title: Self-measurement and self-titration in hypertension: a pilot telemedicine study. Accuracy of blood pressure measurements transmitted through a telemedicine system in underserved populations. Superiority of Ambulatory Over Clinic Blood Pressure Measurement in Predicting Mortality: The Dublin Outcome Study Blood pressure control during telemonitoring of home blood pressure. A randomized controlled trial during 6 months Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial Cellular phone and Internet-based individual intervention on blood pressure and obesity in obese patients with hypertension Accuracy of telemedicine in detecting uncontrolled hypertension and its impact on patient management. Effects of Nurse-Managed Telemonitoring on Blood Pressure at 12-Month Follow-Up Among Urban African Americans Feasibility of blood pressure telemonitoring in patients with poor blood pressure control Blood pressure, stroke, and coronary heart disease: Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Home blood pressure monitoring for pregnant patients with hypertension. Effects of home telemonitoring and community-based monitoring on blood pressure control in urban African Americans: a pilot study. Home blood pressure telemonitoring improves hypertension control in general practice. The TeleBPCare study Telemedicine improves diagnosis of essential hypertension compared with usual care The Informatics for Diabetes and Education Telemedicine (IDEATel) project. Home Monitoring Service Improves Mean Arterial Pressure in Patients with Essential Hypertension Economic evaluation of home blood pressure telemonitoring: A randomized controlled trial Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring: A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association Economic evaluation of home blood pressure monitoring with or without telephonic behavioral self-management in patients with hypertension.
abstract: BACKGROUND Because of poor patient compliance and clinical inertia , hypertension control rates remain poor . Home blood-pressure measurements ( HBPM ) improve compliance of patients and achievement of blood pressure ( BP ) targets . However , few studies have evaluated self-BP management by patients . METHODS In a multicenter , prospect i ve , single-group , open-label pilot study of 111 patients whose hypertension was uncontrolled despite monotherapy , we studied satisfaction with , and feasibility of , HBPM and self-titration of antihypertensive treatment using telemedicine for compliance , efficacy , and safety . After education ( protocol , action plan , and use of the HBPM device ) , patients performed a sequence of HBPM every 2 weeks for 8 weeks . Following a stepwise approach , treatment was increased by the patient at weeks 4 and 6 if average HBPM values exceeded predefined limits . For each titration , the patient informed the Core Center by telemedicine , but BP values were transferred automatically . RESULTS Overall , 80 % of patients were satisfied ( 58 % ) or very satisfied ( 23 % ) with the program ( 95 % confidence interval , 73 % to 87 % ) . Regarding compliance , 78 % of patients fully complied with self-measurement , and just over 71 % titrated their treatment adequately . Physicians were satisfied ( 52 % ) or very satisfied ( 22 % ) with the program . Between the first and final visits ( at week 8) , office systolic/diastolic BP ( mean + /- SD ) decreased significantly from 151 + /- 9/91 + /- 6 to 143 + /- 13/84 + /- 11 mmHg . During the trial ,  HBPM  ( mean + /- SD ) decreased significantly from 149 + /- 13/86 + /- 12 to 138 + /- 16/81 + /- 10 mmHg . No significant safety issues were reported . CONCLUSIONS This innovative approach to the management of hypertension , combining self-measurement and self-titration , is feasible , well-accepted by both patients and physicians , and safe In underserved population s , inadequate surveillance and treatment allows hypertension to persist until actual cardiovascular events occur . Thus , we developed an Internet-based telemedicine system to address the suboptimal control of hypertension and other modifiable risk factors . To minimize cost , the subjects used home monitors for blood pressure ( BP ) measurements and entered these values into the telemedicine system . We hypothesized that patients could accurately measure their BP and transmit these values via a telemedicine system . Inner city and rural subjects ( N = 464 ; 42 % African-American or Hispanic ) with 10 % or greater 10-year risk of cardiovascular disease and with treatable risk factors were r and omized into two groups , control group ( CG ) and telemedicine group ( TG ) . Each subject received a home sphygmomanometer with memory . The TG recorded and entered BP at least weekly . During office visits , the BP meters were downloaded and recorded BP compared to BP values transmitted via telemedicine . The telemedicine ( T ) BP values were similar to the meter recorded ( R ) values ( T : systolic/diastolic BP 133.4 + /- 11.1/77.5 + /- 6.8 mm Hg , and R : systolic/diastolic BP 136.4 + /- 11.9.4/79.7 + /- 7.5 mm Hg ) . The percent error was < 1 % for both systolic ( -0.02 + /- 0.04 % ) and diastolic ( -0.03 + /- 0.04 % ) BP . Lastly , the telemedicine BP values were similar to the office ( O ) BP values for systolic and diastolic BP ( T : systolic/diastolic BP 133.4 + /- 11.1/77.5 + /- 6.8 mm Hg , and O : systolic/diastolic BP 136.3 + /- 20.5/78.1 + /- 10.5 mm Hg ) . In underserved population s , this inexpensive approach of patients using a home monitor and entering these values into a telemedicine system provided accurate BP data The purpose of this study was to determine if ambulatory blood pressure measurement