Effects of Telemedicine and mHealth on Systolic Blood Pressure Management in Stroke Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials

The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review

The Non-adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework (2017) was established as an evidence-based, theory-informed tool to predict and evaluate the success of implementing health and care technologies. While the NASSS is gaining popularity, its use has not been systematically described. Literature reviews on the applications of popular implementation frameworks, such as the RE-AIM and the CFIR, have enabled their advancement in implementation science. Similarly, we sought to advance the science of implementation and application of theories, models, and frameworks (TMFs) in research by exploring the application of the NASSS in the five years since its inception. We aim to understand the characteristics of studies that used the NASSS, how it was used, and the lessons learned from its application. We conducted a scoping review following the JBI methodology. On December 20, 2022, we searched the following databases: Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, Scopus, Web of Science, and LISTA. We used typologies and frameworks to characterize evidence to address our aim. This review included 57 studies that were qualitative (n=28), mixed/multi-methods (n=13), case studies (n=6), observational (n=3), experimental (n=3), and other designs (e.g., quality improvement) (n=4). The four most common types of digital applications being implemented were telemedicine/virtual care (n=24), personal health devices (n=10), digital interventions such as internet Cognitive Behavioural Therapies (n=10), and knowledge generation applications (n=9). Studies used the NASSS to inform study design (n=9), data collection (n=35), analysis (n=41), data presentation (n=33), and interpretation (n=39). Most studies applied the NASSS retrospectively to implementation (n=33). The remainder applied the NASSS prospectively (n=15) or concurrently (n=8) with implementation. We also collated reported barriers and enablers to implementation. We found the most reported barriers fell within the Organization and Adopter System domains, and the most frequently reported enablers fell within the Value Proposition domain. Eighteen studies highlighted the NASSS as a valuable and practical resource, particularly for unravelling complexities, comprehending implementation context, understanding contextual relevance in implementing health technology, and recognizing its adaptable nature to cater to researchers' requirements. Most studies used the NASSS retrospectively, which may be attributed to the framework's novelty. However, this finding highlights the need for prospective and concurrent application of the NASSS within the implementation process. In addition, almost all included studies reported multiple domains as barriers and enablers to implementation, indicating that implementation is a highly complex process that requires careful preparation to ensure implementation success. Finally, we identified a need for better reporting when using the NASSS in implementation research to contribute to the collective knowledge in the field.

Self-monitoring of blood pressure following a stroke or transient ischaemic attack (TASMIN5S): a randomised controlled trial

BACKGROUND

Blood pressure (BP) control following stroke is important but currently sub-optimal. This trial aimed to determine whether self-monitoring of hypertension with telemonitoring and a treatment escalation protocol, results in lower BP than usual care in people with previous stroke or transient ischaemic attack (TIA).

METHODS

Unblinded randomised controlled trial, comparing a BP telemonitoring-based intervention with control (usual care) for hypertension management in 12 primary care practices in England. People with previous stroke or TIA with clinic systolic BP 130-180 mmHg, taking ≤ 3 antihypertensive medications and on stable treatment for at least four weeks were randomised 1:1 using secure online system to intervention or control. The BP:Together intervention comprised self-monitoring of blood pressure with a digital behavioural intervention which supported telemonitoring of self-monitored BP with feedback to clinicians and patients regarding medication titration. The planned primary outcome was difference in clinic measured systolic BP 12 months from randomisation but was not available following early study termination due to withdrawal of funding during the COVID-19 pandemic. Instead, in addition to pre-randomised data, routinely recorded BP was extracted from electronic patient records both pre- and post-randomisation and presented descriptively only. An intention to treat approach was taken.

RESULTS

From 650 postal invitations, 129 (20%) responded, of whom 95 people had been screened for eligibility prior to the pandemic (November 2019-March 2020) and 55 (58%) were randomised. Pre-randomisation routinely recorded mean BP was 145/78 mmHg in the control (n = 26) and 145/79 mmHg in the self-monitoring (n = 21) groups. Post-randomisation mean BP was 134/73 mmHg in the control (n = 19) and 130/75 mmHg in the self-monitoring (n = 25) groups. Participants randomised to self-monitoring used the intervention for ≥ 7 months in 25/27 (93%) of cases.

