (HRQL).

MATERIALS AND METHODS

Ordinal logistic regression was used to identify therapeutic components of the CHF-CePPORT protocol. The primary outcome was the 12-month Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) tertile. Logistic regressions determined the association between 12-month KCCQ-OS tertile, using logon hours for key segments of the protocol, modality of content delivery, and clinical themes.

RESULTS

A total of 117 patients were enrolled in the e-Counseling arm of the CHF-CePPORT trial. Median age was 60 years (IQR 52-69). Total logon hours in the initial 4-month segment of CHF-CePPORT (Sessions 1-16) was associated with increased 12-month KCCQ-OS tertile (Odds Ratio, OR = 1.31, 95% CI, 1.1-1.5, P = 0.001). Within sessions 1-16, improved KCCQ-OS was associated with logon hours for self-assessment tools/trackers (OR = 1.49, 95% CI, 1.1-2.0, P = 0.007), and videos (OR = 1.57, 95% CI, 1.03-2.4, P = 0.04), but not for CHF information pages.

CONCLUSION

This study highlights the importance of using evidence-based guidelines from CBT and MI as core components of digital counseling, delivered through videos and interactive tools/trackers, to improve HRQL with CHF.

Evaluation of a Video-Assisted Patient Education Program to Reduce Blood Pressure Delivered Through the Electronic Medical Record: Results of a Quality Improvement Project

BACKGROUND

Low-cost, automated interventions that increase knowledge and skills around diet and lifestyle modifications are recommended for cardiovascular disease risk reduction.

METHODS

We initiated a quality improvement program to assess the impact of a web-based diet and lifestyle intervention utilizing short animated videos in adults with high blood pressure (BP) at a primary care clinic in Saudi Arabia. We enrolled adults with elevated BP, not on BP medications, who were identified using the electronic medical record. We delivered a web-linked diet and lifestyle intervention using animated videos covering diet and lifestyle topics. Videos and reminders were sent weekly for 5 weeks. Outcomes were proportion who engaged in the program, returned for a repeat BP within 3 months, and change in BP.

RESULTS

We enrolled 269 adult participants, with a mean (SD) age of 41.6 (12.4) years; 77% were male. At the conclusion of the pilot, we demonstrated a high level of engagement: overall, 69% of materials were viewed and 67% of patients returned for BP. Patients who returned had a mean (SD) baseline systolic BP of 138.0 (7.2) mm Hg and a large mean reduction in systolic BP from baseline, -10.5 mm Hg (12.4; P < 0.001).

CONCLUSIONS

Overall, the feasibility of a video-assisted, web-based, diet and lifestyle intervention as a support tool for hypertension management demonstrated a high participation rate and a high return rate for reassessment of BP. These findings suggest that this low-cost, automated intervention may have a great potential as a scalable tool for blood pressure management. However, randomized trials to understanding the effectiveness of the support tools are needed.

Digital Technical and Informal Resources of Breast Cancer Patients From 2012 to 2020: Questionnaire-Based Longitudinal Trend Study

Background

Digitalization offers enormous potential in medicine. In the era of digitalization, the development of the use of digital, technical, and informal resources of breast cancer patients and factors influencing the degree of digitization of patients has been insufficiently researched.

Objective

The aim of this study was to assess the development of the use of digital technical and informal resources in a well-defined patient cohort.

Methods

A longitudinal study on 513 breast cancer patients from 2012 to 2020 was conducted using a questionnaire that included the main aspects of the degree of digitalization, including digital device availability and use, stationary and mobile internet access and use, and communication and information seeking regarding breast cancer diagnosis and treatment.

Results

The majority of patients (421/513, 82.1%) owned the technical resources to benefit from eHealth, used the internet to obtain information (292/509, 57.4%), and were willing to use new eHealth solutions (379/426, 89%). Two-thirds of the patients discussed information about their cancer on the internet with their doctor, one-third found additional treatment options on the internet, and 15.3% (44/287) of the patients stated that this had changed their cancer therapy. The degree of digitization is increasing yet still significantly depends on 3 factors: (1) age (whereas 100% [39/39] of the <59-year-old group used the internet in 2020, 92% of the 60 to 69-year-old group [11/12] and only 47% [6/13] of the >70-year-old group used the internet), (2) education (internet use significantly depended on education, as only 51.8% [59/114] of patients with primary school education used the internet, but 82.4% [126/153] with middle school education and 90.3% [213/236] with high school education used the internet; P<.001), and (3) household size (67.7% [111/164] of patients living alone used the internet, whereas 84.7% [287/339] of patients living in a house with ≥2 people used the internet; P<.001).

Conclusions

To implement digital solutions in health care, knowledge of the composition and degree of the use of digital technical and informal resources of the patient group for which the respective solution is developed is crucial for success.

