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Digital clinical interactions, including telehealth appointments and online patient portals, are now common. Digital health platforms can’t be one-size-fits-all though, LDI Senior Fellow Eric Bressman says. Sustained, effective engagement will require dynamic strategies that adapt to patients’ responses, preferences, and needs.
A study led by Bressman found high engagement with a text-messaging platform for managing hypertension, but also demonstrated the importance of testing digital innovations in pragmatic, randomized controlled trials. Bressman answered questions about the work he did with LDI Senior Fellows Kevin Volpp and Anna Morgan, LDI Statistical Analyst Anthony Girard, and colleagues.
Bressman: Hypertension, or high blood pressure, is a leading risk factor for cardiovascular disease, disability, and death. In the U.S., hypertension is controlled in only 1 in 4 people with the condition.
Hypertension management traditionally requires regular in-person clinic visits. People may have difficulty scheduling visits or if they visit their clinic for another reason, they might not have time to discuss hypertension control. All this may slow adjustment of their medication and delay achieving control. Some evidence supports patients measuring their blood pressure at home for controlling hypertension.
Our trial tested the feasibility and effectiveness of BP Pal, an automated, text message-based program to make intensive hypertension monitoring and medication management easier for patients and clinicians.
Bressman: We selected patients from two Penn Medicine primary care clinics who took hypertension medication but appeared to have uncontrolled blood pressure based on two high clinic measurements in the last year (greater than 140 mmHg systolic blood pressure, with under 120 considered normal). The 300 individuals were randomized to control or intervention groups. Control patients’ clinicians managed their hypertension as usual, without care from the study.
We sent intervention patients a text inviting them to BP Pal. If they accepted, they received a home blood pressure monitor and weekly automated texts from BP Pal, from January to July 2023, with reminders to measure their blood pressure and text in the results. An automated system analyzed the data and alerted a centralized study team about high or low readings. Study clinicians contacted these participants and took actions as needed, including adjusting hypertension medication. Of the 150 invited individuals, 92 completed the program.
Bressman: After the 6-month intervention, we invited all 300 people originally randomized to the control or BP Pal intervention groups to in-clinic blood pressure measurements. Both the control and BP Pal groups had lower systolic blood pressure (about 15 points for intervention and 11 for control) than in their health records. BP Pal patients had a greater decrease, but the difference with the control group wasn’t statistically significant. This was good news for the patients because it indicated better hypertension control than we originally thought.
Blood pressure fluctuates constantly. People can have high readings in a clinic and lower numbers later. Our results might reflect a “regression to the mean,” with our end-of-study measurements revealing blood pressures closer to the average for people with hypertension. Supporting this explanation, the BP Pal group’s first home measurements showed a large drop in blood pressure, even before interacting with study clinicians. It may also indicate that while our intensive approach worked, usual care is pretty good too.
Bressman: This, and other work, shows that patients and clinicians will engage in automated text-messaging programs. In this study, 65% enrolled in BP Pal. Those who rated the experience gave it 76 out of 100 points.
Our results show the importance of testing interventions in prospective, randomized controlled trials. This is often a lesson of pragmatic research that is integrated into everyday care. Even if interventions are popular with patients or look promising in pilot studies, that doesn’t guarantee better clinical outcomes in larger trials.
Future studies must rigorously identify people who might benefit from a digital health program, including selection criteria that try to mitigate phenomena like regression to the mean. This study was a pilot component of the Penn Medicine Healthy Heart program and we’re using what we learned to improve the other components.
Some of our ongoing work studies ways to optimally engage people in digital health programs longitudinally. Sustained participation in digital health will probably require dynamic approaches that learn and adapt to patients’ responses, interaction preferences, and health needs over time. Some people are highly engaged from the start, some lose interest over time, and some never respond. Historically, we have used a one-size-fits-all strategy in designing these programs, but we have the capacity to take a more personalized approach.
Finally, digital health options continue to grow in popularity, and we need to have payment and regulatory frameworks that support them. Remote, digital monitoring is a different care model that might not be reimbursed as office visits are, but it still takes clinician effort. Digital health can also take place across state lines, which our traditional regulatory system is not well-equipped to handle. We need to have payment and regulatory policies that keep up with this new way of providing care.
The study, “Automated Text Message-Based Program to Improve Uncontrolled Blood Pressure in Primary Care Patients: A Randomized Clinical Trial,” was published on December 4, 2024 in the Journal of General Internal Medicine. Authors include Eric Bressman, Klea Profka, Laurie Norton, Kayla Clark, Katy Mahraj, Zakiya Walker, Leslie Reid‑Bey, Anthony Girard, Charles Rareshide, Lin Xu, Jingsan Zhu, Mary Putt, Kevin G. Volpp, and Anna U. Morgan.
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