CONCLUSIONS

Recruitment of people with stroke/TIA to a trial comparing a BP self-monitoring and digital behavioural intervention to usual care was feasible prior to the COVID-19 pandemic and the vast majority of those randomised to intervention used it while the trial was running. Routinely recorded blood pressure control improved in both groups. Digital interventions including self-monitoring are feasible for people with stroke/TIA and should be definitively evaluated in future trials.

TRIAL REGISTRATION

ISRCTN57946500 06/09/2019 Prospective.

Effectiveness and compliance of telemedicine on blood pressure management in poststroke patients: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the effectiveness of telemedicine on blood pressure control and compliance.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search of PubMed, Web of Science, Embase and Cochrane Library for studies of randomised controlled trials (RCTs) of telemedicine on blood pressure control in poststroke survivors from the time of their construction until November 2023. Inclusion criteria were as follows: (1) studies that were RCTs; (2) enrolment of patients who were stroke survivors; (3) studies that compared subjects who received telemedicine with usual care treatment. Exclusion criteria were as follows: (1) studies in which telemedicine was used for other diseases; (2) study protocols with no data; (3) non-English language articles and (4) case reports, conference papers, letters or articles with incomplete data. Quality assessment of included studies was performed using the Cochrane Risk of Bias Tool.

PRIMARY OUTCOME MEASURES

The primary outcomes was the systolic blood pressure (SBP) (mm Hg), diastolic blood pressure (DBP) (mm Hg), patient compliance and the proportion of patients achieving target blood pressure.

RESULTS

A total of 11 studies with 2903 patients were included in this paper. There were 1453 cases in the telemedicine group and 1450 cases in the usual care group. Meta-analysis showed a statistically significant decrease in SBP (mm Hg) in the telemedicine group compared with the usual care group at weeks 3, 6 and 12 of follow-up (week 3: mean difference (MD), -8.8; 95% CI, -12.05 to -5.56; p<0.00001; week 6: MD, -5.13; 95% CI, -8.07 to -2.18; p=0.0007; week 12: MD, -2.78; 95% CI, -4.68 to -0.89; p=0.004). At week 12 of follow-up, there was a statistically significant decrease in DBP (mm Hg) in the telemedicine group compared with the usual care group (MD, -1.57; 95% CI, -2.59 to -0.55; p=0.003). In addition, patient compliance was better in the telemedicine group than in the usual care group (OR, 1.61; 95% CI, 1.29 to 2.01; p<0.0001), and the proportion of patients achieving target blood pressure was higher than in the usual care group (OR, 3.49; 95% CI, 2.64 to 4.63; p<0.00001).

CONCLUSIONS

Compared with usual care, telemedicine interventions can better improve blood pressure control in poststroke survivors and increase patient compliance.

TRIAL REGISTRATION NUMBER

CRD42022382001.

Assessing the impact of telemedicine interventions on systolic and diastolic blood pressure reduction: A systematic review and meta-analysis

BACKGROUND

Hypertension, characterized by high blood pressure, poses a significant risk for cardiovascular diseases, stroke, and heart attack. Managing it is particularly challenging in areas with limited healthcare access and for patients who cannot attend regular in-person visits. Telemedicine interventions offer a promising solution by improving patient adherence and facilitating timely treatment adjustments. This study aims to systematically evaluate the impact of these telemedicine interventions on reducing systolic and diastolic blood pressure.

METHODS

A comprehensive search of PubMed, Scopus, and Web of Science was conducted to identify relevant studies. Two independent reviewers screened and selected eligible articles, extracting key data using a standardized form. The quality of the included studies was assessed with the Mixed Methods Appraisal Tool (MMAT). A random effects model was used to combine the results, with treatment effects measured using standardized mean differences (Hedges's g). Consistency of findings was evaluated through statistical tests, including the Q test and I² statistic, to assess heterogeneity. Data analysis was conducted using Stata statistical software version 17.0.

RESULTS

Of the 2700 articles retrieved, 35 studies were selected for inclusion in the analysis. Using a random-effects model, the overall effect size was Hedges's g = -0.22 (95% CI: -0.30 to -0.15; p-value < 0.001), indicating a small but meaningful reduction in blood pressure (systolic and diastolic). Telemedicine interventions had a greater impact on systolic blood pressure (Hedges's g = -0.27, 95% CI: -0.39 to -0.15; p-value < 0.001) compared to diastolic blood pressure (Hedges's g = -0.17, 95% CI: -0.26 to -0.07; p-value < 0.001), though both reductions were clinically relevant.