predicted total and cardiovascular mortality over and beyond clinic blood pressure measurement and other cardiovascular risk factors ; 5292 untreated hypertensive patients referred to a single blood pressure clinic who had clinic and ambulatory blood pressure measurement at baseline were followed up in a prospect i ve study of mortality outcome . Multiple Cox regression was used to model time to total and cause-specific mortality for ambulatory blood pressure measurement while adjusting for clinic blood pressure measurement and other risk factors at baseline . There were 646 deaths ( of which 389 were cardiovascular ) during a median follow-up period of 8.4 years . With adjustment for gender , age , risk indices , and clinic blood pressure , higher mean values of ambulatory blood pressure were independent predictors for cardiovascular mortality . The relative hazard ratio for each 10-mm Hg increase in systolic blood pressure was 1.12 ( 1.06 to 1.18 ; P<0.001 ) for daytime and 1.21 ( 1.15 to 1.27 ; P<0.001 ) for nighttime systolic blood pressure . The hazard ratios for each 5-mm Hg increase in diastolic blood pressure were 1.02 ( 0.99 to 1.07 ; P = NS ) for daytime and 1.09 ( 1.04 to 1.13 ; P<0.01 ) for nighttime diastolic pressures . The hazard ratios for nighttime ambulatory blood pressure remained significant after adjustment for daytime ambulatory blood pressure . These results have 2 important clinical messages : ambulatory measurement of blood pressure is superior to clinic measurement in predicting cardiovascular mortality , and nighttime blood pressure is the most potent predictor of outcome Aim . To compare the effectiveness of antihypertensive treatment based on telemonitoring of home blood pressure ( BP ) and conventional monitoring of office BP . Methods . Hypertensive patients ( n = 236 ) participated in a r and omized , controlled study . In the intervention group , antihypertensive treatment was based on home BP monitoring . BP readings were registered by a PDA and automatically transmitted to a server , by which the patient and doctor could communicate . In the control group , patients received usual care with office visits to adjust antihypertensive treatment as needed . Primary outcome was difference in systolic daytime ambulatory BP monitoring ( ABPM ) change between baseline and 6 months . Results . In both groups , systolic daytime ABPM decreased significantly from baseline to follow‐up . The decrease in systolic daytime ABPM was −11.9 mmHg in the intervention group and −9.6 mmHg in the control group ( mean difference −2.3 [ 95 % CI −6.1 to −1.5 ] , p = 0.225 ) . The likelihood of daytime ABPM normalization was similar in the two groups [ 32/113 ( 28 % ) vs 46/123 ( 37 % ) , p = 0.139 ] . Conclusion . Antihypertensive treatment based on telemonitoring of home BP was as effective as usual monitoring of office BP with regards to reduction of BP . Trial registration : Clinical Trials.gov identifier : NCT00282334 BACKGROUND Control of blood pressure is a key component of cardiovascular disease prevention , but is difficult to achieve and until recently has been the sole preserve of health professionals . This study assessed whether self-management by people with poorly controlled hypertension result ed in better blood pressure control compared with usual care . METHODS This r and omised controlled trial was undertaken in 24 general practice s in the UK . Patients aged 35 - 85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension . Participants were r and omly assigned in a 1:1 ratio to self-management , consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs , combined with telemonitoring of home blood pressure measurements or to usual care . R and omisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex , baseline systolic blood pressure , and presence or absence of diabetes or chronic kidney disease . Neither participants nor investigators were masked to group assignment . The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point ( 6 months and 12 months ) . All r and omised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis , without imputation for missing data . This study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N17585681 . FINDINGS 527 participants were r and omly assigned to self-management ( n=263 ) or control ( n=264 ) , of whom 480 ( 91 % ; self-management , n=234 ; control , n=246 ) were included in the primary analysis . Mean systolic blood pressure decreased by 12.9 mm Hg ( 95 % CI 10.4 - 15.5 ) from baseline to 6 months in the self-management group and by 9.2 mm Hg ( 6.7 - 11.8 ) in the control group ( difference between groups 3.7 mm Hg , 0.8 - 6.6 ; p=0.013 ) . From baseline to 12 months , systolic blood pressure decreased by 17.6 mm Hg ( 14.9 - 20.3 ) in the self-management group and by 12.2 mm Hg ( 9.5 - 14.9 ) in the control group ( difference between groups 5.4 mm Hg , 2.4 - 8.5 ; p=0.0004 ) . Frequency of most side-effects did not differ between groups , apart from leg swelling ( self-management , 74 patients [ 32 % ] ; control , 55 patients [ 22 % ] ; p=0.022 ) . INTERPRETATION Self-management of hypertension in combination with telemonitoring of  blood pressure measurements represents an important new addition to control of hypertension in primary care . FUNDING Department of Health Policy Research Programme , National Coordinating Centre for Research Capacity Development , and Midl and s Research Practice s Consortium PURPOSE The present study evaluated whether an intervention using a short message service ( SMS ) by cellular phone and Internet would improve blood pressure , weight control , and serum lipids of obese patients with hypertension during 8 weeks . METHODS