Trial Registration

German Register of Clinical Studies DRKS00012364; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012364

Health Behavior Change Programs in Primary Care and Community Practices for Cardiovascular Disease Prevention and Risk Factor Management Among Midlife and Older Adults: A Scientific Statement From the American Heart Association

Cardiovascular disease predominates as the leading health burden among middle-aged and older American adults, but progress in improving cardiovascular health remains slow. Comprehensive, evidenced-based behavioral counseling interventions in primary care are a recommended first-line approach for promoting healthy behaviors and preventing poor cardiovascular disease outcomes in adults with cardiovascular risk factors. Assisting patients to adopt and achieve their health promotion goals and arranging follow-up support are critical tenets of the 5A Model for behavior counseling in primary care. These 2 steps in behavior counseling are considered essential to effectively promote meaningful and lasting behavior change for primary cardiovascular disease prevention. However, adoption and implementation of behavioral counseling interventions in clinical settings can be challenging. The purpose of this scientific statement from the American Heart Association is to guide primary health care professional efforts to offer or refer patients for behavioral counseling, beyond what can be done during brief and infrequent office visits. This scientific statement presents evidence of effective behavioral intervention programs that are feasible for adoption in primary care settings for cardiovascular disease prevention and risk management in middle-aged and older adults. Furthermore, examples are provided of resources available to facilitate the widespread adoption and implementation of behavioral intervention programs in primary care or community-based settings and practical approaches to appropriately engage and refer patients to these programs. In addition, current national models that influence translation of evidence-based behavioral counseling in primary care and community settings are described. Finally, this scientific statement highlights opportunities to enhance the delivery of equitable and preventive care that prioritizes effective behavioral counseling of patients with varying levels of cardiovascular disease risk.

Comparative effect of eHealth interventions on hypertension management-related outcomes: A network meta-analysis

BACKGROUND

Increasingly, health professionals and patients have begun to be involved in eHealth interventions to assist in the self-management of hypertension. Therefore, this study was aimed at comparing the effect of different types of eHealth interventions (phone calls, blood pressure telemonitoring, emails, web-site, smartphone-app, short message service (SMS) and more than two eHealth interventions) on reducing systolic and diastolic blood pressure, increasing adherence to medication treatment, improving physical activity compliance, controlling blood pressure, and improving quality of life (QoL).

METHODS

A systematic search in MEDLINE (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted to identify experimental studies addressing the effect of eHealth interventions on the self-management of hypertension. Comparative evaluation of the eHealth interventions effect were performed by conducting a standard pairwise meta-analysis and a network meta-analysis for direct and indirect comparisons between eHealth interventions and control/non-intervention.

RESULTS

Fifty-one studies were included in the analysis showing a moderate effect size for more than two types of eHealth interventions (-0.46; 95%CI: -0.64, -0.27, p < 0.001 and -0.29; 95%CI: -0.46, -0.13, p < 0.001), phone calls (-0.37; 95%CI: -0.57, -0.17, p < 0.001 and -0.29; 95%CI: -0.52, -0.07, p = 0.011) and smartphone-app (-0.26; 95%CI: -0.50, -0.01, p = 0.040 and -0.40; 95%CI: -0.70, -0.10, p = 0.010) on reducing both systolic and diastolic blood pressure, respectively. Additionally, i) smartphone-app improved medication adherence by 45%; ii) more than two types of eHealth interventions and emails improved physical activity compliance by 18% and 57% respectively; ii) more than two types of eHealth interventions, phone calls, blood pressure telemonitoring, website and SMS improved blood pressure control between 16% and 30%; and iv) blood pressure telemonitoring showed a week effect on QoL CONCLUSIONS: Our study reported eHealth to be a suitable intervention for the self-management of hypertension. Considering our results and the population's accessibility to eHealth devices, eHealth could be a useful and largely scalable tool for the self-management of hypertension.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187468.

The efficacy of cognitive behavioral therapy-based interventions on patients with hypertension: A systematic review and meta-analysis

Recently, the benefits of cognitive behavioral therapy (CBT)-based interventions for patients with hypertension have been recognized, but there has been no systematic review that has comprehensively analyzed the efficacy of CBT on health outcomes in this population. We aimed to explore the therapeutic effect of CBT-based interventions on hypertension patients through a meta-analysis. Relevant randomized controlled trials (RCTs) were obtained by searching electronic databases. The primary outcomes were physiological indicators (blood pressure, blood lipid profile). Secondary outcomes were psychological indicators (anxiety, depression), and the quality of sleep. Stata version 15.0 software was used to analyze the results. A total of 15 RCTs were included. The main analysis revealed that CBT-based interventions reduced systolic pressure: -8.67 (95% CI: -10.67 to -6.67, P = 0.000); diastolic pressure: -5.82 (95% CI: -7.82 to -3.81, P = 0.000); total cholesterol levels: -0.43 (95% CI: -0.76 to -0.10, P = 0.010); depressive symptoms: -3.13 (95% CI: -4.02 to -2.24, P = 0.000); anxiety symptoms: -3.63 (95% CI: -4.40 to -2.87, P = 0.000); and improved quality of sleep: -2.93 (95% CI: -4.40 to -1.47, P = 0.000). Additionally, the results of subgroup analysis indicated that long-term group-based CBT-based interventions were particularly beneficial for blood pressure management in hypertension patients. CBT-based interventions are effective in reducing systolic pressure, diastolic pressure, total cholesterol levels, anxiety symptoms, depressive symptoms, and improving quality of sleep in hypertension patients.