CONCLUSION

This study demonstrates that telemedicine interventions significantly reduce both systolic and diastolic blood pressure, with a more pronounced effect on systolic pressure. The overall effect size indicates a small but meaningful improvement in hypertension management. These findings highlight the potential of telemedicine as an effective strategy for enhancing patient outcomes in hypertension care.

Effects of home-based telemedicine and mHealth interventions on blood pressure in stroke patients: a systematic evaluation and meta-analysis of randomized controlled trials

BACKGROUND

Stroke is a common cerebrovascular disease. Elevated blood pressure is the most significant manageable factor for both initial and recurrent strokes. Despite the potential benefits of telemedicine and mobile health technology (mHealth) in managing blood pressure among stroke patients, there remains skepticism.

OBJECTIVES

This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to assess the effectiveness of telemedicine and mHealth interventions in managing blood pressure in stroke patients.

METHODS

We identified randomized controlled trials (RCTs) evaluating telemedicine and mHealth technology interventions for blood pressure in patients with stroke or transient ischemic attack (TIA) from the inception date of each database up to January 2, 2024 by systematic searches of the PubMed, EMBASE, Web of Science, and Cochrane Library databases. The Cochrane Risk of Bias tool (ROB 2.0) was used to evaluate study quality. Sources of heterogeneity were explored through Meta-regression, subgroup analyses, sensitivity analyses and publication bias assessment. Meta-analysis was performed using R 4.2.2 statistical software.

RESULTS

A total of 13 randomized controlled trials with 3803 participants were included. The meta-analysis found that telemedicine and mHealth improved control of both systolic [MD = -4.37, 95 % CI (-5.50, -3.24), I2 = 43 %, P<0.00001] and diastolic blood pressures [MD = -1.72, 95 % CI (-2.45, -0.98), I2 = 0 %, P<0.00001] in stroke patients compared to the conventional care group. Stroke patients who received telemedicine and mHealth interventions showed improved medication adherence than usual care [SMD=0.52, 95 % CI (0.03, 1.00), I2 = 90 %, P<0.00001]. Meta-regression and subgroup analyses identified several key factors influencing systolic and diastolic blood pressure control in stroke patients, including whether stroke patients have hypertension, the specific forms of telemedicine and mHealth interventions employed, the duration of these interventions, and the frequency of intervention intervals.

CONCLUSIONS

Overall, telemedicine and mHealth reduced stroke patients' systolic blood pressure by an average of 4.37 mm Hg and diastolic blood pressure by an average of 1.72 mm Hg and improved medication adherence compared with usual care. As an emerging medical model, telemedicine and mHealth intervention create a good prospect for the management of blood pressure in stroke patients in the future.

The effect of telemedicine employing telemonitoring instruments on readmissions of patients with heart failure and/or COPD: a systematic review

Background

Hospital readmissions pose a challenge for modern healthcare systems. Our aim was to assess the efficacy of telemedicine incorporating telemonitoring of patients' vital signs in decreasing readmissions with a focus on a specific patient population particularly prone to rehospitalization: patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) through a comparative effectiveness systematic review.

Methods

Three major electronic databases, including PubMed, Scopus, and ProQuest's ABI/INFORM, were searched for English-language articles published between 2012 and 2023. The studies included in the review employed telemedicine incorporating telemonitoring technologies and quantified the effect on hospital readmissions in the HF and/or COPD populations.

Results

Thirty scientific articles referencing twenty-nine clinical studies were identified (total of 4,326 patients) and were assessed for risk of bias using the RoB2 (nine moderate risk, six serious risk) and ROBINS-I tools (two moderate risk, two serious risk), and the Newcastle-Ottawa Scale (three good-quality, four fair-quality, two poor-quality). Regarding the primary outcome of our study which was readmissions: the readmission-related outcome most studied was all-cause readmissions followed by HF and acute exacerbation of COPD readmissions. Fourteen studies suggested that telemedicine using telemonitoring decreases the readmission-related burden, while most of the remaining studies suggested that it had a neutral effect on hospital readmissions. Examination of prospective studies focusing on all-cause readmission resulted in the observation of a clearer association in the reduction of all-cause readmissions in patients with COPD compared to patients with HF (100% vs. 8%).