This is a quasi-experimental design with pre- and follow-up tests . Participants were recruited from the family medicine outpatient department of tertiary care hospital located in an urban city of South Korea . Twenty-eight patients were assigned to an intervention group and 21 to a control group . The goal of intervention was to bring blood pressure , body weight , and serum lipids levels close to normal ranges . Patients in the intervention group were requested to record their blood pressure and body weight in a weekly web based diary through the Internet or by cellular phones . The research ers sent optimal recommendations as an intervention to each patient , by both cellular phone and Internet weekly . The intervention was applied for 8 weeks . RESULTS Systolic ( SBP ) and diastolic blood pressures ( DBP ) significantly decreased by 9.1 and 7.2 mmHg respectively at 8 weeks from the baseline in the intervention group ( p<0.05 ) . However , after 8 weeks from the baseline both SBP and DBP in the control group had not changed significantly . Yet , There were significant mean decreases in body weight and waist circumference by 1.6 kg ( p<0.05 ) and 2.8 cm ( p<0.05 ) in the intervention group , respectively . In the control group increases in body weight and waist circumference ( p<0.05 ) mean changes were also significant . High density lipoprotein cholesterol ( HDL-C ) significantly increased , with a mean change of 3.7 mg/dl at 8 weeks from baseline in the intervention group ( p<0.05 ) . The mean change of HDL-C in the control group was , however , not significant . CONCLUSION During 8 weeks using this web-based intervention by way of cellular phone and Internet SMS improved blood pressure , body weight , waist circumference , and HDL-C in patients with obese hypertension This study was aim ed at assessing the diagnostic accuracy of telemedicine among hypertensive patients . This was a cross-sectional analysis of patients attending a hypertension clinic over a year-long study . Patients were seen both by telemedicine and in-person on the same day with order of the encounters r and omly determined . A telemedicine system , which utilized phone lines , was employed . For each type of encounter , whether telemedicine ( TM ) or in-person ( IP ) , clinical data on blood pressure ( BP ) control as well as physician ordering patterns were collected . Receiver Operator Characteristic ( ROC ) curves were used to assess the validity of TM as compared to IP in the assessment of uncontrolled hypertension .  Sixty-two patients participated result ing in 107-paired visits over the year-long study period . The mean age of the 62 participants was 67.1 + /- 11.4 years ; 56.6 % were men . ROC curves for detecting elevated mean blood pressure provided an area under the curve ( auc ) of 0.87 ( 95 % CI , 0.80 - 0.95 ) . ROC curves for the detection of uncontrolled systolic hypertension provided an auc of 0.86 ( 95 % CI , 0.78 - 0.93 ) . Telemedicine-determined BP differed slightly , but statistically significant ( p < 0.05 ) , from IP assessment s. Meanwhile , there was no difference in ordering diagnostic tests or therapeutics detectable between the two encounter types . Telemedicine proved to be a valid means for detecting uncontrolled BP among hypertensive patients Background : Nearly one in three adults in the United States has hypertension . Hypertension is one of the largest risk factors for cardiovascular diseases , and it is growing in prevalence , especially among African Americans . Objectives : To test the hypothesis that individuals who participate in usual care ( UC ) plus blood pressure ( BP ) telemonitoring ( TM ) will have a greater reduction in BP from baseline to 12-month follow-up than would individuals who receive UC only . Methods : A two-group , experimental , longitudinal design with block stratified r and omization for antihypertensive medication use was used . African Americans with hypertension were recruited through free BP screenings offered in the community . Data were collected through a structured interview and brief physical exam . Cross tabs , repeated measures analysis of variance , and independent t tests were used to analyze the study 's hypothesis . Results : The TM intervention group had a greater reduction in systolic BP ( 13.0 mm Hg ) than the enhanced UC group ( 7.5 mm Hg ; t = −2.09 , p = .04 ) from baseline to the 12-month follow-up . Although the TM intervention group had a greater reduction in diastolic BP ( 6.3 mm Hg ) compared with the enhanced UC group ( 4.1 mm Hg ) , the differences were not statistically significant ( t = −1.56 , p = .12 ) . Discussion : Telemonitoring of BP result ed in clinical ly and statistically significant reductions in systolic BP over a 12-month period ; if maintained over a longer period of time , the reductions could improve care and outcomes significantly for African Americans with hypertension We examined the feasibility of using home blood pressure ( BP ) telemonitoring devices for managing patients with poor BP control .  