Person-Centered Goal Setting: A systematic review of intervention components and level of active engagement in rehabilitation goal setting interventions

OBJECTIVE

This systematic review aims to examine 1) what components are used in current person-centered goal setting interventions for adults with health conditions in rehabilitation and 2) the extent to which the engagement of people in their rehabilitation goal setting is encouraged.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, and Web of Science from inception to November 2020.

STUDY SELECTION

Primary inclusion criteria were peer-reviewed articles that evaluated person-centered goal setting interventions for adults with health conditions in rehabilitation. Two independent reviewers screened 28,294 records, and 22 articles met inclusion criteria.

DATA EXTRACTION

Two reviewers independently completed data extraction and quality assessment using the Physiotherapy Evidence Database (PEDRo) scale based on the original authors' descriptions, reports, and protocol publications. Any discrepancies were resolved by consensus or in consultation with another senior reviewer.

DATA SYNTHESIS

Using narrative synthesis, we found that current person-centered goal setting has variability in their inclusion of intervention components. A considerable number of components are under-implemented in current practice, with formulation of coping plan and follow-up being most commonly left out. The active engagement of people does appear to be promoted within the components that are included in the interventions. Nine studies were high-quality defined as a total PEDro scale score of 6 or above.

CONCLUSIONS

Although current person-centered goal setting encourages the active engagement of people, many of these interventions lack components considered important for supporting goal achievement and optimal outcomes. Future practice may be improved by incorporating a comprehensive set of goal setting components and encouraging the active engagement of people throughout the entire goal setting process. Together, these practices may facilitate the achievement of meaningful rehabilitation goals and improve rehabilitation outcomes for adults with health conditions.

Effectiveness of eHealth Nutritional Interventions for Middle-Aged and Older Adults: Systematic Review and Meta-analysis

BACKGROUND

The risk of development of chronic diseases related to poor nutrition increases with age. In the face of an aging population, it is important for health care sectors to find solutions in delivering health services efficiently and effectively to middle-aged and older adults.

OBJECTIVE

The aim of this systematic review and meta-analysis was to consolidate the literature that reported the effectiveness of eHealth apps in delivering nutritional interventions for middle-aged and older adults.

METHODS

A literature search from five databases (PubMed, CINAHL, Cochrane, Web of Science, and Global Health) from the past 5 years was performed. Studies were selected for inclusion that used eHealth to deliver nutritional interventions to adults aged 40 years and above, and reported health and behavioral outcomes. Two independent reviewers searched for research articles and assessed the eligibility of studies to be included in the review. A third reviewer resolved disagreements on study inclusion. We also assessed the quality of the included studies using the CONSORT 2010 checklist.

RESULTS

A total of 70 studies were included for analysis. The study quality ranged from 44% to 85%. The most commonly used eHealth intervention type was mobile apps (22/70, 31%). The majority of studies (62/70, 89%) provided multicomponent health interventions, which aimed to improve nutrition and other health behaviors (eg, exercise, smoking cessation, medication adherence). Meta-analysis results indicated high and significant heterogeneity; hence, conclusions based on these results should be considered with caution. Nonetheless, the results generally showed that eHealth interventions improved anthropometric and clinical outcomes, but not behavioral outcomes such as fruit and vegetable consumption.

CONCLUSIONS

The use of eHealth apps to deliver health interventions has been increasing in recent years, and these apps have the potential to deliver health services to a larger group of people. Our findings showed that the effectiveness of eHealth apps to deliver health interventions for middle-aged to older adults was supported by the improvement of anthropometric and clinical outcomes. Future work could aim to develop research frameworks in administering eHealth interventions to address heterogeneity in this field of research.

Web-Based Dietary and Physical Activity Intervention Programs for Patients With Hypertension: Scoping Review

BACKGROUND

Hypertension is the root cause of many chronic diseases. Lifestyle changes (ie, dietary alterations and physical activity) are seen to be an important step in the prevention and treatment of hypertension. Educating people through web-based interventional programs could offer an effective solution and help these patients with hypertension in the existing health care scenario.

OBJECTIVE

In this study, the researchers conducted a scoping literature review of the web-based dietary changes and physical activity-related intervention programs designed for the patients with hypertension and identified the methodologies, effectiveness, protocols, and theories, which could affect and improve existing clinical activities.

