The Role of Telemedicine in Hypertension Management: Focus on Blood Pressure Telemonitoring

Abstract

This review aims at updating and critically assessing the role of telemedicine, and in particular, of home blood pressure telemonitoring (HBPT), in the management of the hypertensive patient. Result from several randomized trials suggest that HBPT represents a promising tool for improving blood pressure (BP) control of hypertensive patients, in particular, those at high risk. Most studies documented a significant BP reduction with regular HBPT compared to usual care. HBPT interventions showed a very high degree of acceptance by patients, helped improving the patients' quality of life, and were associated with lower medical costs than standard care, even though such costs were offset by those of the technology, thus reducing the overall cost-effectiveness of HBPT. The high heterogeneity of the technologies, study designs, and type of patients in the various studies suggest that further well-designed, large cohort, prospective studies are needed to identify key elements of HBPT approach to be able to give impact on specific outcomes. Likely, patients who need a constant monitoring of multiple vital signs and a tight BP control, such as high risk patients with chronic diseases (ischemic heart disease or heart failure, diabetes, etc.), as well as non-adherent patients, may particularly benefit from HBPT. In general, HBPT can be an advantageous choice when a network among healthcare professionals (doctors, nurses, and pharmacists) is needed to improve the screening and management of hypertension and related comorbidities and to achieve an effective prevention of cardiovascular diseases in the community.

Full text

1 23
Current Hypertension Reports
ISSN 1522-6417
Volume 17
Number 4
Curr Hypertens Rep (2015) 17:1-13
DOI 10.1007/s11906-015-0535-3
The Role of Telemedicine in Hypertension
Management: Focus on Blood Pressure
Telemonitoring
Stefano Omboni & Rossella Ferrari

1 23
Your article is protected by copyright and all
rights are held exclusively by Springer Science
+Business Media New York. This e-offprint is
for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at link.springer.com”.

BLOOD PRESSURE MONITORING AND MANAGEMENT (J COCKCROFT, SECTION EDITOR)
The Role of Telemedicine in Hypertension Management: Focus
on Blood Pressure Telemonitoring
Stefano Omboni &Rossella Ferrari
#Springer Science+Business Media New York 2015
Abstract This review aims at updating and critically
assessing the role of telemedicine, and in particular, of home
blood pressure telemonitoring (HBPT), in the management of
the hypertensive patient. Result from several randomized trials
suggest that HBPT represents a promising tool for improving
blood pressure (BP) control of hypertensive patients, in par-
ticular, those at high risk. Most studies documented a signifi-
cant BP reduction with regular HBPT compared to usual care.
HBPT interventions showed a very high degree of acceptance
by patients, helped improving the patients’quality of life, and
were associated with lower medical costs than standard care,
even though such costs were offset by those of the technology,
thus reducing the overall cost-effectiveness of HBPT. The
high heterogeneity of the technologies, study designs, and
type of patients in the various studies suggest that further
well-designed, large cohort, prospective studies are needed
to identify key elements of HBPT approach to be able to give
impact on specific outcomes. Likely, patients who need a con-
stant monitoring of multiple vital signs and a tight BP control,
such as high risk patients with chronic diseases (ischemic
heart disease or heart failure, diabetes, etc.), as well as non-
adherent patients, may particularly benefit from HBPT. In
general, HBPT can be an advantageous choice when a net-
work among healthcare professionals (doctors, nurses, and
pharmacists) is needed to improve the screening and manage-
ment of hypertension and related comorbidities and to achieve
an effective prevention of cardiovascular diseases in the
community.
Keywords Tele medi cine .Hypertension .Home blood
pressure monitoring .Home blood pressure telemonitoring .
Quality of life .Healthcare costs
Introduction
The term telemedicine commonly refers to the use of medical
information exchanged from one site to another via electronic
communications in order to improve a patient’s clinical health
status. Formally, telemedicine includes a growing variety of
applications and services using two-way video, phone calls, e-
mail, the Internet, smart phones, wireless tools, and other
forms of telecommunications technology [1].
Telemedicine was first introduced in hospitals approxi-
mately 40 years ago, with the aim of extending care to patients
in remote areas, and since then, its use has spread rapidly.
Although poor implementation, low reimbursement levels,
and lack of physician support have represented and still rep-
resent important barriers slowing down diffusion of telemed-
icine in daily practice, this tool is becoming an integral part of
healthcare, being more and more often integrated into the
ongoing operations of hospitals, specialty departments, home
health agencies, private physician offices as well as con-
sumers’homes and workplaces. According to the most recent
survey from HIS technologies, the number of patients using
telemedicine services is projected to reach 7 million in 2018,
from less than 350,000 in 2013 [2].
Telemedicine positively affects all branches of medicine
offering to healthcare professionals and patients a tool for
improving disease management. For this reason, more and
more often telemedicine has become synonymous of
telehealth, a definition encompassing a wide range of remote
healthcare services. Patient consultations via video
This article is part of the Topical Collection on Blood Pressure
Monitoring and Management
S. Omboni (*):R. Ferrari
Clinical Research Unit, Italian Institute of Telemedicine,
Via Colombera 29, 21048 Solbiate Arno, Varese, Italy
e-mail: stefano.omboni@iitelemed.org
Curr Hypertens Rep (2015) 17:21
DOI 10.1007/s11906-015-0535-3
Author's personal copy