We enrolled 591 subjects with a diagnosis of hypertension . Patients were r and omized to usual care ( n = 147 ) or to the intervention arm ( n = 441 ) . Those in the intervention arm were issued with a home BP telemonitoring device . The device transmitted BP readings automatically via the home telephone line . Technical alerts were generated if patients did not transmit their BP readings according to the protocol . During the first six months , 693 technical alerts were generated by 267 patients . About half of these patients ( 112 ) generated more than two technical alerts . Resolution of the alerts showed that 61 % were caused by patient non-adherence . Patients who generated > 2 technical alerts were younger ( 61 vs. 64 years ; P = 0.001 ) and were more likely to be non-Caucasian  ( 64 % vs. 47 % , P = 0.002 ) than those generating 2 or fewer alerts . Despite the potential for improving health care using home BP telemonitoring , certain patients will require more support to use the equipment successfully The associations of  diastolic blood pressure ( DBP )  with  stroke  and with coronary heart disease ( CHD ) were investigated in nine major prospect i ve observational studies : total 420,000 individuals , 843 strokes , and 4856 CHD events , 6 - 25 ( mean 10 ) years of follow-up . The combined results demonstrate positive , continuous , and apparently independent associations , with no significant heterogeneity of effect among different studies . Within the range of DBP studied ( about 70 - 110 mm Hg ) , there was no evidence of any " threshold " below which lower levels of DBP were not associated with lower risks of stroke and of CHD . Previous analyses have described the uncorrected associations of DBP measured just at " baseline " with subsequent disease rates . But , because of the diluting effects of r and om fluctuations in DBP , these substantially underestimate the true associations of the usual DBP ( ie , an individual 's long-term average DBP ) with disease . After correction for this " regression dilution " bias , prolonged differences in usual DBP of 5 , 7.5 , and 10 mm Hg were respectively associated with at least 34 % , 46 % , and 56 % less stroke and at least 21 % , 29 % , and 37 % less CHD . These associations are about 60 % greater than in previous uncorrected analyses . ( This regression dilution bias is quite general , so analogous corrections to the relations of cholesterol to CHD or of various other risk factors to CHD or to other diseases would likewise increase their estimated strengths . ) The DBP results suggest that for the large majority of individuals , whether conventionally " hypertensive " or " normotensive " , a lower blood pressure should eventually confer a lower risk of vascular disease This study was conducted to evaluate the effect of automated telephone patient monitoring and counseling on patient adherence to antihypertensive medications and on blood pressure control . A r and omized controlled trial was conducted in 29 greater Boston communities . The study subjects were 267 patients recruited from community sites who were > or= 60 years of age , on antihypertensive medication , with a systolic blood pressure ( SBP ) of > or= 160 mm Hg and /or a diastolic blood pressure ( DBP ) of > or= 90 mm Hg . The study compared subjects who received usual medical care  with those who used a computer-controlled telephone system in addition to their usual medical care during a period of 6 months . Weekly , subjects in the telephone group reported self-measured blood pressures , knowledge and adherence to antihypertensive medication regimens , and medication side-effects . This information was sent to their physicians regularly . The main study outcome measures were change in antihypertensive medication adherence , SBP and DBP during 6 months , satisfaction of patient users , perceived utility for physicians , and cost-effectiveness .  The mean age of the study population was 76.0 years ; 77 % were women ; 11 % were black .  Mean antihypertensive medication adherence improved 17.7 % for telephone system users and 11.7 % for controls ( P = .03 ) . Mean DBP decreased 5.2 mm Hg in users compared to 0.8 mm Hg in controls ( P = .02 ) . Among nonadherent subjects , mean DBP decreased 6.0 mm Hg for telephone users , but increased 2.8 mm Hg for controls ( P = .01 ) . For telephone system users , mean DBP decreased more if their medication adherence improved ( P = .03 ) . The majority of telephone system users were satisfied with the system . Most physicians integrated it into their practice s. The system was cost-effective , especially for nonadherent patient users . Therefore , weekly use of an automated telephone system improved medication adherence and blood pressure control in hypertension patients . This system can be used to monitor patients with hypertension or with other chronic diseases , and is likely to improve health outcomes and reduce health services utilization and costs OBJECTIVE To determine whether automated measurement of blood pressure and pulse in a home setting can be easily accomplished by pregnant women with chronic hypertension . STUDY DESIGN In this prospect i ve investigation , seven women with chronic hypertension complicating pregnancy recorded their blood pressure at home twice a day . These data were offloaded once daily into a computer at a remote site , and a computerized printout of these data was received by the physician . RESULTS The patients participated in the study for 12.2 + /- 5.8 weeks ( range 4 to 18 weeks ) and were between 23 and 42 weeks ' gestation .  