Feasibility of Emergency Department–initiated, Mobile Health Blood Pressure Intervention: An Exploratory, Randomized Clinical Trial

BACKGROUND Elevated blood pressure (BP) is pervasive among patients that visit emergency departments (EDs) for their care. METHODS In this review article, we outline the current approach to the management of these individuals and highlight the crucial role emergency medicine clinicians play in reducing the morbidity associated with elevated BP. RESULTS We highlight the critical importance of immediate treatment when elevated BP contributes to new or worsening end-organ injury but emphasize that such hypertensive emergencies are rare. For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe. Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system. To address this, we present novel perspectives that envision a new role for emergency medicine in chronic hypertension management—one that acknowledges the significant population-level gaps in BP control that contribute to disparities in cardiovascular disease and sets the stage for future changes in systems-based practice. CONCLUSIONS Emergency medicine plays a key and evolving role in reducing morbidity associated with elevated BP.

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“… 55 Additional resources include mobile health follow-up and engagement, home BP monitor, and community health workers. 40 , 59–61 …”

Section: Nonemergent Hypertensionmentioning

confidence: 99%

Hypertension Management in Emergency Departments

Miller

McNaughton

Joyce

et al. 2020

American Journal of Hypertension

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“…We conducted a pilot feasibility trial of the healthy behavior text messaging and weekly prompted BP self-monitoring in the University of Michigan ED. [12] In this study, we created real-time automated alerts using the EHR to identify potentially eligible participants and procedures for recruitment of ED patients. Real-time automated EHR alerts were set to identify patients with systolic BP ≥ 160 mmHG or diastolic BP ≥ 100 mmHG.…”

Section: Existing and Preliminary Datamentioning

confidence: 99%

Reach Out Behavioral Intervention for Hypertension Initiated in the Emergency Department Connecting Multiple Health Systems: Study Protocol for a Randomized Control Trial

Meurer

Dinh

Kidwell

et al. 2020

Preprint

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Background: Hypertension is the most important modifiable risk factor for cardiovascular disease, the leading cause of mortality in the United States. The Emergency Department represents an underutilized opportunity to impact difficult-to-reach populations. There are 136 million visits to the Emergency Department each year and nearly all have at least one blood pressure measured and recorded. Additionally, an increasing number of African Americans and socioeconomically disadvantaged patients are overrepresented in the Emergency Department patient population. In the age of electronic health records and mobile health, the Emergency Department has the potential to become an integral partner in chronic disease management. The electronic health records in conjunction with mobile health behavior interventions can be leveraged to identify hypertensive patients to impact otherwise unreached populations. Methods: Reach Out is a factorial trial studying multicomponent, behavioral interventions to reduce blood pressure in the Emergency Department patient population. Potential participants are identified by automated alerts from the electronic health record and, following consent, receive a blood pressure cuff to take home. During the initial screening phase, they are prompted to submit weekly blood pressure readings. Responders with persistent hypertension are then randomized into one of three component arms, consisting of varying intensity levels: (1) healthy behavior text messaging (daily vs. none), (2) blood pressure self-monitoring (daily vs. weekly), and (3) facilitated primary care provider appointment scheduling and transportation (yes vs. no). If participants are randomized to receive facilitated primary care provider appointment scheduling and are not established with a primary care provider, care will be established at a local Federally Qualified Health Center. Participants are followed for twelve-months. Discussion: The Reach Out study is designed to determine which behavioral intervention components or ‘dose’ of components contributes to a reduction in systolic blood pressure after one year (Aim 1). The study will also assess the effect of primary care provider appointment assistance on total primary care follow-up visits of hypertensive patients treated in an urban, safety net Emergency Department (Aim 2). Ideally, the Reach Out system will contribute to hypertension management, serving as a model for safety net hospitals and Federally Qualified Health Centers to improve chronic disease management in underserved communities. Trial Registration: This study was registered at clinicaltrials.gov, identifier NCT03422718. The record was first available to the public on 01/30/2018 prior to the enrollment of patients on 03/25/2019. KEYWORDS Hypertension, Emergency Medicine, Randomized Clinical Trial, Multiphase Optimization Strategy

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“…However, the impact of automated texting on BP targets is less clear, with mixed evidence about its effectiveness. Randomized trials suggest no effect of automated texting on achieving target BP [ 12 , 13 ], while other evidence suggests varying degrees of benefit [ 14 , 15 ].…”

Section: Introductionmentioning

confidence: 99%

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study

Davoudi¹,

Lee²,

Chivers³

et al. 2020

J Med Internet Res

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Background Automated texting platforms have emerged as a tool to facilitate communication between patients and health care providers with variable effects on achieving target blood pressure (BP). Understanding differences in the way patients interact with these communication platforms can inform their use and design for hypertension management. Objective Our primary aim was to explore the unique phenotypes of patient interactions with an automated text messaging platform for BP monitoring. Our secondary aim was to estimate associations between interaction phenotypes and BP control. Methods This study was a secondary analysis of data from a randomized controlled trial for adults with poorly controlled hypertension. A total of 201 patients with established primary care were assigned to the automated texting platform; messages exchanged throughout the 4-month program were analyzed. We used the k-means clustering algorithm to characterize two different interaction phenotypes: program conformity and engagement style. First, we identified unique clusters signifying differences in program conformity based on the frequency over time of error alerts, which were generated to patients when they deviated from the requested text message format (eg, ###/## for BP). Second, we explored overall engagement styles, defined by error alerts and responsiveness to text prompts, unprompted messages, and word count averages. Finally, we applied the chi-square test to identify associations between each interaction phenotype and achieving the target BP. Results We observed 3 categories of program conformity based on their frequency of error alerts: those who immediately and consistently submitted texts without system errors (perfect users, 51/201), those who did so after an initial learning period (adaptive users, 66/201), and those who consistently submitted messages generating errors to the platform (nonadaptive users, 38/201). Next, we observed 3 categories of engagement style: the enthusiast, who tended to submit unprompted messages with high word counts (17/155); the student, who inconsistently engaged (35/155); and the minimalist, who engaged only when prompted (103/155). Of all 6 phenotypes, we observed a statistically significant association between patients demonstrating the minimalist communication style (high adherence, few unprompted messages, limited information sharing) and achieving target BP (P<.001). Conclusions We identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

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Feasibility of Emergency Department–initiated, Mobile Health Blood Pressure Intervention: An Exploratory, Randomized Clinical Trial

Cited by 20 publications

References 26 publications

Hypertension Management in Emergency Departments

Hypertension Management in Emergency Departments

Reach Out Behavioral Intervention for Hypertension Initiated in the Emergency Department Connecting Multiple Health Systems: Study Protocol for a Randomized Control Trial

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study

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