Conclusions

This systematic review suggests that current telemedicine interventions employing telemonitoring instruments can decrease the readmission rates of patients with COPD, but most likely do not impact the readmission-related burden of the HF population. Implementation of novel telemonitoring technologies and conduct of more high-quality studies as well as studies of populations with ≥2 chronic disease are necessary to draw definitive conclusions.

Systematic Review Registration

This study is registered at the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY), identifier (INPLASY202460097).

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.

Protocol for a mixed-methods study to explore implementation outcomes of the Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) across 10 hospitals in Ghana

BACKGROUND

Stroke survivors are at a substantially higher risk for adverse vascular events driven partly by poorly controlled vascular risk factors. Mobile health interventions supported by task shifting strategies have been feasible to test in small pilot trials in low-income settings to promote vascular risk reduction after stroke. However, real-world success and timely implementation of such interventions remain challenging, necessitating research to bridge the know-do gap and expedite improvements in stroke management. The Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) is a nurse-led mHealth intervention for blood pressure control among stroke survivors, currently being assessed for efficacy in a hybrid clinical trial across 10 hospitals in Ghana compared with usual care. This protocol aims to assess implementation outcomes such as feasibility, appropriateness, acceptability, fidelity, cost and implementation facilitators and barriers of the PINGS-II intervention.

METHODS AND ANALYSIS

This study uses descriptive mixed methods. Qualitative data to be collected include in-depth interviews and FGDs with patients who had a stroke on the PINGS-II intervention, as well as key informant interviews with medical doctors and health policy actors (implementation context, barriers and facilitators). Data will be analysed by thematic analysis. Quantitative data sources include structured questionnaires for clinicians (feasibility, acceptability and appropriateness), and patients who had a stroke (fidelity and costs). Analysis will include summary statistics like means, medians, proportions and exploratory tests of association including χ2 analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Committee for Human Research Publication and Ethics at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Voluntary written informed consent will be obtained from all participants. All the rights of the participants and ethical principles guiding scientific research shall be adhered to. Findings from the study will be presented in scientific conferences and published in a peer-reviewed scientific journal. A dissemination meeting will be held with relevant agencies of the Ghana Ministry of Health, clinicians, patient group representatives, and non-governmental organisations.

Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Background

Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs.

Methods

In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227.

Findings

We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%].

Interpretation

Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence.

Funding

None.

The Status Quo of Internet Medical Services in China: A Nationwide Hospital Survey

Background: Internet medical services (IMS) have been rapidly promoted across China, especially since the outbreak of COVID-19. However, a nationwide study is still lacking. Objective: To unveil the whole picture of IMS across tertiary and secondary hospitals in China, and to evaluate potential influence of the hospital general characteristics, medical staff reserve, and patient visiting capacity on IMS provision. Methods: An online cross-sectional survey was conducted, and 1,995 tertiary and 2,824 secondary hospitals completed questionnaires from 31 administrative regions in China during July 1 and October 31, 2021. Those hospitals are defined having abilities of providing IMS if at least one following service are available: (1) online appointment of diagnoses and treatments; (2) online disease consultation; (3) electronic prescription; and (4) drug delivery. The logistic regression models are used to detect the possible roles on developing IMS. Results: A majority (68.9%) of tertiary hospitals and 53.0% secondary hospitals have provided IMS (p < 0.01). Tertiary hospital also had much higher proportions than secondary hospitals in online appointment of diagnoses and treatments (62.6% vs. 46.1%), online disease consultation (47.3% vs. 16.9%), electronic prescription (33.2% vs. 9.6%), and drug delivery (27.8% vs. 4.6%). In multivariate model, IMS hospitals may be associated significantly with having more licensed doctors (≥161 vs. <161: odds ratio [OR], 1.30; 1.13-1.50; p < 0.01), having more frequency of registration appointments (≥3,356 vs. <3,356: OR, 1.77; 1.54-2.03; p < 0.01), having higher frequency of patient follow-ups (≥1,160 vs. <1,160: OR, 1.36; 1.15-1.61; p < 0.01), having laboratory test appointments (Yes vs. No: OR, 1.25; 1.06-1.48; p = 0.01), and having treatment appointments (Yes vs. No: OR, 1.27; 1.11-1.46; p < 0.01) in the past 3 months. Conclusions: The coverage of IMS is appreciable in China, but the IMS market is still greatly extended and improved. The provision of IMS depends primarily on the scales of the hospitals, including medical staff reserve and patient visiting capacity.