conferencing, transmission of still images, website for pa-
tients, remote monitoring of vital signs (so-called
telemonitoring), continuing medical education, consumer-
focused wireless applications, and nursing call centers, among
other applications, are all considered part of telehealth [1].
At variance from health information technology, which
more commonly pertains to electronic medical records and
related information systems, telemedicine refers to the actual
delivery of remote clinical services using information technol-
ogy. A branch or specific application of telemedicine is repre-
sented by telemonitoring, defined as the use of information
technology to monitor patients at a distance.
Telemonitoring allows remote data transmission of main
vital [e.g., blood pressure (BP) and heart rate] and non-vital
parameters, from the patient’s living site to the doctor’soffice.
It is a technology applying particularly well to patients with
chronic illnesses or conditions, such as arterial hypertension,
diabetes, chronic obstructive pulmonary disease, heart failure,
etc.
Specifically considering arterial hypertension, a
telemonitoring application which is becoming more and more
popular among doctors and their patients is the home blood
pressure telemonitoring (HBPT), which is based on electronic
automated BP monitors storing and forwarding BP readings to
a remote computer where they are reviewed by the referring
physician for treatment adjustments [3].
In this review, we aim to update the reader on the role of
telemedicine in hypertension management, focusing in partic-
ular on the recent data regarding the clinical efficacy of HBPT
interventions compared to usual care.
Telemedicine Technologies and Services for Hypertension
Management
During the recent years, growing interest regarding the impact
of telemedicine in reducing the burden of chronic cardiovas-
cular diseases led to an increasing number of randomized as
well as pragmatic trials aimed at evaluating the clinical effec-
tiveness of telemedicine for the primary and secondary pre-
vention of cardiovascular diseases [4•,5]. A particular focus
on telemedicine is being dedicated to arterial hypertension due
to the burden of suboptimal BP: telemedicine may represent a
useful tool to improve BP control and reduce the long-term
social costs related to increased frequency of cardiovascular
events when hypertension is not controlled, both in terms of
clinical outcomes and increased social and healthcare costs.
As a matter of fact, suboptimal BP cost 370 billion US dollars
(approximately 282 billion euros) globally in 2001; this rep-
resents about 10 % of the world’s overall healthcare expendi-
tures. It has been estimated that over a 10-year period, high BP
may cost nearly 1 trillion US dollars (762 trillion euros) glob-
ally in health spending, if current BP levels persist. Indirect
costs could be as high as 3.6 trillion US dollars annually (274
trillion euros) [6]. Nowadays, the technological outbreaks
have made available several different tools which can be used
to deliver services to both healthcare professionals and hyper-
tensive patients through telemedicine, by creating a healthcare
network centered around the patient. Some of the most com-
mon services currently provided to hypertensive patients and
doctors are listed in Table 1.
The availability of high-speed normal landlines and the
Internet represents a unique opportunity for easily creating
networks between hospitals and community health centers in
rural or suburban areas, without the need of expensive ad hoc
technologies. Live interactivevideoorstoreandforward
transmission of diagnostic images, vital signs, and/or video
clips along with patient data may be used by the primary care
physician in order to allow a consultation with a patient or
a specialist assisting the primary care physician in render-
ing a diagnosis. Web-based monitoring centers may be
used for monitoring patients’vital signs, such as BP, heart
rate, respiratory function, and adherence to antihyperten-
sive therapy at home or providing them care services.
Tools for remote patient’s BP or other vital sign monitor-
ing at home, supplemented by visiting nurses and tele-
phone calls, may be used to remotely collect and send
data to a home health agency or a remote diagnostic test-
ing facility for interpretation and distribution to the refer-
ring physicians. Point-to-point connections using private
high speed networks may be required by hospitals and
clinics in order to deliver dedicated services to other hos-
pitals and to outsource specialty services or independent
medical service providers. Web-based e-health patient ser-
vice sites may provide direct consumer outreach services
over the Internet and may be used to forward medical and
health information to the patients and to promote on-line
discussion groups, providing peer-to-peer support. Finally,
telemedicine may be used to supply medical education and
update to physicians in charge of hypertension manage-
ment and to organize online medical education seminars
for targeted groups in remote locations.
Tab l e 1 Typical services which can be provided to healthcare
professionals and hypertensive patients through telemedicine
•Electronic health records
•Remote consultation and diagnosis (via videoconference)
•Monitoring of health parameters (e.g., blood pressure)
•Monitoring of patient’s adherence to treatment
•Transmission of diagnostic images
•Web-based health information (interactive education programs on
lifestyle and behavior) and on-line discussion groups for patients
•Continuing medical education for healthcare professionals
21 Page 2 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

Advantages and Benefits of Telemedicine in Hypertension
Management
The application of telemedicine to hypertension care brings
several important advantages, which are shared with many
other chronic conditions currently managed through telemed-
icine technologies (Table 2)[7,8]. A main advantage of tele-
medicine is to establish and build an enduring and long-term
relationship with patients, a particularly important feature in
case of hypertension, a lifetime condition needing continuous
medical supervision. More in general, the use of telemedicine
may help empowering hypertensive patients, influencing their
attitudes and behaviors, and improving their medical condi-
tion. Telemedicine allows physicians and health facilities to
expand their reach, beyond their own offices, and to easily
provide service to an increased number of patients, in both
rural and urban areas. With telemedicine much of the current
time demands on physician could be eliminated because care
may be the net result of shared management between patients
and doctors. The number of patients served by a single phy-
sician may thus be consistently raised. Increased doctor-
patient contact entails increased awareness about patient’s
needs and medical history, thereby expanding the access to
health facilities for hypertension screening and detection,
and providing continuous and superior care with reduced
costs. Although some observers fear that telemedicine may
minimize the patient–physician relationship, increasing the
risk that the hypertensive patients, after a period of acquain-
tance to technologies, may self-manage their condition, this
seems to be unlikely. Instead, telemedicine can reinforce and
empower the physician-patient relationship, may even try to
individualize it, and thus improve BP and cardiovascular risk
control. As a matter of fact, clinicians might be able to spend
more time with the patients who need them most and may
benefit of a diagnostic support by expert colleagues even in
absence of specific knowledge on the disease management
[9].
Although many are convinced that remote patient’sman-
agement through information technology may reduce the
quality of the delivered care, there is strong evidence that the
quality of healthcare services provided via telemedicine to
hypertensive patients is as good as that given in traditional
in-person consultations [4•]. Telemedicine allows hyperten-
sive patients to easily and rapidly communicate to their doc-
tors the occurrence of acute symptoms or sudden BP raises. It
also enhances the monitoring, tracking, and communication of
various biometric information, as we will discuss later in this
paper, enabling greater engagement and partnership in their
care, and reducing the patient stress. Telemedicine services
offer hypertensive patients the access to diagnostic procedures
(e.g., ambulatory BP or ECG monitoring) that might not be
available otherwise, without the need to travel long distances.
In fact, there is established evidence that demand of telemed-
icine is increased among patients, their family and their com-
munity. And many studies have documented patient satisfac-
tion and support for telemedicine services, particularly those
based on mobile technologies [10].
In the case of hypertensive patients, mobile health technol-
ogies may provide a more flexible platform to enhance patient
self-care activities, which can play a major role in achieving
good BP control. As a matter of fact other electronic health
systems like those requiring wired connections and a personal
computer, and an Internet access may reduce access for many
older patients, as discussed later [11].
Home Blood Pressure Telemonitoring
As mentioned above, HBPT is a particular application of tele-
medicine. Basically, it consists in a process of automatic BP
data transmission from the patient’s home to the doctor’sof-
fice or to a clinic. HBPT is generally based on the use of
electronic automated upper arm or wrist BP monitors storing
BP values obtained at patient’s home. Several systems are
available on the market, which are characterized by the differ-
ent modalities of data collection, transmission and reporting,
and by additional features such as reminding facilities for BP
measurement to be performed and/or for medication intake,
and automatic data reporting. Among the available technolo-
gies, wireless systems, at present mostly based on bluetooth or
near field communication technology, seem to be particularly
promising because they are user-friendly and not limited by
the patient’s appliances: they also minimize disruption due to
additional wiring. Such technologies allow linking the medi-
cal devices to interfaces with built-in mobile telephone-based
transmission systems (e.g., smartphones or tablets) or to Wi-Fi
access points more and more often available in many users’
dwellings. Data are then forwarded to a remote computer
Tabl e 2 Advantages of telemedicine in the hypertension management
•Establishment of a tight relationship between the patient and the
referring physician
•Empowerment and reinforcement of the physician-patient relationship
•Possibility for the physician to reach underserved areas and their
population
•Increase in the number of patients to be served
•Reduction in travel time and related stresses for the patient
•Assessment of data in real time
•Acceleration of the delivery of best practice
•Improvement in the quality of care and in the health outcomes
•Potential cost efficiency: long-term reduction of social and healthcare
expenditure
•Access to medical services or diagnostic procedures not available
otherwise
Curr Hypertens Rep (2015) 17:21 Page 3 of 13 21
Author's personal copy