Average mean arterial pressure in the home was 102 + /- 10 mm Hg , and average pulse was 81 + /- 11 beats per minute . In the clinic , the values were 112 + /- 13 mm Hg and 90 + /- 30 beats per minute ( p < 0.05 ) . Each patient was easily taught how to use the machine . CONCLUSIONS The home blood pressure monitoring device was easy to use and correlated well with values recorded by health professionals for this limited number of subjects . It was particularly helpful to patients ( n = 5 ) who lived long distances ( more than 60 miles ) from the clinic and to women who needed adjustments of antihypertensive medication BACKGROUND African Americans have a higher prevalence and greater severity of hypertension than do other minorities and whites . This fact is particularly problematic when one realizes that the rate of control and treatment of hypertension in the US population is getting worse rather than better . Alternative strategies to promote blood pressure control need to be tested . OBJECTIVES The purpose of this pilot study was to test the following hypothesis : Persons who participate in nurse-managed home telemonitoring ( HT ) plus usual care or who participate in nurse-managed community-based monitoring ( CBM ) plus usual care will have greater improvement in blood pressure from baseline to 3 months ' follow-up than will persons who receive usual care only . METHODS This study used a r and omized controlled design ; participants were r and omly assigned to 1 of 3 groups that were stratified by use or nonuse of antihypertension medication . One-way analysis of variance ( ANOVA ) and analysis of covariance ( ANCOVA ) controlling for age and body weight were used to determine changes in blood pressure from baseline to 3 months . The sample contained 26 African Americans with a mean age of 59 years . RESULTS Both the HT group and the CBM group had clinical ly and statistically significant ( P < .05 ) drops in systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) at 3 months ' follow-up , with participants in the HT group demonstrating the greatest improvement ( HT : baseline SBP 148.8 + /- 13.8 , DBP 90.2 + /- 5.79 ; 3 months ' follow-up SBP 124.1 + /- 13.82 , DBP 75.58 + /- 11.4 ; CBM : baseline SBP 155.25 + /- 17.014 , DBP 89.42 + /- 10.95 ; 3 months ' follow-up SBP 142.3 + /- 12.1 , DBP 78.25 + /- 6.86 ) . There was little change in SBP or DBP at 3 months ' follow-up in the usual care only group . CONCLUSION These are important pilot results , which if replicated in a larger sample will significantly improve care for urban African Americans with hypertension Background Self blood pressure monitoring at home may improve blood pressure control and patients ' compliance with treatment , but its implementation in daily practice faces difficulties . Teletransmission facilities may offer a more efficient approach to long-term home blood pressure monitoring . Methods Twelve general practitioners screened 391 consecutive uncontrolled mild – moderate hypertensive patients ( 80 % treated ) , 329 of whom ( 58 ± 11 years , 54 % men ) were r and omized to either usual care on the basis of office blood pressure ( group A , n = 113 ) or to integrated care on the basis of teletransmitted home blood pressure  ( group B , n = 216 ) . Twenty-four-hour ambulatory blood pressure monitoring  was performed at baseline and after 6 months , during which treatment was optimized according to either office ( group A ) or home ( group B ) blood pressure values . We compared differences between groups in the rate of daytime ambulatory blood pressure normalization ( < 130/80 mmHg ) , need of treatment changes during follow-up , quality of life scores , and healthcare costs . Results Baseline office blood pressures were 149 ± 12/89 ± 9 and 148 ± 13/89 ± 7 mmHg in groups A ( n = 111 ) and B ( n = 187 ) respectively , the corresponding daytime values being 140 ± 11/84 ± 8 and 139 ± 11/84 ± 8 mmHg . The percentage of daytime blood pressure normalization was higher in group B ( 62 % ) than in group A ( 50 % ) ( P < 0.05 ) . There were less frequent treatment changes in group B than in group A ( 9 vs. 14 % , P < 0.05 ) . Quality of life tended to be higher and costs lower in group B. Conclusion Patients ' management based on home blood pressure teletransmission led to a better control of ambulatory blood pressure than with usual care , with a more regular treatment regimen A r and omized controlled trial was conducted to assess the efficacy of a telemedicine service for the diagnosis of essential hypertension . The telemedicine service consisted of using an automatic home blood pressure monitor connected to an ordinary telephone line for the transmission of the data to a central computer . After use of the home monitor for a week , the results were converted to a report form and faxed to the patient 's physician . The gold st and ard for assessment of true hypertension status was 24 h ambulatory blood pressure monitoring . A total of 74 patients from outpatient clinics were r and omized into either the  telemedicine service  or  usual care . Use of the telemedicine service significantly improved the detection of essential hypertension compared with usual care : in the telemedicine group , 64 % of patients with essential hypertension were diagnosed ; in the usual care group , 26 % of patients with essential hypertension were diagnosed . Furthermore , diagnosis occurred earlier in the telemedicine group than in patients receiving usual care .  Specificity and positive predictive value were similar in the two groups Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . We conducted a r and omized controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . In New York City , 98 % of participants were black or Hispanic , 69 % were Medicaid-eligible , and 93 % reported annual household income < or = $ 20,000 . In upstate New York , 91 % were white , 14 % Medicaid eligible , and 50 % reported annual household income < or = $ 20,000 . A baseline survey found that 95 % of participants in New York City and 67 % in upstate New York reported that they did not know how to use a computer . The primary endpoints were HgbA1c , blood pressure , and low density lipoprotein ( LDL ) cholesterol levels . In the intervention group ( N = 844 ) , mean HgbA1c improved over 1 year from 7.35 % to 6.97 % , and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( N = 353 ) . In the usual care group ( N = 821 ) , mean HgbA1c improved over 1 year from 7.42 % to 7.17 % . Adjusted net reductions ( 1-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mmHg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dl ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dl . The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . A satisfaction survey of intervention group participants ( N = 346 respondents ) showed high levels of satisfaction with major intervention components . A satisfaction survey of participating primary care physicians ( N = 116 respondents ) showed positive perceptions for acceptability , impact on patients and communication .  