METHODS

This review followed the scoping review methodology to identify and process the peer-reviewed studies published between 2010 and 2020. The literature searches were conducted on the following electronic databases: PubMed, Web of Science, MEDLINE (Medical Literature Analysis and Retrieval System Online), ScienceDirect, Scopus, and Google Scholar. By using relevant search terms, studies were included if they offered information related to the web-based intervention tools, specifically dietary and physical activity intervention for patients with hypertension. Studies written or translated in English language and published within the date range (January 2010 to March 2020) were included.

RESULTS

Overall, 1441 articles were initially identified. The reviewers included 35 articles after removing duplicates and screening titles. Only 21 articles were assessed for full review, and 15 were kept for analysis. The researchers selected 15 web-based intervention articles published on the topic of hypertension from 7 countries. A few of these 15 web-based tools (4, 27%) included more than 3 functions and provided a lot of important information (such as appointments, health records, or viewable care). Several tools were standalone tools (11, 73%), while most of the tools supported communication intervention-related lifestyle or behavioral changes (13, 87%) and medication adherence (6, 40%). It was found that physicians (9, 60%), allied health professionals (5, 33%), and nurses (5, 33%) were the health care providers who generally used these tools for communicating with their patients. More than half of the above tools (10, 67%) were assessed by different researchers in randomized controlled trials, while 5 tools (33%) were investigated in nonrandomized studies.

CONCLUSIONS

We identified many web-based intervention programs for patients with hypertension from the literature databases. The findings indicate that numerous benefits can be derived after using a web-based dietary and physical activity intervention program for hypertension focusing on lifestyle changes. However, developers need to consider the preferences of the patients with regard to the information or the design features while developing or modifying web-based educational websites. These tools could be used for designing a patient-tailored website intervention program that is based on diet and physical activities for patients with hypertension.

Automated E-Counseling for Chronic Heart Failure: CHF-CePPORT Trial

BACKGROUND

International task force statements advocate telehealth programs to promote health-related quality of life for patients with chronic heart failure (CHF). To that end, we evaluated the efficacy and usability of an automated e-counseling program.

METHODS

This Canadian multi-site double-blind randomized trial assessed whether usual care plus either internet-based e-counseling (motivational and cognitive-behavioral tools for CHF self-care) or e-based conventional CHF self-care education (e-UC) improved 12-month Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS). Secondary outcomes included program engagement (total logon weeks, logons, and logon hours), total CHF self-care behaviors, diet (fruit and vegetable servings), 6-minute walk test, and 4-day step count. The association between program engagement and health-related quality of life was assessed using KCCQ-OS tertiles.

RESULTS

We enrolled 231 patients, median age =59.5 years, 22% female, and elevated median KCCQ-OS=83.0 (interquartile range, 68-93). KCCQ-OS increase ≥5 points was not more prevalent for e-counseling, n=29 (29.6%) versus e-UC, n=32 (34.0%), P=0.51. E-Counseling versus e-UC increased total logon weeks (P=0.02), logon hours (P=0.001), and logons (P<0.001). Only e-counseling showed a positive association between 12-month KCCQ-OS tertile and logon weeks (P=0.04) and logon hours (P=0.004). E-Counseling increased CHF self-care behavior and diet but not 6-minute walk test or 4-day step count.

CONCLUSIONS

The primary KCCQ-OS end point was negative for this trial. Only e-counseling showed a positive association between program engagement and 12-month KCCQ-OS tertile, and it improved CHF self-care behavior and diet. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01864369.

Hypertension management in 2030: a kaleidoscopic view

The last decade has witnessed the healthcare system going paperless with increased use of electronic healthcare records. Artificial intelligence tools including smartphones and smart watches have changed the landscape of day-to-day lives. Digitisation, decentralisation of healthcare and empowerment of allied healthcare providers and patients themselves have made shared clinical decision-making a reality. The year 2020 quickly turned into an unprecedented time in our lives with the entry of COVID-19. Amidst a pandemic, healthcare systems rapidly adapted and transformed, and changes that otherwise would have taken a decade, took a mere few weeks (Webster, Lancet 395:1180-1, 2020). This essay reviews evidence of transformation in the realm of hypertension management, namely diagnosis, lifestyle changes, therapeutics and prevention of hypertension at both individual and population levels, and presents an extrapolation of how this transformation might shape the next decade.

A systematic review of the dose-response relationship between usage and outcomes of online physical activity weight-loss interventions

BACKGROUND

Online physical activity interventions can be an effective strategy for weight loss. However, there is a lack of systematic reviews examining the relationship between intervention usage (dose) and participants' response to online physical activity interventions for weight loss. It remains unclear whether certain usage metrics (e.g. login frequency, percent of content accessed) would be associated with improvements in behavioral outcomes. Understanding the dose-response relationship for online physical activity interventions for weight loss would be important for designing and evaluating future interventions.

OBJECTIVE

1) Review the methods used to assess intervention usage and 2) to explore the association between intervention usage metrics and outcomes for online physical activity interventions for weight-loss.