(server) of the telemedicine provider through a telephone line
(wired or wireless), by a modem or an acoustic coupling sys-
tem, or, as done in most of the more recent systems, through
the Internet. Data transmission is usually achieved through a
landline broadband or cellular network and security is ensured
by encryption protocols (S-HTTP or S-FTP). When data are
received at the central telemedicine server they are stored and
automatically analyzed. Reports are generated, including
graphic display of time variations in the monitored parameters
and their averages over the recording period. Case managers
may review the data before they are presented to the reporting
physician and interact with the patient. At the end of this
process, a medical report is forwarded to the patient and refer-
ring primary physician through a website, via e-mail or
through dedicated smartphone apps (Fig. 1)[3].
HBPT shares the same advantage of home self-BP moni-
toring: the lack of alarm reaction during the measurement and
the potential to obtain several reproducible BP measurements
over several days under daily-life conditions. Moreover,
HBPT has additional advantages for patients and doctors; in
particular, HBPT encompasses the assessment of data in real
time and the accelerated delivery of best practice when com-
bined to decision-making strategies [12]. A list of the main
advantages of HBPT is summarized in Table 3[3,13]
Feasibility and User Acceptability of Home Blood
Pressure Telemonitoring
Making services usable and acceptable by patients is vital if
telemedicine technologies and services are to be taken up and
to be successful in practice. Interestingly, HBPT seems to be
well accepted by hypertensive patients. In most studies, pa-
tients showed a high degree of adherence to telemonitoring
programs and a regular use of these technologies, probably
Fig. 1 Example of a typical
home blood pressure
telemonitoring system. S-FTP
Secure File Transfer Protocol,
S-HTTP Secure Hyper Text
Transfer Protocol
Tab l e 3 Advantages of the combination of home blood pressure
monitoring with the data teletransmission for patients and doctors
Advantages of HBPT
•No alarm reaction to blood pressure measurement
•Several and highly reproducible blood pressure measurements over time
•Evaluation of blood pressure during daily life
Advantages of HBPT for patients
•Active patient’s involvement in the disease management (particularly
important for critically ill patients)
•Increase in patient’s compliance to treatment
•Reduced visits and costs of management
•Optimization of therapy
•Better individual blood pressure level estimation and control
Advantages of HBPT for doctors
•Teletransmission of blood pressure readings with feedback to ensure a
quick update of doctor on patient’s health status
•Strict patient’smonitoring
•Centralized automatic analysis (no need of local software or specific
computer skills)
•Detailed medical report
•Active support to medical decision
•Saving of doctor’stime
•Simplification of the doctors’intervention
•Promotion of counselling between general practitioners and specialists,
and more in general healthcare operators (including community
pharmacists)
21 Page 4 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

because of the greater predisposition of hypertensive patients
to use electronic BP monitors at home. The studies showed
also a very high degree of acceptance of these techniques by
patients. A summary of the main studies currently available on
such aspects of HBPT is reported in Table 4.
Such a positive feedback from patients on the use of HBPT
services is mostly related to the recent technological advances,
and in particular on the release of mobile systems, which
turned into practical benefits such as ease to use, reliability,
and improved human–technology interactions. However, to
allow uptake of telemedicine technologies, some of the cur-
rent barriers need to be overcome in the future and the systems
should have basic requirements as those proposed in Table 5.
People should easily interact with and easily configure the
devices and software according to their own needs: the impor-
tance of such feature has been highlighted in the IDEATel
Study [30], which was based on a rather old technology. In
this study, many participants found learning how to use the
computer challenging and support was needed in many cases.
This was consistent with the very low level of computer liter-
acy and educational status of the study population, which is
common to most long-term longitudinal studies. Advances in
mobile health technology for telemonitoring had developed
more versatile products and flexible enough to easily support
self patient management of the facility. Most studies on hy-
pertensive patients with such technologies have shown im-
provements in system usability and acceptability [15,16,19,
22,23,29].
The selection of educated patient groups and pre-set in-
structions may all be key success factors to improve ability
to HBPT. Given that the patients with a chronic disease
targeted in home telemonitoring applications do not all have
the same level of technological skill and education, the same
professional constraints, or the same lifestyle, and that some
may have a slight visual or motor deficit, it would be prefer-
able for application providers to ensure that patients have the
technological device best suited to their specific needs [31].
A recent qualitative study has attempted to identify factors
facilitating or hindering the effectiveness of HBPT and those
influencing its potential translation to routine practice [32].
The study enrolled 25 high risk hypertensive patients in 6
primary care practices. Patients were asked to use a system
made-up of a validated electronic home BP monitor and a
mobile phone used to transfer the BP readings via SMS to a
secure website accessible to the user and their doctor or nurse.
The BP monitor was linked to the mobile phone wirelessly,
via bluetooth. Both patients and clinicians considered that a
BP measurement based on the average of multiple readings
Tabl e 4 Degree of adherence to the HBPT program and acceptance of the technology by patients enrolled in different trials
Author, year [ref.] Transmission type No. of patients Type of hypertensive patients Adherence to HBPT (%)
Denolle, 1999 [3] Telephone 55 Pregnancy 90
Bondmass, 2000 [3] Telephone 33 Uncomplicated 88
Artinian, 2001 [14] Telephone 26 Uncomplicated 67
Omboni, 2004 [3] Telephone 195 Uncomplicated 90
Scherr, 2006 [15] Mobile phone 20 Cardiac decompensation 83
Bobrie, 2007 [16] Mobile phone 33 Diabetes 83
McCant, 2009 [17] Telephone 441 Uncomplicated 75
Wakefield, 2011 [18] Telephone 195 Diabetes 70
Logan, 2012 [19] Mobile phone 55 Diabetes 65
Kerby, 2012 [20] Telephone 213 Uncomplicated 73
Kerry, 2013 [21] Telephone (vocal) 168 Stroke 48
McKinstry, 2013 [22] Mobile phone 200 Uncomplicated 89
Rifkin, 2013 [23] Mobile phone 28 Chronic kidney disease 78
Author, year [ref.] Transmission type No. of patients Type of hypertensive patients Acceptance of the technology (%)
Friedman, 1996 [24] Telephone (vocal) 276 Uncomplicated 69
Rogers, 2001 [25] Telephone 121 Uncomplicated 96
Omboni, 2004 [3] Telephone 195 Uncomplicated 96
Scherr, 2006 [15] Mobile phone 20 Cardiac decompensation 100
Bobrie, 2007 [16] Mobile phone 33 Diabetes 81
Logan, 2007 [26] Telephone 22 Diabetes, pneumopathy, cardiopathy 73
Santamore, 2008 [27] Internet 161 High risk patients 92
McManus, 2010 [28] Telephone 234 Uncomplicated 71
Neumann, 2011 [29] Mobile phone 30 Uncomplicated 97
Rifkin, 2013 [23] Mobile phone 28 Chronic kidney disease 96
Curr Hypertens Rep (2015) 17:21 Page 5 of 13 21
Author's personal copy