Telemedicine case management  improved glycemic control , blood pressure levels , and total and LDL-cholesterol levels at 1 year of follow-up . Telemedicine is an effective method for translating modern approaches to disease management into effective care for underserved population Although the use of telecommunication systems in medicine has been increasing , few trials have assessed the efficacy of such technology for improving blood pressure in patients with essential hypertension ( 1 , 2 ) . Friedman and colleagues ( 1 ) found that when hypertensive patients used a telephone-linked computer system to report blood pressure , diastolic blood pressure decreased significantly . Bondmass and colleagues ( 2 ) also found a significant decrease in both diastolic and systolic blood pressure , although their trial lacked controls . In these studies and in other trials of home monitoring , self-report of blood pressure was the basic mechanism for transmission of information to physicians ( 1 - 8 ) . This may have consequences for patient care , since it has recently been shown that patients often erroneously report blood pressure , especially patients whose blood pressure is uncontrolled ( 9 ) . Johnson and colleagues ( 9 ) found that in approximately 20 % of instances , self-report of blood pressure differed from the electronic reading by more than 10 mm Hg . Another limitation of previous trials is accurate assessment of the outcome . In some studies , the outcome was determined by one or two blood pressure readings taken during an office visit or by a technician in the home setting ( 1 , 4 - 7 ) . Only one study of 31 patients used  automatic ambulatory blood pressure monitoring ( ABPM )  to assess usual blood pressure at baseline and exit ( 3 ) . Twenty-fourhour ABPM recordings yield a more reliable assessment of usual blood pressure levels during the course of daily activities ( 10 ) . To improve on the previous studies , we design ed a r and omized , controlled trial that used 24-hour ABPM measurements at baseline and at exit to determine change in blood pressure more accurately . The intervention was a service provided to physicians that used electronic transmission of results and did not rely on  self-report of blood pressure . Methods Study Protocol From May 1999 to April 2000 , five internists from the Department of Medicine at the State University of New York Upstate Medical University in Syracuse recruited patients from internal medicine outpatient practice s affiliated with the general medicine division . Out patients seen by these physicians were covered by private insurance plans or Medicare . Eligible patients were adults who had previously received a diagnosis of essential hypertension and were under evaluation for a change in antihypertensive therapy because of 1 ) elevated blood pressure [ systolic pressure 140 or diastolic pressure 90 mm Hg ] despite current antihypertensive therapy , 2 ) undesirable side effects of current antihypertensive medication , or 3 ) office systolic pressure of at least 180 mm Hg or diastolic pressure of at least 110 mm Hg with no current use of antihypertensive medication . For patients with diabetes mellitus , heart disease , stroke , nephropathy , peripheral arterial disease , or hypertensive retinopathy , an office systolic pressure of at least 130 mm Hg or an office diastolic pressure of at least 85 mm Hg was a criterion for eligibility . Patients who were younger than 18 years of age , were pregnant , had secondary hypertension , or did not have the mental or physical capacity to monitor blood pressure at home were excluded . All patients were informed of the study procedures , the risks and benefits of participation , confidentiality , rights , and personnel to contact for additional information . The institutional review board at Upstate Medical University approved the trial , and all patients gave written consent before participation . Patients received printed educational material s on nonpharmacologic approaches to blood pressure  control from the National Heart , Lung , and Blood Institute ( 11 ) . These approaches included reducing weight , increasing physical activity , and changing diet if necessary . At baseline , height and weight were recorded at the clinic for all patients . Body mass index was calculated as kg/m2 . Printed information on the treatment of hypertension from the Sixth Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( National High Blood Pressure Education Program ) ( 12 ) was available at each clinical site as a reference for physicians and clinical staff . Study Group Assignment We conducted a r and omized trial with concurrent controls . The two study groups were home service and usual care .  