METHODS

We conducted a systematic review following the PRISMA guidelines to examine the dose-response relationship of online-based interventions targeting physical activity. We used the following keywords: web OR internet OR online OR eHealth AND physical activity OR exercise, AND engagement OR dose OR dose-response OR usage AND obesity OR weight*. Peer-reviewed articles published between 2006 and 2019 were included.

RESULTS

A total of five articles met the inclusion criteria. The mean intervention length was 10 ± 6 months (range 2-30 months). The usage metrics were total number of logins, login frequency, and usage of online tools. All usage metrics reported were found to be related to outcomes in physical activity interventions for weight-loss.

CONCLUSION

Our findings suggest that usage metrics for online physical activity interventions for weight-loss included login frequency, login duration, and use of online tools. Increased intervention usage appeared to be associated with an improvement in participant's weight, physical activity behaviors, and intervention retention. Future research should examine innovative ways to maintain intervention usage throughout the intervention.

Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Cardiovascular disease is the leading cause of death in the US, and poor diet and lack of physical activity are major factors contributing to cardiovascular morbidity and mortality.

OBJECTIVE

To review the benefits and harms of behavioral counseling interventions to improve diet and physical activity in adults with cardiovascular risk factors.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through September 2019; literature surveillance through July 24, 2020.

STUDY SELECTION

English-language randomized clinical trials (RCTs) of behavioral counseling interventions to help people with elevated blood pressure or lipid levels improve their diet and increase physical activity.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from studies by one reviewer and checked by a second. Random-effects meta-analysis and qualitative synthesis were used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events, mortality, subjective well-being, cardiovascular risk factors, diet and physical activity measures (eg, minutes of physical activity, meeting physical activity recommendations), and harms. Interventions were categorized according to estimated contact time as low (≤30 minutes), medium (31-360 minutes), and high (>360 minutes).

RESULTS

Ninety-four RCTs were included (N = 52 174). Behavioral counseling interventions involved a median of 6 contact hours and 12 sessions over the course of 12 months and varied in format and dietary recommendations; only 5% addressed physical activity alone. Interventions were associated with a lower risk of cardiovascular events (pooled relative risk, 0.80 [95% CI, 0.73-0.87]; 9 RCTs [n = 12 551]; I2 = 0%). Event rates were variable; in the largest trial (Prevención con Dieta Mediterránea [PREDIMED]), 3.6% in the intervention groups experienced a cardiovascular event, compared with 4.4% in the control group. Behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure, low-density lipoprotein cholesterol levels, fasting glucose levels, and adiposity at 12 to 24 months' follow-up. Measurement of diet and physical activity was heterogeneous, and evidence suggested small improvements in diet consistent with the intervention recommendation targets but mixed findings and a more limited evidence base for physical activity. Adverse events were rare, with generally no group differences in serious adverse events, any adverse events, hospitalizations, musculoskeletal injuries, or withdrawals due to adverse events.

CONCLUSIONS AND RELEVANCE

Medium- and high-contact multisession behavioral counseling interventions to improve diet and increase physical activity for people with elevated blood pressure and lipid levels were effective in reducing cardiovascular events, blood pressure, low-density lipoproteins, and adiposity-related outcomes, with little to no risk of serious harm.

Internet-based patient- primary care physician-cardiologist integrated management model of hypertension in China: study protocol for a multicentre randomised controlled trial

INTRODUCTION

The control rate of hypertension is low in China, especially in rural, western and minority areas. This is related to poor medical skills among physicians in primary care institutions and low levels of trust among patients. However, primary healthcare institutions are the main battleground for the prevention and treatment of hypertension. It is worth exploring how to most effectively integrate patients, primary care physicians and cardiologists in tertiary hospitals, to build a long-term mechanism for the prevention and treatment of hypertension. In this study, we aim to evaluate the clinical effectiveness and conduct a health economic evaluation of an internet-based patient-primary care physician-cardiologist integrated management model of hypertension in areas of China with different socioeconomic levels.

METHODS AND ANALYSIS

This is a 12-month, multicentre, randomised controlled trial involving patients with hypertension in urban communities and rural areas of Sichuan Province, China. Each primary healthcare institution will cooperate with their tertiary hospital through the Red Shine Chronic Disease Management System (RSCDMS). Patients will be randomly assigned 1:1 to two groups: (1) a traditional care group; (2) an intervention group in which primary care physicians and cardiologists can share patient data and manage patients together through the RSCDMS. Patients can upload their blood pressure (BP) values and communicate with physicians using the system. The primary outcome is the change in systolic BP over a 12-month period. Secondary outcomes are changes in diastolic BP, BP control rate, values of 24-hour ambulatory BP monitoring, difference in cost-effectiveness between the groups, patient satisfaction, medication adherence and home BP monitoring compliance. All data will be recorded and stored in the RSCDMS and analysed using IBM SPSS V.26.0.