from HBPT system was trustworthy and could be used in
usual care settings. The technology increased patient’s en-
gagement in the management of their condition, but profes-
sional time for maintaining telemetry support and greater pa-
tient engagement increased workloads and demanded service
organization, limiting its diffusion among general
practitioners.
Older patients are among the less technologically skilled
patients and may particularly need user-friendly appliances. In
a recent randomized, controlled study enrolling 43 veterans
with stage 3 or greater kidney disease and uncontrolled hyper-
tension, the use of a web-based HBPT facility was associated
with a high compliance to the monitoring schedule (29 trans-
mitted BP readings per months, corresponding to a 96 % com-
pliance rate) and with 78 % of the patients continuing to reg-
ularly use the device. The low-cost wireless monitoring strat-
egy applied in this study was likely responsible for a greater
data sharing between patients and clinic and a very high ad-
herence to the study protocol [23].
Thus, according to the evidence collected so far, it is rea-
sonable to infer that among the main conditions limiting a
successful HBPT program stand the educational level and
features of the patients targeted by the telemonitoring inter-
vention, the complexity of the technology employed, the char-
acteristics of the telemonitoring program and workflow orga-
nization [33].
Impact of Home Blood Pressure Telemonitoring on Blood
Pressure Control and Other Patients’Outcome
One of the main established advantages of HBPT is the po-
tential for improvement of hypertension control and associat-
ed healthcare outcomes. In a recent meta-analysis, we con-
ducted in more than 7,000 hypertensive patients enrolled in
23 selected high quality randomized controlled studies, office
BP was reduced significantly more in the telemonitoring
group than in patients receiving usual care. Across the studies,
the mean office SBP and DBP reductions were larger in the
HBPT group by nearly 5 and 2 mmHg, respectively (Fig. 2)
[34••]. The level of heterogeneity among studies was high,
though a sensitivity analysis did not significantly alter the
study results, the range of weighted mean differences being
very similar to the overall random effect. A significantly
(p<0.001) larger proportion of patients achieved office BP
normalization (BP target: <140/90 mmHg for non-diabetic
patients and <130/80 mmHg for diabetic patients) in the inter-
vention group [RR and 95 % confidence interval: 1.16 (1.04,
1.29)] than in the control group.
In the five comparison studies assessing intervention effect
on ambulatory BP, its reduction was smaller than that for
office BP, although still greater in the HBPT group for both
SBPandDBP(Fig.2). Interestingly absence of heterogeneity
was demonstrated for the studies based on ambulatory BP,
suggesting that such an endpoint might be a more robust pre-
dictor of intervention effectiveness than office BP.
The number of antihypertensive drugs used by patients at
entry was similar in the HBPT and usual care group (1.8± 1.6
for both, p=0.954) in the eight studies (2,691 subjects)
reporting on this parameter. However, at the end of the study
the HBPT group had a significantly (p<0.001)larger prescrip-
tion of antihypertensive medications [+0.40 (+0.17, +0.62)]
than the control group. Adherence to treatment was high and
did not differ (p=0.481) between the intervention (91.8 %)
and usual care group (89.8 %) in the three studies (773 sub-
jects) evaluating this parameter. The number of office consul-
tations during the study was slightly smaller in the interven-
tion group, the difference being nearly statistically significant
vs. the control group [0.18 (0.37, +0.00), p=0.055].
In the same systematic review, adverse events were report-
ed in 205 of the 1,362 patients randomized to HBPT (13.1 %)
versus 184 of the 1,563 assigned to usual care (11.8 %) over a
median follow-up period of 24 weeks. There was no between-
Table 5 Desirable features for the uptake of telemedicine solutions
among hypertensive patients
•Practical design of the device
•Easy interaction (user-friendly)
•System readily configurable
•Minimal or no technical assistance during a prolonged use
•Personalization and customization
•Compliance with ethical, privacy and safety requirements
•User acceptability
•Affordable costs (ideally reimbursable service)
Fig. 2 Weighted mean differences (and 95 % confidence intervals) in
office and ambulatory systolic (SBP) and diastolic blood pressure (DBP)
changes between patients randomized to home blood pressure
telemonitoring (HBPT) and patients followed by their healthcare givers
in the usual clinical setting. The asterisks refer to the statistical signifi-
cance of the difference (HBPT vs. usual care): ***p<0.001 [redrawn
from 44 by permission]
21 Page 6 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

group statistically significant (p=0.263) difference in the rel-
ative risk of adverse events [1.22 (0.86, 1.71)]; however, the
few studies (four) included in the meta-analysis were not de-
signed or powered to detect reduction or increase in mortality
or differences in clinical events. Moreover, in these studies
adverse events were not homogeneously quantified and not
always appropriately assessed [34••]. The number of medica-
tions, but not the level of adherence to treatment, the number
of office visits and the rate of adverse events presented a high
and significant heterogeneity across the studies.
Few randomized studies also assessed another clinically
relevant outcome of intervention: quality of life. The evalua-
tion was based on the Short Form (SF)-12 and SF-36 instru-
ments, which proved to be useful and valid for patients with
chronic diseases, including hypertension. Although only four
studies (1,262 subjects) assessed the impact of HBPT on qual-
ity of life, the results may have a statistical robustness due to
the homogeneity of the effect sizes among the studies. Quality
of life was improved in patients using HBPT in the physical
domain; the physical component summary (PCS) was signif-
icantly better in the HBPT group (+2.78, p<0.001), whereas
mental component summary (MCS) did not significantly dif-
fer between group (−0.11, p=0.890; Fig. 3)[34••].
We concluded that HBPT allowed to achieve a better BP
control in hypertensive patients respect to usual care and that
this was reasonably due to a more intensive treatment received
by the patients in the intervention group, as adherence to hy-
pertension medications and number of office visits were both
comparable between the two study arms [34••].
Other meta-analyses demonstrated the effectiveness of
HBPT for improving BP control in hypertensive patients [4•,
31,35–39]. However, all of them reached the same conclusion
that given the high level of heterogeneity of studies, future
well designed, large-scale, prospective, controlled trials will
be needed to understand the long-term benefit of such tech-
nologies, in particular their actual cost-effectiveness and their
benefit beyond BP control. These two issues will be dealt in
depth in the next two sections.
Home Blood Pressure Telemonitoring: Cost-Effectiveness
Cost-effectiveness analysis for HBPT as a strategy for hyper-
tension management is difficult to interpret due to the variety
of factors involved in the different studies, such as levels of
risk factors, comorbidities, costs of personnel, telemedicine
devices, communication, and data management infrastruc-
tures. Costs of technologies and social insurance systems
across the countries are extremely different as well. Notably,
the cost assignment shows a great variability: most studies
considered only overall healthcare costs, whereas only few
others provided a more comprehensive evaluation. Therefore
a cost-effectiveness analysis of HBPT should take into ac-
count the different healthcare systems and settings.
In our meta-analysis [34••], based on the available data
from six studies (4,227 subjects), in the HBPT group, along
with a clear benefit in terms of greater BP reduction, the over-
all costs were significantly higher (+662.92 euros, p<0.0001)
than in the usual care group (Fig. 4)[34••]. In other words,
HBPT was more clinically effective but cost more; however,
the medical costs (technology excluded) were only +12 euros
higher with HBPT. Additionally, when expenses were
corrected for the BP lowering magnitude, the average incre-
mental cost-effectiveness ratio (ICER)—that is the cost per
additional 1 mmHg of BP reduction—was 406 euros for
SBP and 829 euros for DBP over a median follow-up period
of 4 years, which means 100–200 euros per person per year
per 1 mmHg of BP reduction. Considering only medical costs
HBPT proved to be rather cost-effective, with a mean ICER of
+32 euros for SBP and +25 euros for DBP. Unfortunately,
medical costs were offset by those of the equipment and tech-
nologies, which contributed to the overall healthcare costs
Fig. 3 Weighted mean difference
(95 % confidence interval, CI) in
mean Short Form (SF)-12 or SF-
36 physical component (PCS) and
mental component (MCS) at
study end between patients of the
home blood pressure
telemonitoring (HBPT) and usual
care (UC) group [from 44 by
permission]
Curr Hypertens Rep (2015) 17:21 Page 7 of 13 21
Author's personal copy

