Background: Uncontrolled hypertension is the largest contributor to all-cause and cardiovascular mortality. Nurseand pharmacist-led telehealth care (TC) interventions have resulted in large, lasting improvements in blood pressure compared with clinic-based care (CC) under controlled research conditions but have not been studied at scale under real-world conditions.
Methods: This cluster-randomized trial in 21 primary care clinics used electronic health record algorithms triggered during primary care encounters to enroll patients 18–85 years old with hypertension and blood pressure of >150/95 mmHg. TC patients (n=1424) were recommended to follow up with a pharmacist in 2 weeks to obtain home blood pressure telemonitoring and telephone management visits. CC patients (n=1648) were recommended to follow up with a medical assistant for a blood pressure check in 2 weeks. The primary outcome was the difference in change in systolic blood pressure (SBP) between groups over 12 months using blood pressure data from the electronic health record. A secondary per protocol analysis among patients who enrolled and adhered to recommended follow-up within 6 weeks used inverse probability weighting to account for potential bias.
Results: Enrolled patients had a mean age of 60 years and were 47% male, 7% Asian, 19% Black, 69% White, and 2% Hispanic. Mean enrollment blood pressure was 164/94 mmHg. Within 6 weeks, 27% of TC patients had a pharmacist visit (of whom 80% began telemonitoring) and 32% of CC patients had a medical assistant visit. Change in SBP was similar in TC (-18.7 mmHg) and CC (-17.5 mmHg) patients (difference of -1.2 mmHg [95% CI: -2.9, 0.6]). However, in the per protocol analysis, TC patients had greater decrease in SBP than CC patients (-4.6 mmHg [95% CI: -7.7, -1.5]). Patient surveys showed higher ratings of care, more frequent self-monitoring, and greater use of home blood pressure for treatment changes in TC.
Conclusion: Patient engagement in the TC intervention was much lower in this pragmatic trial than in a previous explanatory trial, and the primary analysis showed equivalent decrease in SBP in both groups. However, among those who engaged in follow-up care, TC patients had a larger decrease in SBP. Additional research is needed to study effects of strategies to encourage uptake of telehealth care in realworld patients with hypertension.