ETHICS AND DISSEMINATION

This study has been approved by the Biomedical Research Ethics Committee of the West China Hospital of Sichuan University in Sichuan, China (No. 2020-148). Written informed consent will be obtained from all participants. The results of this study will be disseminated to the public through academic conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000030677.

Effect of electronic health interventions on metabolic syndrome: a systematic review and meta-analysis

OBJECTIVE

We aimed to examine whether eHealth interventions can effectively improve anthropometric and biochemical indicators of patients with metabolic syndrome (MetS).

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, the Web of Science, Embase, Medline, CINAHL, PsycINFO, the Cochrane Library, the Chinese National Knowledge Infrastructure, the Wanfang and Weipu databases were comprehensively searched for papers that were published from database inception to May 2019. Articles were included if the participants were metabolic syndrome (MetS) patients, the participants received eHealth interventions, the participants in the control group received usual care or were wait listed, the outcomes included anthropometric and biochemical indicators of MetS, and the study was a randomised controlled trial (RCT) or a controlled clinical trial (CCT). The Quality Assessment Tool for Quantitative Studies was used to assess the methodological quality of the included articles. The meta-analysis was conducted using Review Manager V.5.3 software.

RESULTS

In our review, seven RCTs and two CCTs comprising 935 MetS participants met the inclusion criteria. The results of the meta-analysis revealed that eHealth interventions resulted in significant improvements in body mass index (standardised mean difference (SMD)=-0.36, 95% CI (-0.61 to -0.10), p<0.01), waist circumference (SMD=-0.47, 95% CI (-0.84 to -0.09), p=0.01) and systolic blood pressure(SMD=-0.35, 95% CI (-0.66 to -0.04), p=0.03) compared with the respective outcomes associated with the usual care or wait-listed groups. Based on the included studies, we found significant effects of the eHealth interventions on body weight. However, we did not find significant positive effects of the eHealth interventions on other metabolic parameters.

CONCLUSIONS

The results indicated that eHealth interventions were beneficial for improving specific anthropometric outcomes, but did not affect biochemical indicators of MetS. Therefore, whether researchers adopt eHealth interventions should be based on the purpose of the study. More rigorous studies are needed to confirm these findings.

Utilising digital health to improve medication-related quality of care for hypertensive patients: An integrative literature review

BACKGROUND

Hypertension or high blood pressure is considered as a significant contributor and risk factor to many serious conditions, approximately 1.13 billion people have hypertension globally. However, the integrated technologies can upscale health provisions and improve the effectiveness of the healthcare system. WHO has recommended that the digital health interventions (DHIs) and the Health System Challenges should be used in tandem in addressing health.

AIM

To summarise the outcomes from a range of research which investigated the use of DHI to improve the medication-related quality of care (MRQOC) for hypertensive patients.

METHODS

An integrative literature review was undertaken in October 2019 using the Medline, Cumulative Index of Nursing and Allied Health Literature, and Scopus databases for publications in English with no date limit.

RESULTS

In total, 18433 participants were included in this review from 28 studies meeting the eligibility criteria. There were 19 DHI identified within eight countries: Australia, Canada, India, South Korea, Lebanon, Pakistan, the United Kingdom, and the United States of America. The DHI were provided as community-based, clinical-based and home-based program through mobile phone, mobile health system, short message service, and telehealth, digital medicine, and online healthcare (web-based). The mean age of participants was 59 ranging from 42 to 81 years with an average mean systolic blood pressure of 143.3 mmHg at baseline, ranging from 129.0 mmHg to 159.0 mmHg. The proportion of male participants ranged from 13.9% to 92.0%. Eighteen interventions showed evidence of reduction in blood pressure and improvement of self-management in relation to medication adherence and blood pressure control. The reduction of systolic blood pressure ranged between 1.9 mmHg and 26.0 mmHg, with a mean of 10.8 mmHg. The digital health was found positively associated with the MRQOC for hypertensive patients such as improvement in medication adherence and medication management; better blood pressure control; maintaining follow-ups appointment and self-management; increasing access to healthcare particularly among patients living in rural area; and reducing adverse events. However, some interventions found no significant effect on hypertensive care. The follow up duration varied between 2 mo and 18 mo with an average attrition rate of 10.1%, ranging from 0.0% to 17.4%.

CONCLUSION

Utilising digital health innovation for hypertensive care in different settings with tailored interventions positively impacted on MRQOC leading to an improvement of patient outcomes and their quality of life. Nevertheless, inconclusive findings were found in some interventions, and inconsistent outcomes between DHI were noted. A future research and evidence-based DHI for hypertension or chronic diseases should be developed through the evidence-to-decision framework and guidelines.

The Effectiveness of Self-Management of Hypertension in Adults Using Mobile Health: Systematic Review and Meta-Analysis

Background

Effective treatment of hypertension requires careful self-management. With the ongoing development of mobile technologies and the scarcity of health care resources, mobile health (mHealth)–based self-management has become a useful treatment for hypertension, and its effectiveness has been assessed in many trials. However, there is a paucity of comprehensive summaries of the studies using both qualitative and quantitative methods.