increase. [34••]. If these costs are compared with a cost-
effective intervention in cardiovascular diseases as estimated
by NHS (approximately 12.500 euros for life saved-year),
HBPT seems to be rather cost-effective [40]. However, it
seems straightforward that in the future attention should be
paid to the development of cheaper telemonitoring technolo-
gies in order to improve the cost-effectiveness ratio in favor of
HBPT, making it a promising alternative to existent clinical
practice.
The finding of the economic evaluation of the HINT
Sstudy[41,42] suggests that, to optimize the invest-
ment in home and telephone-based interventions, it is
critically important for health systems to consider apply-
ing interventions to specific subpopulations of patients
that are most likely to benefit from intensive home-
based monitoring and self-management efforts. Further-
more, implementation should also consider whether in-
tervention generates other patient-centered outcomes or
efficiencies in other aspects of medical care saving such
as slowing progression of the chronic disease [42].
In a recent post hoc economic evaluation on data of
a pragmatic randomized controlled trial involving 401
primary care patients with uncontrolled day-time ambu-
latory BP, during the 6 months of follow-up HBPT re-
sulted significantly more effective in terms of BP reduc-
tion, but also significantly more expensive than usual
care (the mean difference per patient was 115.32 pounds,
equivalent to approximately 145 euros; p<0.001 vs.
usual care) [43•]. Increased costs were due to
telemonitoring service costs (70.77 pounds, approximately
90 euros), patient training and additional general practi-
tioner and nurse consultations (approximately one addi-
tional general practitioner consultation and a half a
practice nurse consultation). The mean cost of SBP re-
duction (ICER) was 25.60 pounds/mmHg (32 euros/mmHg):
this indicated that HBPT was both more costly, but also
more effective than usual care. The author concluded
that if such clinical gains are maintained, the additional
costs of HBPT might be compensated for by reductions
in the cost of future cardiovascular events. Nevertheless,
in the future, studies allowing longer term modeling of
costs and outcomes are required to fully analyze the
cost-effectiveness implications of HBPT.
Home Blood Pressure Telemonitoring Needs a More
Robust Evidence on its Efficacy
Objectively it must be admitted that in the light of the studies
published so far evidence on HBPT clinical efficacy and eco-
nomic benefit is incomplete. Available randomized studies do
show a high heterogeneity of the main effect, due to variety of
technologies of data transmission, measuring devices, fre-
quency of monitoring, endpoints, interface with different
types of healthcare professionals to review and act on mea-
surements, frequency of patient-to-healthcare provider con-
tacts, duration of study, and more in general, type of patients
and study designs. Some secondary outcomes (cost, adher-
ence to treatment, feasibility, etc.) have not been evaluated
systematically, and strong evidence on the clinical and eco-
nomic impact of HBPT is definitely still lacking.
Although several meta-analyses and systematic reviews on
HBPT interventions for patients with chronic diseases, includ-
ing arterial hypertension, have been published, most of them
appear to lack in optimal scientific rigor due to intrinsic meth-
odological issues. A recent study tried to evaluate this issue by
assessing the quality of the major systematic reviews and me-
ta-analyses, making use of the R-AMSTAR (Revised Assess-
ment of Multiple Systematic Reviews) instrument. The au-
thors pointed out that the methodologies to proper conduct
systematic reviews and meta-analyses, and eliminate potential
risks of bias, have not yet fully integrated in the area of HBPT
[44]. Moreover, the high level of heterogeneity of pub-
lished studies suggests that well-designed, large-scale, ran-
domized, controlled studies are needed to prove the clini-
cal usefulness of HBPT [34••,35,44]. To definitely dem-
onstrate the usefulness of HBPT more objective study
endpoints should be considered. For instance office BP
should be replaced by a more robust and objective esti-
mation of BP control, such as ambulatory BP. Studies
should try to compare, possibly in the same subjects, the
different impact of conventional HBPM, based on diary
logbooks periodically showed to the doctors, versus that
of a regular HBPT with nurse- or pharmacist-led support
and personalized recommendations on life style. Proba-
bly studies focusing on particularly high risk patients,
for whom an optimal BP control is particularly difficult
to achieve, should be planned.
Fig. 4 Weighted mean difference
(95 % confidence interval, CI) in
the healthcare costs during the
study (in euros) between the
home blood pressure
telemonitoring (HBPT) and usual
care (UC) group [from 44 by
permission]
21 Page 8 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

Is Home Blood Pressure Telemonitoring Better than
Conventional Self Home Blood Pressure Monitoring?
Compared with conventional self HBPM, HBPT may en-
hance the quality of data reporting and ease its interpretation
by doctors. As a matter of fact, it is well known that HBP
readings may be unreliable due to the elevated risk of over-
or under-reporting with logbook manual entries of HBP mea-
surements [45]. Even in case of memory-equipped devices,
doctor’s feedback is not immediate and evaluation may be
time-consuming and inaccurate.
The evidence originating from randomized studies sug-
gests that HBPT may positively affect BP control to a greater
extent than conventional HBPM, particularly in the long term.
A recent meta-analysis including 52 prospective studies
assessed the impact of self HBPM with or without additional
support (including telemonitoring) vs. usual care [46••]. Self
HBPM alone (without additional support) was associated with
statistically significant average reductions in both SBP and
DBP of 3.9 and 2.4 mmHg at 6 months (10 studies). These
changes were smaller and no longer statistically significant at
12 months of follow-up (1.5 mmHg for SBP and 0.8 mmHg
for DBP, 8 studies). For self HBPM plus additional support
(including telemonitoring), high strength evidence supported
a lower BP as compared to usual care with reductions ranging
from 3.4 to 8.9 mmHg for SBP and from 1.9 to 4.4 mmHg for
DBP at 12 months in 5 good quality studies. Thirteen trials
directly compared the effectiveness of self HBPM with addi-
tional support versus self HBPM without additional support
(or with less intensive additional support). Groups differed in
the type of support, with some studies including electronic
transmission of BP measurements. Overall, the evidence was
rated by the authors of the meta-analysis as low-strength and
failed to support a difference between the two approaches in
terms of office BP lowering.
Thus current studies seem to support a clinically relevant
impact of hypertension management of self HBPM with some
form of additional support compared with usual care. Howev-
er, further direct comparative studies are needed to verify
whether in the same subjects HBPT may have some additional
advantage as compared to self HBPM alone, particularly to
provide sustainability and long-term clinical effectiveness of
this approach.
Home Blood Pressure Telemonitoring for High Risk
Patients
Hypertension is frequently associated with other chronic dis-
eases or cardiovascular risk factors, which makes adequate BP
control often difficult to achieve. The effectiveness of tele-
medicine intervention based on HBPT for high risk patients
was examined in few randomized studies.
The IDEATeL randomized, controlled, longitudinal study
enrolled 1,665 elderly, ethnically diverse, medically under-
served hypertensive diabetic patients which were randomly
allocated to intervention or usual care, and monitored over
5 years of follow up [30]. The intervention consisted of a
home telemedicine unit with a web camera for videoconfer-
encing between the patient and the nurse in charge of single
case management. The study results revealed that patients in
the intervention group had an office BP reduction larger [4.3
(1.9, 6.7) mmHg for SBP and 2.6 (1.5, 3.7) mmHg for DBP,
p<0.05 and p<0.001] than those assigned to the usual care
group: such differencespresent at 1 year were maintained over
5 years of follow-up.
Patients with chronic diseases, and particularly diabetics,
are engaged in self-care activities, whose effectiveness re-
quires reliable information and healthcare provider collabora-
tion. A randomized controlled study demonstrated the effec-
tiveness of HBPT combined with self-care support as com-
pared to conventional self HBPM in reaching BP target in
diabetic patients with uncontrolled systolic hypertension
[19]. The telemonitoring system provided self-care messages
on the smartphone of 244 hypertensive diabetic patients after
each reading. The primary endpoint of the study was the mean
ambulatory SBP, which significantly (p<0.001) decreased at
1-year follow-up only in the interventiongroup by 9.1 mmHg.
Furthermore, 51 % of the subjects receiving the intervention
achieved recommended target of <130/80 mmHg compared
with 31 % in the control group (p<0.05; Fig. 5). These im-
provements were obtained without medication intensification
or additional clinic visits to physicians. Thus HBPT with au-
tomated self-care support reduced the BP in diabetic patients
with uncontrolled systolic hypertension and improved hyper-
tension control.
Another randomized controlled pilot trial enrolled 137 hy-
pertensive patients with type 2 diabetes, at risk of renal disease
Fig. 5 Reduction of day-time systolic blood pressure (SBP) and percent-
age of diabetic patients with uncontrolled hypertension who reached the
target of 24-h average BP <130/80 mmHg, in the group randomized to
home blood pressure monitoring (HBPM) and in that randomized to
home blood pressure telemonitoring (HBPT). The asterisks refer to the
statistical significance of the between-group difference (***p<0.001;
*p<0.05) [redrawn from 19 by permission]
Curr Hypertens Rep (2015) 17:21 Page 9 of 13 21
Author's personal copy