User-Centered Mobile Applications for Stroke Survivors (MAPPS): A Mixed-Methods Study of Patient Preferences

OBJECTIVE

Investigate stroke survivors' (SS) preferences for a hypothetical mHealth app for post-stroke care and to study the influence of demographic variables on these preferences.

DESIGN

Mixed-methods, sequential, observational study.

SETTING

Focus groups (phase 1) were conducted to identify SS perceptions and knowledge of mHealth applications (apps). Using grounded theory approach, recurring themes were identified. A multiple-choice questionnaire of 5 desired app features was generated using these themes and mailed to SS (national survey, phase 2). SS' demographics and perceived usefulness (yes/no) for each feature were recorded. In-person usability testing (phase 3) was conducted to identify areas of improvement in user interfaces of existing apps. Summative telephone interviews (phase 4) were conducted for final impressions supplementary to national survey.

PARTICIPANTS

SS aged >18 years recruited from study hospital, national stroke association database, stroke support and advocacy groups. Non-English speakers and those unable to communicate were excluded.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

(1) Percentage of SS (phase 2) identifying proposed app features to be useful. (2) Influence of age, sex, race, education, and time since stroke on perceived usefulness.

RESULTS

Ninety-six SS participated in focus groups. High cost, complexity, and lack of technical support were identified as barriers to adoption of mHealth apps. In the national survey (n=1194), ability to track fitness and diet (84%) and communication (70%) were the most and least useful features, respectively. Perceived usefulness was higher among younger SS (P<.001 to .006) and SS of color (African American and Hispanic) (ORs 1.73-4.41). Simple design and accommodation for neurologic deficits were main recommendations from usability testing.

CONCLUSIONS

SS are willing to adopt mHealth apps that are free of cost and provide technical support. Apps for SS should perform multiple tasks and be of simple design. Greater interest for the app's features among SS of color may provide opportunities to address health inequities.

Assessing the Effectiveness of mHealth Interventions for Diabetes and Hypertension Management in Africa: Systematic Review and Meta-Analysis

Background

Mobile health (mHealth) interventions are effective in improving chronic disease management, mainly in high-income countries. However, less is known about the efficacy of mHealth interventions for the reduction of cardiovascular risk factors, including for hypertension and diabetes, which are rapidly increasing in low- and middle-income countries.

Objective

This study aimed to assess the efficacy of mHealth interventions for diabetes and hypertension management in Africa.

Methods

We searched PubMed, Cochrane Library, Google Scholar, African Journals Online, and Web of Science for relevant studies published from inception to July 2022. The main outcomes of interest were changes in hemoglobin A1c (HbA1c), systolic blood pressure, and diastolic blood pressure. The random or fixed effect model was used for the meta-analysis, and the I2 statistic was used to gauge study heterogeneity. Z tests and P values were used to evaluate the effect of mHealth interventions on HbA1c and blood pressure levels.

Results

This review included 7 studies (randomized controlled trials) with a total of 2249 participants. Two studies assessed the effect of mHealth on glycemic control, and 5 studies assessed the effect of mHealth on blood pressure control. The use of mHealth interventions was not associated with significant reductions in HbA1c levels (weighted mean difference [WMD] 0.20, 95% CI -0.40 to 0.80; P=.51) among patients with diabetes and systolic blood pressure (WMD -1.39, 95% CI -4.46 to 1.68; P=.37) and diastolic blood pressure (WMD 0.36, 95% CI -1.37 to 2.05; P=.69) among patients with hypertension. After conducting sensitivity analyses using the leave-one-out method, the Kingue et al study had an impact on the intervention, resulting in a 2 mm Hg reduction in systolic blood pressure (WMD -2.22, 95% CI -3.94 to -0.60; P=.01) but was nonsignificant for diastolic blood pressure and HbA1c levels after omitting the study.

Conclusions

Our review provided no conclusive evidence for the effectiveness of mHealth interventions in reducing blood pressure and glycemic control in Africa among persons with diabetes and hypertension. To confirm these findings, larger randomized controlled trials are required.