To ensure an equal number of patients in both study groups , we used a blocking procedure with r and om permuted blocks of varying size to reduce predictability . R and omization was stratified by the number of prescription medications patients were taking ( 0 to 2 or 3 ) at study entry , which served as a general indicator of morbidity . Sequentially numbered , sealed , opaque envelopes were used for assignment . The r and omization procedure was concealed to physicians and clinical research staff , but physicians , investigators , and patients were aware of group assignment when r and omization was complete . In addition , adherence to the protocol was monitored independently of the clinicians . A priori sample size was calculated to detect a mean ( SD ) difference in blood pressure of 3 5 mm Hg between the two study groups . This yielded 60 patients per group with 90 % power ( = 0.05 [ two-tailed ] ) . Intervention The intervention was a telecommunication service consisting of three components : automatic blood pressure recording at home , central processing , and electronic reports provided weekly to the primary physician and patient . We used a home blood pressure monitoring device that transmitted data over analog telephone lines ( Model 52500 , Welch Allyn , Inc. , Skaneateles Falls , New York ) and was vali date d according to the st and ards of the American National St and ard Institute , Inc. , and the Association for the Advancement of Medical Instrumentation ( 13 ) . The oscillometric device ( 16.26 cm 10.92 cm 6.6 cm ) had a digital display for blood pressure and pulse and used automatic pressurization and exhaust for cuff inflation and deflation . Patients were instructed to take their blood pressure three times in the morning before eating or drinking and three times in the evening before going to bed . After each reading , the device automatically dialed the Service and Support Center at Welch Allyn and transmitted the data . Patients were asked to conduct this routine at least three days each week for a minimum of 8 weeks and could take additional readings if they desired . A computer program was developed to display the results in a report form , which was then faxed to each patient 's physician . The report form contained information on the mean systolic pressure , mean diastolic pressure , and heart rate ( overall , morning , and evening ) . It also graphed the pressure by date and displayed individual readings in tabular form . Both physicians and patients received a report form each week , as well as a summary report form at the end of the trial . When physicians received report forms that indicated elevated pressure , they adjusted antihypertensive medications through a telephone call , an office visit , or both . At the time of the trial , the service cost $ 24.95 per month . Patients assigned to usual care were treated for hypertension according to the guidelines of the Joint National Committee on Prevention , Detection , and Treatment of High Blood Pressure ( 12 ) . Question naire Information Information about patients ' medical histories , past diagnoses of disease , and use of medications was obtained from question naires . The Baecke question naire of habitual physical activity was used to assess usual activity levels ( 14 ) . Subscales included a work index , a sports index , and a nonsports leisure index , as well as a total physical activity score . Dietary intake was estimated by using the Block screening question naire , which consists of two subscales : intake of highly saturated fatty foods and intake of fruit , vegetables , and high-fiber grains ( 15 ) . Questions about smoking and stress were taken from the previously vali date d Health Habits and History Question naire ( 16 ) . The study question naire was collected at the time of the second 24-hour ambulatory readings . Outcome Measures The primary end point was the change in mean arterial pressure during the trial ( baseline to exit ) for home service compared with usual care . A clinical research nurse ( the study manager ) fitted participants with a 24-hour ABPM device at baseline and at exit . The nurse gave the patients detailed instructions for using the device . The ABPM device automatically recorded blood pressure every half-hour from 7:00 a.m. to 11:00 p.m. and every hour from 11:00 p.m. to 7:00 a.m. Information from baseline and exit ABPM readings was given to physicians only after the patient exited the trial . All blood pressure measurements indicated in this report refer to these 24-hour readings . Means and SDs were recorded for systolic pressure , diastolic pressure , arterial pressure , and heart rate by using 24-hour ABPM . Mean arterial pressure was measured as ( diastolic pressure + 1/3 [ systolic pressure diastolic pressure ] ) . The ABPM device also recorded the percentage of readings above the desired target levels ( 140 mm Hg systolic or 90 mm Hg diastolic for patients without target organ damage ; 130 mm Hg systolic or 85 mm Hg diastolic for patients with target organ damage ) . Patients were scheduled to remain in the trial for a minimum of 8 weeks . During the sixth and seventh weeks , appointments were made to schedule second 24-hour ABPM sessions . For both the home service and usual care groups , the median time from baseline to exit was 11 weeks . The final patient receiving usual care exited at 20 weeks , and the final patient receiving home service exited at 28 weeks . Statistical Analysis All information was entered into an Excel data base ( Microsoft Corp. , Redmond , Washington ) and was manually rechecked for errors . Statistical analyses were conducted by using STATISTICA software ( Abstract Aims . The purpose of the present study was to compare the costs of  home blood pressure ( BP ) telemonitoring ( HBPM )  with the costs of conventional office BP monitoring . In a r and omized controlled trial , 105 hypertensive patients performed HBPM and 118 patients received usual care with conventional office BP monitoring  during 6 months . Costs were quantified from the healthcare perspective . Non-parametric simulations were performed to quantify the uncertainty around the mean estimates and cost-effectiveness acceptability curves were made . Major findings . Systolic and diastolic daytime and night-time ambulatory BP ( ABP ) were reduced in both groups . The uncertainty around the incremental cost effectiveness ratio point estimates was considerable for both systolic and diastolic ABP . For systolic ABP , the difference in cost effectiveness ratio between the two groups was 256 Danish kroner (DKK)/mmHg [ 95 % uncertainty interval , UI −860 to 4544 ] . For diastolic ABP , the difference in cost effectiveness ratio between the two groups was 655 DKK/mmHg [ 95 % UI −674 to 69315 ] . Medication and consultation costs were lowest in the intervention group , but were offset by the cost of the telemonitoring equipment . Conclusions . Cost-effectiveness analysis showed that telemonitoring of home BP was more costly compared with usual monitoring of office BP . The cost-effectiveness result is surrounded with considerable uncertainty . Trial registration : Clinical Trials.gov identifier : NCT282334 Home blood pressure monitoring ( HBPM ) overcomes many of the limitations of traditional office blood pressure ( BP ) measurement and is both cheaper and easier to perform than ambulatory BP monitoring . Monitors that use the oscillometric method are currently available that are accurate , reliable , easy to use , and relatively inexpensive . An increasing number of patients are using them regularly to check their BP at home , but although this has been endorsed by national and international guidelines , detailed recommendations for their use have been lacking . There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors , which is the BP that best predicts cardiovascular risk . Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect ( the increase of BP during an office visit ) , home readings are more reproducible than office readings and show better correlations with measures of target organ damage . In addition , prospect i ve studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP ( Class IIa ; Level of Evidence A ) . This call-to-action article makes the following recommendations : ( 1 ) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension ; ( 2 ) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to st and ard international protocol s. They should be shown how to use them by their healthcare providers ; ( 3 ) Two to 3 readings should be taken while the subject is resting in the seated position , both in the morning and at night , over a period of 1 week . A total of ≥12 readings are recommended for making clinical decisions ; ( 4 ) HBPM is indicated in patients with newly diagnosed or suspected hypertension , in whom it may distinguish between white-coat and sustained hypertension . If the results are equivocal ,  ambulatory BP  monitoring may help to establish the diagnosis ; ( 5 ) In patients with prehypertension , HBPM may be useful for detecting masked hypertension ; ( 6 ) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence ; ( 7 ) The target HBPM goal for treatment is < 135/85 mm Hg or < 130/80 mm Hg in high-risk patients ; ( 8) HBPM is useful in the elderly , in whom both BP variability and the white-coat effect are increased ; ( 9 ) HBPM is of value in patients with diabetes , in whom tight BP control is of paramount importance ; ( 10 ) Other population s in whom HBPM may be beneficial include pregnant women , children , and patients with kidney disease ; and ( 11 ) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed BACKGROUND The Take Control of Your Blood Pressure trial evaluated the effect of a multicomponent telephonic behavioral lifestyle intervention , patient self-monitoring , and both interventions combined compared with usual care on reducing systolic blood pressure during 24 months . The combined intervention led to a significant reduction in systolic blood pressure compared with usual care alone . We examined direct and patient time costs associated with each intervention . METHODS We conducted a prospect i ve economic evaluation alongside a r and omized controlled trial of 636 patients with hypertension participating in the study interventions .  Medical costs were estimated using electronic data representing medical services delivered within the health system . Intervention-related costs were derived using information collected during the trial , administrative records , and published unit costs . RESULTS During 24 months , patients incurred a mean of $ 6,965 ( s.d . , $ 22,054 ) in inpatient costs and $ 8,676 ( s.d . , $ 9,368 ) in outpatient costs , with no significant differences among the intervention groups . With base-case assumptions , intervention costs were estimated at $ 90 ( s.d . , $ 2 ) for home blood pressure monitoring , $ 345 ( s.d . , $ 64 ) for the behavioral intervention ( $ 31 per telephone encounter ) , and $ 416 ( s.d . , $ 93 ) for the combined intervention . Patient time costs were estimated at $ 585 ( s.d . , $ 487 ) for home monitoring , $ 55 ( s.d . , $ 16 ) for the behavioral intervention , and $ 741 ( s.d . , $ 529 ) for the combined intervention . CONCLUSIONS Our analysis demonstrated that the interventions are cost-additive to the health-care system in the short term and that patients ' time costs are nontrivial
target: TC led to a greater decrease in systolic and diastolic BP  than UC .
  The differences between TC and UC for systolic BP tend to become larger when no treatment modification is applied .
  TC seems a valuable tool for hypertension management
background: There is an increasing interest for using telecare(TC ) in the management of hypertension .