progression [47]. In the intervention group, patients’home
blood glucose and BP readings were transmitted to a
smartphone and then to the central server; whereas in the
control group, patients were assigned to usual care. In the
intervention group SBP decreased significantly after 6 months
of follow-up (6.5 mmHg, p=0.027), whereas it was un-
changed in the control group (+2.1 mmHg, p=0.570). Patients
who achieved a SBP of <120 mmHg had lower average blood
glucose than those with higher readings.
The importance of targeting specific types of intervention
to specific patient severity groups has been highlighted in a
randomized controlled trial focused on 845 patients with stage
2 uncontrolled hypertension receiving home-based post-acute
care. Nurse-led intervention, providing additional medication
review and patient self-management support during post-
acute care period, significantly improved BP control in these
high risk patients. [48].
The TASMIN-SR is an ongoing trial set out to investigate
whether self-management is effective and cost-effective also
in a subpopulation of high risk patients (with diabetes, stroke,
or other conditions) previously enrolled in the TASMINH2
trial [49]. If successful, this model may be applicable for hy-
pertension management in these high risk patients.
Finally, the TELEBPMET study is another ongoing open
label, parallel group, randomized controlled trial which aims
to assess the superiority of HBPT versus usual care in high-
risk hypertensive patients with the metabolic syndrome. This
study will also study and compare patient’s personality traits
as predictive factors of adherence to antihypertensive treat-
ment between randomization groups. The impact of HBPT
on additional and economic outcomes will be further investi-
gated on a relative long-term follow up of 12 months [50].
Home Blood Pressure Telemonitoring and Telehealth
Networks
A key point for a successful BP management by HBPT is the
networking among healthcare providers and, in particular, the
counseling between doctor and pharmacist or nurse, namely a
new model of care based on telephone/web services for BP
control whose effectiveness was indeed showed in a number
of trials.
One of the first studies to address this specific model of
telemedicine service in the hypertension management was the
Electronic Communications and Home Blood Pressure Mon-
itoring (e-BP) Study. This was a randomized controlled trial,
which enrolled 778 participants with uncontrolled essential
hypertension and Internet access. The main outcome measures
were the percentage of patients with controlled BP (<140/
90 mmHg) and changes in SBP and DBP at 12 months. Par-
ticipants were randomly assigned to usual care, HBPM and
secure patients web site training only, or HBPM and secure
web site training plus clinical pharmacist care management
delivered through web communications [51]. Adding web-
based pharmacist care to HBPM and web training significant-
ly increased the percentage of patients with controlled BP
compared to HBPM and web training only and usual care
(Fig. 6, left panel). BP benefits occurred mainly in patients
with more severe hypertension at baseline (SBP≥160 mmHg)
with web-based pharmacist team patients almost twice as like-
ly to have controlled BP (54 vs. 20 % usual care at 12 months,
p<0.01) [51,52]. Interestingly, the web-delivered pharmacy
team care resulted in greater reductions in SBP and improved
BP control also 1-year after the completion and discontinua-
tion of the interventions (Fig. 6, right panel). However, similar
to previous studies [53••,54] the control group under usual
care continued to improve, and differences between groups
narrowed. Also at 1-year after intervention, the largest benefit
occurred in those patients with more severe hypertension at
baseline followed by the web-based pharmacist team (56 % of
BP control vs. 34 % usual care group and 23 % web only
group, p=0.05 and p<0.005 respectively) [52].
Another randomized controlled trial enrolled 450 patients
with uncontrolled BP, including patients with comorbidities
(obesity, diabetes, chronic kidney disease, or a history of car-
diovascular disease) and severe hypertension, with a baseline
mean SBP of 148 mmHg and DBP of 85 mmHg [55]. Patients
were allocated to receive a telemonitoring intervention
(telemonitors and transmission of BP data to pharmacists
who adjusted antihypertensive therapy accordingly) or usual
care. The intervention lasted 12 months: after this period pa-
tients discontinued HBPT, returned to the care of their primary
physicians, and no longer received support from a study phar-
macist, though were followed-up for additional 6 months. At
both 6 and 12 months the proportion of patients with BP
Fig. 6 Percentage of patients with controlled (<140/90 mmHg) office
blood pressure (BP) in three different settings: usual care only (control),
usual care plus home blood pressure telemonitoring (HBPT) and web site
training, usual care plus HBPT, and web site training plus web-based
pharmacist care. Data are shown at 12 months of follow-up (left panel)
and at 1-year after discontinuation of the intervention (right panel). The
asterisks refer to the statistical significance of the between-group differ-
ence (***p<0.001; **p<0.01) [redrawn from 51 and 52 by permission]
21 Page 10 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