Mobile health for cardiovascular risk management after cardiac surgery: results of a sub-analysis of The Box 2.0 study

Aims

Lowering low-density lipoprotein (LDL-C) and blood pressure (BP) levels to guideline recommended values reduces the risk of major adverse cardiac events in patients who underwent coronary artery bypass grafting (CABG). To improve cardiovascular risk management, this study evaluated the effects of mobile health (mHealth) on BP and cholesterol levels in patients after standalone CABG.

Methods and results

This study is a post hoc analysis of an observational cohort study among 228 adult patients who underwent standalone CABG surgery at a tertiary care hospital in The Netherlands. A total of 117 patients received standard care, and 111 patients underwent an mHealth intervention. This consisted of frequent BP and weight monitoring with regimen adjustment in case of high BP. Primary outcome was difference in systolic BP and LDL-C between baseline and value after three months of follow-up. Mean age in the intervention group was 62.7 years, 98 (88.3%) patients were male. A total of 26 449 mHealth measurements were recorded. At three months, systolic BP decreased by 7.0 mmHg [standard deviation (SD): 15.1] in the intervention group vs. -0.3 mmHg (SD: 17.6; P < 0.00001) in controls; body weight decreased by 1.76 kg (SD: 3.23) in the intervention group vs. -0.31 kg (SD: 2.55; P = 0.002) in controls. Serum LDL-C was significantly lower in the intervention group vs. controls (median: 1.8 vs. 2.0 mmol/L; P = 0.0002).

Conclusion

This study showed an association between home monitoring after CABG and a reduction in systolic BP, body weight, and serum LDL-C. The causality of the association between the observed weight loss and decreased LDL-C in intervention group patients remains to be investigated.

Effectiveness of Remote Interventions to Improve Medication Adherence in Patients after Stroke: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Stroke affects more than 30 million people every year, but only two-thirds of patients comply with prescribed medication, leading to high stroke recurrence rates. Digital technologies can facilitate interventions to support treatment adherence.

PURPOSE

This study evaluates the effectiveness of remote interventions and their mechanisms of action in supporting medication adherence after stroke.

METHODS

PubMed, MEDLINE via Ovid, Cochrane CENTRAL, the Web of Science, SCOPUS, and PsycINFO were searched, and meta-analysis was performed using the Review Manager Tool. Intervention content analysis was conducted based on the COM-B model.

RESULTS

Ten eligible studies were included in the review and meta-analysis. The evidence suggested that patients who received remote interventions had significantly better medication adherence (SMD 0.49, 95% CI [0.04, 0.93], and p = 0.03) compared to those who received the usual care. The adherence ratio also indicated the interventions' effectiveness (odds ratio 1.30, 95% CI [0.55, 3.10], and p = 0.55). The systolic and diastolic blood pressure (MD -3.73 and 95% CI [-5.35, -2.10])/(MD -2.16 and 95% CI [-3.09, -1.22]) and cholesterol levels (MD -0.36 and 95% CI [-0.52, -0.20]) were significantly improved in the intervention group compared to the control. Further behavioural analysis demonstrated that enhancing the capability within the COM-B model had the largest impact in supporting improvements in adherence behaviour and relevant clinical outcomes. Patients' satisfaction and the interventions' usability were both high, suggesting the interventions' acceptability.

CONCLUSION

Telemedicine and mHealth interventions are effective in improving medication adherence and clinical indicators in stroke patients. Future studies could usefully investigate the effectiveness and cost-effectiveness of theory-based and remotely delivered interventions as an adjunct to stroke rehabilitation programmers.

Prevalence, treatment, and attributed mortality of elevated blood pressure among a nationwide population-based cohort of stroke survivors in China

Background

Elevated blood pressure (BP) is associated with substantial morbidity and mortality in stroke survivors. China has the highest prevalence of stroke survivors and accounts for one-third of stroke-related deaths worldwide. We aimed to describe the prevalence and treatment of elevated BP across age, sex, and region, and assess the mortality attributable to elevated BP among stroke survivors in China.