Objective

This systematic review aimed to measure the effectiveness of mHealth in improving the self-management of hypertension for adults. The outcome measures were blood pressure (BP), BP control, medication adherence, self-management behavior, and costs.

Methods

A systematic search was conducted using 5 electronic databases. The snowballing method was used to scan the reference lists of relevant studies. Only peer-reviewed randomized controlled trials (RCTs) published between January 2010 and September 2019 were included. Data extraction and quality assessment were performed by 3 researchers independently, adhering to the validation guideline and checklist. Both a meta-analysis and a narrative synthesis were carried out.

Results

A total of 24 studies with 8933 participants were included. Of these, 23 studies reported the clinical outcome of BP, 12 of these provided systolic blood pressure (SBP) and diastolic blood pressure (DBP) data, and 16 articles focused on change in self-management behavior and medication adherence. All 24 studies were included in the narrative synthesis. According to the meta-analysis, a greater reduction in both SBP and DBP was observed in the mHealth intervention groups compared with control groups, −3.78 mm Hg (P<.001; 95% CI −4.67 to −2.89) and −1.57 mm Hg (P<.001; 95% CI −2.28 to −0.86), respectively. Subgroup analyses showed consistent reductions in SBP and DBP across different frequencies of reminders, interactive patterns, intervention functions, and study duration subgroups. A total of 16 studies reported better medication adherence and behavioral change in the intervention groups, while 8 showed no significant change. Six studies included an economic evaluation, which drew inconsistent conclusions. However, potentially long-term financial benefits were mentioned in all economic evaluations. All studies were assessed to be at high risk of bias.

Conclusions

This review found that mHealth self-management interventions were effective in BP control. The outcomes of this review showed improvements in self-management behavior and medication adherence. The most successful mHealth intervention combined the feature of tailored messages, interactive communication, and multifaceted functions. Further research with longer duration and cultural adaptation is necessary. With increasing disease burden from hypertension globally, mHealth offers a potentially effective method for self-management and control of BP. mHealth can be easily integrated into existing health care systems.

Trial Registration

PROSPERO CRD42019152062; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=152062

Effects of self-guided e-counseling on health behaviors and blood pressure: Results of a randomized trial

OBJECTIVE

1) Evaluate the efficacy of e-Counseling vs. Control to promote lifestyle behaviors at 4 and 12-month follow-ups, 2) examine whether these behaviors changes were associated with lower blood pressure (BP), and Framingham Risk Index (FRI) at 12-month.

METHODS

Hypertensive patients (n = 264) were randomized to the e-Counseling or the Control group. Primary trial outcome was BP and secondary outcomes included exercise and diet behaviors. This study presented the results of secondary outcomes. Linear mixed models evaluated treatment effects at 4 and 12-month. Treatment-by-sex exploratory analyses were conducted if no main treatment effect was observed.

RESULTS

Daily steps significantly improved in e-Counseling vs. Controls at 12-month. Urinary sodium at 12-month did not significantly differ between the groups, but treatment-by-sex analysis showed that e-Counseling females lowered urinary sodium relative to Controls at 12 months. Improvements in steps and dietary sodium were significantly associated with improvements in BP and FRI at 12-month.

CONCLUSION

This hypertension e-Counseling protocol can promote long-term lifestyle behavior changes. Adherence to the lifestyle behavior change was associated with BP and FRI reduction at 12-month.

PRACTICE IMPLICATIONS

The hypertension e-counseling protocol has the potential to improve hypertension care and intervention reach.

Angiotensin-converting enzyme inhibitory peptides from Lactobacillus delbrueckii QS306 fermented milk

Angiotensin-converting enzyme inhibitory peptides were isolated and identified from milk fermented using Lactobacillus delbrueckii QS306. The peptide with the highest angiotensin-converting enzyme inhibitory activity (C5) was purified using ultrafiltration with 10 and 3 kDa molecular mass cut-off membranes, Sephadex G-15 (Sigma-Aldrich, St. Louis, MO) gel filtration chromatography, reversed-phase HPLC, and Orbitrap Elite (Thermo Fisher Scientific Inc., Waltham, MA) liquid chromatography-tandem mass spectrometry. We obtained peptide LPYPY by microbial fermentation, which was derived from κ-casein f (AA 77-81). We synthesized LPYPY using an Fmoc solid-phase synthesis method and explored the secondary structure of the pentapeptide. The half maximal inhibitory concentration for the angiotensin-converting enzyme inhibitory activity of LPYPY was 12.87 μg/mL. The results provide additional information for ongoing research and the development of functional foods having antihypertensive effects.