control (<140/90 or <130/80 mmHg in patients with diabetes
or chronic kidney disease) was significantly (p=0.001)greater
in the telemonitoring group (57 %) than in the usual care
group (30 %). SBP decreased more from baseline among pa-
tients in the telemonitoring intervention group at 6 months
[10.7 (14.3, 7.3) mmHg, p<0.001], at 12 months [9.7 (13.4,
6.0), p<0.001], and at 18 months [6.6 (10.7, 2.5) mmHg, p=
0.004]. Thus the synergy between HBPT and pharmacist case
management of high risk hypertensive patients allowed a bet-
ter BP control compared with usual care during the 12 months
of intervention, extended by 6 months of post-intervention
follow-up [55].
The general practitioner-pharmacist counseling may have a
crucial role for hypertension screening and management of
follow-up. The TEMPLAR study (TEleMonitoring of blood
Pressure in Local phARmacies) is the first ongoing Italian
Registry on 24-h BP telemonitoring in community pharma-
cies, aiming at verifying the level of BP control in treated and
untreated patients undergoing 24-h BP monitoring in pharma-
cies upon general practitioners’prescription. Preliminary
study results seem to support the role of community pharma-
cies for the improvement of the detection of high BP in the
population [56].
Combined intervention of telemedicine also with nurse-led
care showed to improve hypertension management in large
randomized controlled trials that enrolled hypertensive high
risk patients [41,57]. Thus clinical experiences that combined
electronic technologies with team care have had the most pos-
itive results. However, the studies show a high degree of het-
erogeneity and there are still shortcomings regarding cost-ef-
fectiveness, long-term benefits of technology enhanced by
team interventions which need further investigation in the fu-
ture [53••].
Conclusions
In summary, HBPT seems to be a promising tool for improv-
ing BP control among hypertensive patients, particularlythose
at high risk. In the majority of studies regular HBPT yielded
greater BP reductions and a larger proportion of patients
achieving BP normalization than usual care. The most plausi-
ble cause of such outcome was that patients in the intervention
group usually received a more intensive treatment. In terms of
quality of life, HBPT did not adversely affect health status
assessed by a generic validated scale. Indeed, the physical
component of quality of life was improved by the interven-
tion, a finding that may have positive implications in long-
term hypertension management. From the perspective of cost-
effectiveness, HBPT was associated with lower medical costs,
which were, however, offset by those of the equipment and
technologies. Unfortunately, the impact of the technology in
terms of cost is difficult to assess because in the various
studies, published over the last 20 years, old and outdated
technologies were compared to more recent and advanced
ones. Hence, further studies are needed to identify specific
key elements of HBPT approach able to impact on specific
outcomes.
On the basis of what is known from studies published sofar
HBPT is likely to represent a realistic strategy to improve
hypertension management when a particularly tighter BP con-
trol is needed, such as in high risk patients, elderly, diabetics,
etc. HBPT may be used when a support to the doctor is ap-
propriate for a closer and continuous monitoring of the pa-
tients, as in case of high risk patients, but also of non-
adherent patients or subjects living in remote areas. Besides,
HBPT can be an advantageous choice in situations requiring
monitoring of multiple vital signs (e.g., cardiac patients, dia-
betics, etc.). HBPT and, more in general, a telemedicine ap-
proach is the only option when a network among healthcare
professionals needs to be established in order to improve the
screening and management of hypertension and related co-
morbidities, and consequently achieve an effective prevention
of cardiovascular diseases in the community.
Compliance with Ethics Guidelines
ConflictofInterest Stefano Omboni reports personal fees from
Biotechmed Ltd and Microlife. Rossella Ferrari declares no conflict of
interest.
SO has received consultancy fees from Biotechmed Ltd., provider of
telemedicine services, and from Microlife, manufacturer of blood pres-
sure measuring devices. RF has no conflict of interest to declare.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
•Of importance
•• Of major importance
1. Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N,
et al. What is telemedicine? A collection of 104 peer-reviewed
perspectives and theoretical underpinnings. Telemed J E Health.
2007;13:573–90.
2. IHS. Telehealth Report 2014.
3. Parati G, Omboni S. Role of home blood pressure telemonitoring in
hypertension management: an update. Blood Press Monit. 2010;15:
285–95.
4.•Purcell R, McInnes S, Halcomb EJ. Telemonitoring can assist in
managing cardiovascular disease in primary care: a systematic re-
view of systematic reviews. BMC Fam Pract. 2014;15:34. This
systematic review showed that telemonitoring has the potential to
enhance primary care management of cardiovascular diseases by
improving patient outcomes and reducing health costs. However, it
Curr Hypertens Rep (2015) 17:21 Page 11 of 13 21
Author's personal copy

also underlined that further research is needed to explore the spe-
cific impact and relative value of the different elements of
telemonitoring interventions.
5. Merriel SW, Andrews V, Salisbury C. Telehealth interventions for
primary prevention of cardiovascular disease: a systematic review
and meta-analysis. Prev Med. 2014;64:88–95.
6. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of
nonoptimal blood pressure. J Hypertens. 2009;27:1472–7.
7. Paré G, Jaana M, Sicotte C. Systematic review of home
telemonitoring for chronic diseases: the evidence base. J Am Med
Inform Assoc. 2007;14:269–77.
8. Jones A, Hedges-Chou J, Bates J, Loyola M, Lear SA, Jarvis-
Selinger S. Home telehealth for chronic disease management: se-
lected findings of a narrative synthesis. Telemed J E Health.
2014;20:346–80.
9. Shea K, Chamoff B. Patient reactions to vital sign measures: com-
paring home monitoring technology to face-to-face delivery. Home
Health Care Manag Pract. 2011;23:454–60.
10. Steinhubl SR, Muse ED, Topol EJ. Can mobile health technologies
transform health care? JAMA. 2013;310:2395–6.
11. Logan AG. Transforming hypertension management using mobile
health technology for telemonitoring and self-care support. Can J
Cardiol. 2013;29:579–85.
12. Sivakumaran D, Earle KA. Telemonitoring: use in the management
of hypertension. Vasc Health Risk Manag. 2014;10:217–24.
13. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al.
European Society of Hypertension practice guidelines for home
blood pressure monitoring. J Hum Hypertens. 2010;24:779–85.
14. Artinian NT, Washington OG, Templin TN. Effects of home
telemonitoring and community-based monitoring on blood pres-
sure control in urban African Americans: a pilot study. Heart
Lung. 2001;30:191–9.
15. Scherr D, Zweiker R, Kollmann A, Kastner P, Schreier G, Fruhwald
FM. Mobile phone-based surveillance of cardiac patients at home. J
Telemed Telecare. 2006;12:255–61.
16. Bobrie G, Postel-Vinay N, Delonca J, Corvol P, SETHI
Investigators. Self-measurement and self-titration in hypertension:
a pilot telemedicine study. Am J Hypertens. 2007;20:1314–20.
17. McCant F, McKoy G, Grubber J, Olsen MK, Oddone E, Powers B,
et al. Feasibility of blood pressure telemonitoring in patients with
poor blood pressure control. J Telemed Telecare. 2009;15:281–5.
18. Wakefield BJ, Holman JE, Ray A, Scherubel M, Adams MR, Hillis
SL, et al. Effectiveness ofhome telehealth in comorbid diabetes and
hypertension: a randomized, controlled trial. Telemed J E Health.
2011;17:254–61.
19. Logan AG, Irvine MJ, McIsaac WJ, Tisler A, Rossos PG, Easty A,
et al. Effect of home blood pressure telemonitoring with self-care
support on uncontrolled systolic hypertension in diabetics.
Hypertension. 2012;60:51–7.
20. Kerby TJ, Asche SE, Maciosek MV, O’Connor PJ, Sperl-Hillen
JM, Margolis KL. Adherence to blood pressure telemonitoring in
a cluster-randomized clinical trial. J Clin Hypertens. 2012;14:668–
74.
21. Kerry SM, Markus HS, Khong TK, Cloud GC, Tulloch J, Coster D,
et al. Home blood pressure monitoring with nurse-led telephone
support among patients with hypertension and a history of stroke:
a community-based randomized controlled trial. CMAJ. 2013;185:
23–31.
22. McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S,
et al. Telemonitoring based service redesign for the management of
uncontrolled hypertension: multicentre randomised controlled trial.
BMJ. 2013;346:f3030.
23. Rifkin DE, Abdelmalek JA, Miracle CM, Low C, Barsotti R, Rios
P, et al. Linking clinic and home: a randomized, controlled clinical
effectiveness trial of real-time, wireless blood pressure monitoring
for older patients with kidney disease and hypertension. Blood
Press Monit. 2013;18:8–15.
24. Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J,
Torgerson J, et al. A telecommunications system for monitoring
and counseling patients with hypertension. Impact on medication
adherence and blood pressure control. Am J Hypertens. 1996;9:
285–92.
25. Rogers MA, Small D, Buchan DA, Butch CA, Stewart CM,
Krenzer BE,et al. Home monitoring service improves mean arterial
pressure in patients with essential hypertension. A randomized,
controlled trial. Ann Intern Med. 2001;134:1024–32.
26. Logan AG. Transforming hypertension management using mobile
health technology for telemonitoring and self-care support. Can J
Cardiol. 2013;29:579–85.
27. Santamore WP, Homko CJ, Kashem A, McConnell TR, Menapace
FJ, Bove AA. Accuracy of blood pressure measurements transmit-
ted through a telemedicine system in underserved populations.
Telemed J E Health. 2008;14:333–8.
28. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S,
et al. Telemonitoring and self-management in the control of hyper-
tension (TASMINH2): a randomised controlled trial. Lancet.
2010;376:163–72.
29. Neumann CL, Menne J, Rieken EM, Fischer N, Weber MH, Haller
H, et al. Blood pressure telemonitoring is useful to achieve blood
pressure control in inadequately treated patients with arterial hyper-
tension. J Hum Hypertens. 2011;25:732–8.
30. Shea S, Weinstock RS, Teresi JA, Palmas W, Starren J, Cimino JJ,
et al. A randomized trial comparing telemedicine case management
with usual care in older, ethnically diverse, medically underserved
patients with diabetes mellitus: 5 year results of the IDEATel study.
J Am Med Inform Assoc. 2009;16:446–56.
31. Paré G, Mogadem K, Pineau G, St-Hilaire C. Clinical effects of
home telemonitoring in the context of diabetes, asthma, heart failure
and hypertension: a systematic review. J Med Internet Res.
2010;12:e21.
32. Hanley J, Ure J, Pagliari C, Sheikh A, McKinstry B. Experiences of
patients and professionals participating in the HITS home blood
pressure telemonitoring trial: a qualitative study. BMJ Open.
2013;3:e002671.
33. Egede LE, Strom JL, Fernandes J, Knapp RG, Rojugbokan A.
Effectiveness of technology-assisted case management in low in-
come adults with type 2 diabetes (TACM-DM): study protocol for a
randomized controlled trial. Trials. 2011;12:231.
34.•• OmboniS, Gazzola T, Carabelli G, ParatiG. Clinical usefulness and
cost effectiveness of home blood pressure telemonitoring: meta-
analysis of randomized controlled studies. J Hypertens. 2013;31:
455–68. One ofthe first systematic reviews documenting the benefit
of blood pressure telemonitoring on different clinical outcomes, and
its cost-efficacy.
35. Omboni S, Guarda A. Impact of home blood pressure
telemonitoring and blood pressure control: a meta-analysis of ran-
domized controlled studies. Am J Hypertens. 2011;24:989–98.
36. AbuDagga A, Resnick HE, Alwan M. Impact of blood pressure
telemonitoring on hypertension outcomes: a literature review.
Telemed J E Health. 2010;16:830–8.
37. Verberk WJ, Kessels AG, Thien T. Telecare is a valuable tool for
hypertension management, a systematic review and meta-analysis.
Blood Press Monit. 2011;16:149–55.
38. Zullig LL, Melnyk SD, Goldstein K, Shaw RJ, Bosworth HB. The
role of home blood pressure telemonitoring in managing hyperten-
sive populations. Curr Hypertens Rep. 2013;15:346–55.
39. Liu S, Dunford SD, LeungYW, Brooks D, Thomas SG, Eysenbach
G, et al. Reducing blood pressure with Internet-based interventions:
a meta-analysis. Can J Cardiol. 2013;29:613–21.
21 Page 12 of 13 Curr Hypertens Rep (2015) 17:21
Author's personal copy

