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Digital interventions, defined as any intervention accessed and taking input from patients in the form of a computer/Web-based program or mobile phoned-based app, can potentially help empower patients to self-manage long-term conditions such as hypertension. Importantly, digital interventions have the potential to provide patients with personalized information and support for active involvement in treatment as well as cost saving.
The purpose of this systematic review is to synthesize the evidence for using digital interventions to support patient self-management of hypertension, and determine their impact on control and reduction of blood pressure, other clinical outcomes, quality of life, medication adherence, health service utilization, and economic benefits.
A systematic search of bibliographic databases including Medline, Embase, CINAHL, and PsycINFO will be undertaken. Abstracts and citations will be independently screened by 2 researchers against predetermined inclusion criteria. Any disagreements will be resolved by discussion and further consideration of the inclusion criteria. Only randomized controlled trials which have been published in peer peer-reviewed journals with a diagnosis of hypertension will be considered. Inclusion criteria will be (1) adults (age ≥ 18 years) with hypertension (as defined by the primary authors); (2) an interactive digital intervention compared with usual care; and (3) outcomes of objectively measured change in blood pressure. Data extraction from identified articles will be undertaken by 2 independent reviewers using a uniform template. The main outcomes are systolic blood pressure (SBP) and diastolic blood pressure (DBP), and quality of life indicators. Secondary outcomes include cost- effectiveness, medication adherence, emotional well-being, and physical activity. Risk of bias of included studies will be assessed using the Cochrane tool.
Our research is currently ongoing. Data will be summarized narratively, and if possible, meta-analyses will be performed to assess the impact of the interventions on outcomes.
By summarizing and synthesizing available data, this review will help inform policy on the use of digital interventions for self-management of hypertension and will clarify areas for further research.
Prospero 2014: CRD42014010268; http://www.crd.york.ac.uk/PROSPERO/display_record.asp? ID=CRD42014010268 (Archived by WebCite at http://www.webcitation.org/6c5alQQJL)
Hypertension has been shown to be the highest attributable risk to death from cardiovascular disease, which is the leading cause of premature mortality worldwide [
The success of blood pressure management depends, to a large degree, on the willingness and ability of the patient to change and maintain certain behaviors and adhere to medication regimens [
One potential method for improving self-management is through the use of interactive digital interventions, which offer the possibility of empowering patients to self-manage their long-term conditions, and by providing patients with better access to personalized information and support for active involvement in treatment, as well as producing significant savings in treatment costs [
Examining the effect of interactive digital interventions in comparison to usual care is important as there is evidence that successful implementation depends on clearly demonstrating their benefits and cost effectiveness to clinicians [
The term “digital intervention” can relate to a number of different types of intervention. For the purpose of this review it will include any intervention accessed through a computer (work or home), mobile phone, or other handheld devices, and include a Web-based program, desktop computer program, or apps that provide self-management information. Intervention participants may input information online or offline through the particular device used. The intervention must function without any directive input from health professionals, and be “interactive” in nature. We define “interactive” as requiring contributions from program users (eg, entering personal data and making choices) that alter pathways within the program to produce tailored material and feedback [
For the purposes of the review, we define a self-management support intervention as the care taken by individuals toward their own health and well-being comprised by the actions they take (1) to lead a healthy lifestyle, (2) to meet their social, emotional, and psychological needs, (3) to care for their long-term condition, and (4) to prevent further illness or accidents [
Inclusion criteria, based on participants, interventions, comparisons, outcomes, and study design (PICOS acronym) [
Searches will be undertaken by a professional systematic review company (York Health Economic Consortium). The search strategy is shown in
The search strategy will combine the following concepts and study-type filter: (1) hypertension, (2) digital intervention, (3) self-management, and (4) RCTs.
Search terms for the intervention concept were informed by those used in a previous systematic review conducted on digital asthma self-management interventions [
Relevant studies will be ascertained by screening using Distiller software [
Types of primary outcome measures.
Outcome measure description | Primary outcome | Secondary outcome |
Clinical | Mean systolic and diastolic blood pressure |
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|
Quality of life indicators |
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Cognitive |
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Self-efficacy |
Behavioural |
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Medication adherence |
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|
Dietary change |
|
|
Physical activity |
|
|
Alcohol intake |
Affective |
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Depression |
|
|
Anxiety |
|
|
Emotional well-being |
|
|
Satisfaction with care |
Economic |
|
Health service utilization |
|
|
Costs of intervention |
Studies that meet the inclusion criteria will be screened in full by 2 reviewers working independently to extract relevant population, intervention, and outcome data using the Distiller software [
Risk of bias will be assessed in each of the included studies by the 2 researchers working independently using the Cochrane collaboration tool for assessing bias [
Details of the populations studied and each intervention will be presented in a table format describing patient and intervention characteristics. We will conduct a narrative synthesis describing, where possible, the components of the interventions including theoretical underpinning, what the mode of delivery was (eg, mobile phone, tablet, personal computer, or Web-based facilitation), how the information was uploaded (online/offline) and where (home/work/other), how ongoing engagement was encouraged, and how often it was used.
Where possible and appropriate we will undertake a meta-analysis that will compare changes between intervention and control participants in outcomes for which adequate data from a minimum of 3 studies are available. We will pool the data for each outcome using mean differences for continuous outcomes and relative risks for dichotomous outcomes. Studies of self-monitoring in hypertension have shown significant heterogeneity and so it is likely that that a random effects model will be required. This decision will be made following estimation of heterogeneity using the
Any subgroup analyses undertaken will be defined a priori. If the data permit, we will undertake the following subgroup analyses: (1) interventions that included self-monitoring of blood pressure versus those that did not, (2) mode of delivery (mobile phone versus other), and (3) primary goal of the intervention (reduction of blood pressure versus any other).
Our research is currently ongoing. Data will be summarized narratively and, if possible, meta-analyses will be performed to assess the impact of intervention on outcomes. The aim is to have all the results completed, written, and published by the beginning of 2016.
This review and proposed meta-analysis are part of a study aiming to investigate the best way of providing people with an interactive digital intervention for hypertension that can help them self-manage their health condition, with support as needed from health care professionals. It is thus important to assess previous research on digital interventions to support patient self-management of hypertension and assess the effects, if any, on control and reduction of blood pressure, other clinical outcomes, quality of life, medication adherence, health service utilization, and health care costs. The results of this review will aid our understanding of current knowledge in relation to the utility of digital self-management interventions for hypertension and identify important research gaps.
Search strategy for Ovid Medline(R) in-process and other non-indexed citations and Ovid Medline(R): 1946 to present.
blood pressure
diastolic blood pressure
randomized controlled trial
systolic blood pressure
This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-1211-20001). The views expressed in this study are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. NHS Solent is the grant host. We would like to acknowledge all members of the DIPSS investigator team including Bryan Williams, Susan Michie, Carl R May, Peter Smith, Mark Weal, Adam Geraghty, James Raftery, Lily Yao, Rebecca Kandiyali, Bob Gann, Tony Snell, Sarah WiIliams, Keith Manship, Shelley Mason, and Katharine Jenner.
All authors drafted, read, and approved the manuscript.
None declared.