Achieving Rapid Blood Pressure Control With Digital Therapeutics: Retrospective Cohort and Machine Learning Study

BACKGROUND

Behavioral therapies, such as electronic counseling and self-monitoring dispensed through mobile apps, have been shown to improve blood pressure, but the results vary and long-term engagement is a challenge. Machine learning is a rapidly advancing discipline that can be used to generate predictive and responsive models for the management and treatment of chronic conditions and shows potential for meaningfully improving outcomes.

OBJECTIVE

The objectives of this retrospective analysis were to examine the effect of a novel digital therapeutic on blood pressure in adults with hypertension and to explore the ability of machine learning to predict participant completion of the intervention.

METHODS

Participants with hypertension, who engaged with the digital intervention for at least 2 weeks and had paired blood pressure values, were identified from the intervention database. Participants were required to be ≥18 years old, reside in the United States, and own a smartphone. The digital intervention offers personalized behavior therapy, including goal setting, skill building, and self-monitoring. Participants reported blood pressure values at will, and changes were calculated using averages of baseline and final values for each participant. Machine learning was used to generate a model of participants who would complete the intervention. Random forest models were trained at days 1, 3, and 7 of the intervention, and the generalizability of the models was assessed using leave-one-out cross-validation.

RESULTS

The primary cohort comprised 172 participants with hypertension, having paired blood pressure values, who were engaged with the intervention. Of the total, 86.1% participants were women, the mean age was 55.0 years (95% CI 53.7-56.2), baseline systolic blood pressure was 138.9 mmHg (95% CI 136.6-141.3), and diastolic was 86.2 mmHg (95% CI 84.8-87.7). Mean change was -11.5 mmHg for systolic blood pressure and -5.9 mmHg for diastolic blood pressure over a mean of 62.6 days (P<.001). Among participants with stage 2 hypertension, mean change was -17.6 mmHg for systolic blood pressure and -8.8 mmHg for diastolic blood pressure. Changes in blood pressure remained significant in a mixed-effects model accounting for the baseline systolic blood pressure, age, gender, and body mass index (P<.001). A total of 43% of the participants tracking their blood pressure at 12 weeks achieved the 2017 American College of Cardiology/American Heart Association definition of blood pressure control. The 7-day predictive model for intervention completion was trained on 427 participants, and the area under the receiver operating characteristic curve was .78.

CONCLUSIONS

Reductions in blood pressure were observed in adults with hypertension who used the digital therapeutic. The degree of blood pressure reduction was clinically meaningful and achieved rapidly by a majority of the studied participants. Greater improvement was observed in participants with more severe hypertension at baseline. A successful proof of concept for using machine learning to predict intervention completion was presented.

Psychobehavioral Profiles to Assist Tailoring of Interventions for Patients With Hypertension: Latent Profile Analysis

Background

Practice guidelines advocate combining pharmacotherapy with lifestyle counseling for patients with hypertension. To allow for appropriate tailoring of interventions to meet individual patient needs, a comprehensive understanding of baseline patient characteristics is essential. However, few studies have empirically assessed behavioral profiles of hypertensive patients in Web-based lifestyle counseling programs.

Objective

The objectives of this study were to (1) specify baseline psychobehavioral profiles of patients with hypertension who were enrolled in a Web-based lifestyle counseling trial, and (2) examine mean differences among the identified profile groups in demographics, psychological distress, self-reported self-care behaviors, physiological outcomes, and program engagement to determine prognostic implications.

Methods

Participants (N=264; mean age 57.5 years; 154/264, 58.3% female; 193/264, 73.1% white) were recruited into a longitudinal, double-blind, randomized controlled trial, designed to evaluate an online lifestyle intervention for hypertensive patients. A series of latent profile analyses identified psychobehavioral profiles, indicated by baseline measures of mood, motivation, and health behaviors. Mean differences between profile groups were then explored.

Results

A 2-class solution provided the best model fit (the Bayesian information criterion (BIC) is 10,133.11; sample-size adjusted BIC is 10,006.54; Lo-Mendell-Rubin likelihood ratio test is 65.56, P=.001). The 2 profile groups were (1) adaptive adjustment, marked by low distress, high motivation, and somewhat satisfactory engagement in health behaviors and (2) affectively distressed, marked by clinically significant distress. At baseline, on average, affectively distressed patients had lower income, higher body mass index, and endorsed higher stress compared with their adaptive adjustment counterparts. At 12-months post intervention, treatment effects were sustained for systolic blood pressure and Framingham risk index in the adaptive adjustment group, and those in the adaptive adjustment group were 2.4 times more likely to complete the 12-month intervention study, compared with their affectively distressed counterparts.

Conclusions

Interventions for patients who are adaptively adjusted may differ in focus from those designed for the affectively distressed patients. As such, this study underscores the importance of identifying psychobehavioral profiles, as they allow for evidence-based tailoring of lifestyle counseling programs for patients with hypertension.

Trial Registration

ClinicalTrials.gov NCT01541540; https://clinicaltrials.gov/ct2/show/NCT01541540 (Archived by WebCite at http://www.webcitation.org/6yzZYZcWF)