40. Martin S, Rice N, Smith PC. Does health care spending improve
health outcomes? Evidence from English programme budgeting
data. J Health Econ. 2008;27:826–42.
41. Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith
V, et al. Home blood pressure management and improved blood
pressure control: results from a randomized controlled trial. Arch
Intern Med. 2011;171:1173–80.
42. Wang V, Smith VA, Bosworth HB, Oddone EZ, Olsen MK,
McCant F, et al. Economic evaluation of telephone self-
management interventions for blood pressure control. Am Heart
J. 2012;163:980–6.
43.•Stoddart A, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S,
Sheikh A, Krishan A, Padfield P, McKinstry B. Telemonitoring-
based service redesign for the management of uncontrolled hyper-
tension (HITS): cost and cost-effectiveness analysis of a
randomised controlled trial. BMJ Open 2013;3. The most recent
trial supporting the evidence that telemonitoring is more effective
at reducing blood pressure than usual care but alsomore expensive.
The authors suggest that longer-term modelling of costs and out-
comes is required to fully examine the cost-effectiveness implica-
tions of blood pressure telemonitoring.
44. Kitsiou S, Parè G, Jaana M. Systematic reviews and meta-analyses
of home telemonitoring interventions for patients with chronic dis-
eases: a critical assessment of their methodological quality. J Med
Internet Res. 2013;15:e150.
45. Mengden T, HernandezMedina RM, Beltran B, Alvarez E, Kraft K,
Vetter H. Reliability of reporting self-measured blood pressure
values by hypertensive patients. Am J Hypertens. 1998;11:1413–7.
46.•• Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM. Self-measured blood
pressure monitoring in the management of hypertension: a system-
atic review and meta-analysis. Ann Intern Med. 2013;159:185–94.
The most recent systematic review on the clinical efficacy of home
blood pressure monitoring, showing that self-measured blood pres-
sure monitoring with or without additional support effectively
lowers blood pressure compared with usual care. Additional sup-
port (including telemonitoring) enhances the blood pressure-
lowering effect.
47. Earle KA, Istepanian RS, Zitouni K, Sungoor A, Tang B. Mobile
telemonitoring for achieving tighter targets of blood pressure con-
trol in patients with complicated diabetes: a pilot study. Diabetes
Technol Ther. 2010;12:575–9.
48. Pezzin LE, Feldman PH, Mongoven JM, McDonald MV, Gerber
LM, Peng TR. Improving blood pressure control: results of home-
based post-acute care interventions. J Gen Intern Med. 2011;26:
280–6.
49. O’Brien C, Bray EP, Bryan S, Greenfield SM, Haque MS, Hobbs
FD, et al. Targets and self-management for the control of blood
pressure in stroke and at risk groups (TASMIN-SR): protocol for
a randomised controlled trial. BMC Cardiovasc Disord. 2013;13:
21.
50. Parati G, Omboni S, Compare A, Grossi E, Callus E, Venco A, et al.
Blood pressure control and treatment adherence in hypertensive
patients with metabolic syndrome: protocol of a randomized con-
trolled study based on home blood pressure telemonitoring vs. con-
ventional management and assessment of psychological determi-
nants of adherence (TELEBPMET Study). Trials. 2013;14:22.
51. Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J,
et al. Effectiveness of home blood pressure monitoring, Web com-
munication, and pharmacist care on hypertension control: a ran-
domized controlled trial. JAMA. 2008;299:2857–67.
52. Green BB, Anderson ML, Ralston JD, Catz SL, Cook AJ. Blood
pressure 1 year after completion of web-based pharmacist care.
JAMA Internal Med. 2013;173:1250–2.
53.•• Carter BL, Bosworth HB, Green BB. The hypertension team: the
role of the pharmacist, nurse and teamwork in hypertension therapy.
J Clin Hypertens. 2012;14:51–65. The innovative concept of hyper-
tension management centered on the patient and based on the use of
health information technologies.
54. Wentzlaff DM, Carter BL, Ardery G, Franciscus CL, Doucette WR,
Chrischilles EA, et al. Sustained blood pressure control following
discontinuation of a pharmacist intervention. J Clin Hypertens.
2011;13:431–7.
55. Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Groen SE,
Kadrmas HM, et al. Effect of home blood pressure telemonitoring
and pharmacist management on blood pressure control: a cluster
randomized clinical trial. JAMA. 2013;310:46–56.
56. Omboni S, Caserini M. Telemonitoring of 24-h blood pressure in
local pharmacies and blood pressure control in the community:
results from the TEMPLAR project. J Hypertens. 2014;32(e-sup-
plement 1):e13.
57. Bove AA. Using modern communications to manage chronic heart
disease. Am Heart Hosp J. 2010;8:25–8.
Curr Hypertens Rep (2015) 17:21 Page 13 of 13 21
Author's personal copy