Materials and methods

Based on 3,820,651 participants aged 35–75 years from all 31 provinces in mainland China recruited from September 2014 to September 2020, we assessed the prevalence and treatment of elevated BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) among those with self-reported stroke and stratified by age group, sex, and geographic region. We estimated the age- and sex-specific population attributable fractions of death from elevated BP.

Results

Among 91,406 stroke survivors, the mean (SD) age was 62 (8) years, and 49.0% were male. The median interquartile range (IQR) stroke duration was 4 (2, 7) years. The prevalence of elevated BP was 61.3% overall, and increased with age (from 47.5% aged 35–44 years to 64.6% aged 65–75 years). The increment of prevalence was larger in female patients than male patients. Elevated BP was more prevalent in northeast (66.8%) and less in south (54.3%) China. Treatment rate among patients with elevated BP was 38.1%, and rates were low across all age groups, sexes, and regions. Elevated BP accounted for 33 and 21% of cardiovascular and all-cause mortality among stroke survivors, respectively. The proportion exceeded 50% for cardiovascular mortality among patients aged 35–54 years.

Conclusion

In this nationwide cohort of stroke survivors from China, elevated BP and its non-treatment were highly prevalent across all age groups, sexes, and regions. Elevated BP accounted for nearly one-third cardiovascular mortality in stroke survivors, and particularly higher in young and middle-aged patients. National strategies targeting elevated BP are warranted to address the high stroke burden in China.

Moving Towards Equity With Digital Health Innovations for Stroke Care

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Health Equity and Actionable Disparities in Stroke: 2021 Update

There are stark inequities in stroke incidence, prevalence, acute care, rehabilitation, risk factor control, and outcomes. To address these inequities, it is critical to engage communities in identifying priorities and designing, implementing, and disseminating interventions. This issue of Stroke features health equity themed lectures delivered during the International Stroke Conference and Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving meetings in 2021 as well as articles covering issues of disparities and diversity in stroke. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, received the 2021 William Feinberg Award Lecture for his lifetime achievements in seeking global and local solutions to cerebrovascular health inequities. The second annual Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving symposium, which took place the day before the International Stroke Conference in February 2021, focused on community-engaged research for reducing inequities in stroke. Phil Gorelick, MD was awarded the Edgar J. Kenton III Award for his lifetime achievements in using community engagement strategies to recruit and retain Black participants in observational studies and clinical trials. Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke delivered the keynote lecture on stroke inequities and Richard Benson, MD, PhD, Director of the Office of Global Health and Health Disparities at National Institute of Neurological Disorders and Stroke, gave a lecture focused on National Institute of Neurological Disorders and Stroke efforts to address inequities. Nichols et al highlighted approaches of community-based participatory research to address stroke inequities. Verma et al showcased digital health innovations to reduce inequities in stroke. Das et al showed that the proportion of underrepresented in medicine vascular neurology fellows has lowered over the past decade and authors provided a road map for enhancing the diversity in vascular neurology. Clearly, to overcome inequities, multipronged strategies are required, from broadening representation among vascular neurology faculty to partnering with communities to conduct research with meaningful impact.

Demand for Mobile Health in Developing Countries During COVID-19: Vietnamese's Perspectives from Different Age Groups and Health Conditions

BACKGROUND

Vietnam's economy and intellectual standards have witnessed significant development, improving conditions for residents to acquire novel mHealth applications. Additionally, the outbreak of the COVID-19 pandemic has influenced Vietnamese awareness of healthcare; however, previous studies have only been clinician-centered rather than customer-centered.

METHODS

This study addresses this literature gap by interviewing 50 Vietnamese participants grouped by age, namely Generation X, Generation Y, and Generation Z, and health conditions, namely whether participants or family members have chronic illness. The study utilized semi-structured and in-depth interviews to collect the data and used thematic analysis to analyze the data under the unified theory of acceptance and use of technology framework.

RESULTS

Most participants were willing to adopt this technology and demanded a convenient and user-friendly one-stop-shop solution, endorsements from credible and authoritative sources, and professional customer services. However, each group also had distinctive demands and behaviors.

CONCLUSION

This study contributes theoretically by providing context-rich demand for Vietnamese customers across three generations and healthcare conditions during the COVID-19 pandemic and comparing their behavior with pre-COVID literature. While this research provides helpful information for potential app developers, this study also suggests that mHealth developers and policymakers should pay more attention to the differences in the demand of age groups and health conditions.