Utilising digital health to improve medication-related quality of care for hypertensive patients: An integrative literature review

Table 1 Summary of included articles

Ref.	Country/Study size	Project title	Study design	Age (mean ± SD)	Male (%)	SBP (mean ± SD, mm Hg)
Ajay et al[23], 2016	India, n = 6061	mPower Heart	Mixed methods	NR	NR	146.1
Bloss et al[39], 2016	United States, n = 160	NR	Pre-post	56 ± 9.0	50.0	138.9
Bosworth et al[27], 2011	United States, n = 591	HINTS	RCT	64 ± 10.0	92.0	129.0 ± 19.6
Crowley et al[42], 2016	United States, n = 591	HINTS	RCT	64 ± 10.0	92.0	129.0 ± 19.6
Crowley et al[31], 2011	United States, n = 591	HINTS	RCT	64 ± 10.0	92.0	129.0 ± 19.6
Frias et al[43], 2017	United States, n = 118	DMO	Cluster RCT	59	50.5	149.3 ± 1.5
Guthrie et al[25], 2019	United States, n = 172	DTxs	Cohort	55	13.9	138.9
Jung et al[24], 2017	South Korea, n = 64	eHSM	Quasi-experimental	81 ± 8.6	22.6	133.9 ± 15.1
Jackson et al[44], 2012	United States, n = 591	HINTS	RCT	64 ± 10.0	92.0	129.0 ± 19.6
Kim et al[45], 2016	United States, n = 160	NR	Pre-Post	56 ± 9.0	50.0	138.9
Lewinski et al[46], 2019	United States, n = 18	mHealth	Pre-post	57	38.1	139.5 ± 19.8
Litke et al[28], 2018	United States, n = 122	CPS	Retrospective	NR	NR	159.0
Liu et al[40], 2018	Canada, n = 128	NR	RCT	57 ± 0.8	52.3	140.0 ± 1.1
Maciejewski et al[47], 2014	United States, n = 591	HINTS	RCT	64 ± 10.0	92.0	129.0 ± 19.6
McGillicuddy et al[22], 2015	United States, n = 18	SMASK	RCT	42 ± 12.0	55.6	139.1 ± 4.4
Milani et al[48], 2016	United States, n = 556	Ochsner	Pre-post	68 ± 10.0	46.0	147.0 ± 5
Moorhead et al[49], 2017	United States, n = 57	DMO	RCT	59	50.5	149.3 ± 1.5
Noble et al[29], 2016	United Kingdom, n = 39	DHFS	Pre-post	61	NR	154.3 ± 18.9
Nolan et al[50], 2018	Canada, n = 264	REACH	RCT	58	42.0	141.5
Nordyke et al[26], 2019	United States, n = 172	DTxs	Cohort	55	13.9	138.9
Patel et al[51], 2013	United States, n = 50	Pill Phone	RCT	53 ± 8.7	31.0	144.0
Rehman et al[52], 2019	Pakistan, n = 120	NR	RCT	NR	NR	149.3 ± 5.6
Saleh et al[53], 2018	Lebanon, n = 3481	NR	Cross-sectional	NR	38.6	≥ 140.0
Saleh et al[32], 2018	Lebanon, n = 2359	eSahha	RCT	NR	43.7	133.7 ± 16.1
Saleh et al[54], 2018	Lebanon, n = 2359	eSahha	RCT	NR	43.7	133.7 ± 16.1
Prabhakaran et al[41], 2019	India, n = 3695	mWellcare	Cluster RCT	55 ± 11.0	55.2	152.5 ± 14.7
Tobe et al[30], 2019	Canada, n = 243	DREAM‐GLOBAL	RCT	49 ± 12.8	50.7	143.0 ± 12.0
Williams et al[55], 2012	Australia, n = 80	MESMI	RCT	68.0 ± 8.3	56.4	> 140.0, < 160.0

SBP: Systolic blood pressure; NR: Not report; HINTS: Hypertension Intervention Nurse Telemedicine Study; RCT: Randomised Controlled Trial; CPS: Clinical pharmacy specialists; DMO: Digital medicine offering; eHSM: eHealth self-management; SMASK: Smartphone Medication Adherence Saves Kidneys; DHFS: Digital health feedback system; DTxs: Digital therapeutics; MESMI: Medication Self-Management Intervention.

Table 2 Comparison of main elements between digital health interventions for hypertensive care

Project	Study base/area	Intervention	Focus area	Follow up (mo)	Drop off (%)
mPower Heart[23]	Primary care; rural	Mobile phone	Clinical decision-support	18	NR
NR (Mobile) [39,45]	Home; NR	Mobile phone	Health care resource utilization; health self-management	6	13.0
HINTS[27,31,42,44,47]	Home; urban	Telemedicine	Improving BP control	18	15.0
DMO[43,49]	Clinic; urban	Digital medicine	Effect of the DMO on BP; patient engagement; provider decision making	3	11.0
DTxs[25,26]	NR	Mobile phone	Effectiveness of Dtxs on reducing BP; using machine learning to predict intervention completion	3	17.4
eHSM[24]	Community; urban	Telehealth	Monitoring self-management; control of blood pressure	6	6.1
mHealth[46]	Community; rural	Telehealth and SMS	Patient-centred care and self-management	6	16.3
CPS[28]	Primary care; rural	Telehealth	Medication management; healthcare access and quality in rural areas	29	NA
NR (Internet)[40]	Home; urban	Internet	Expert-driven e-counselling in motivating lifestyle change to control blood pressure	4	11.0
SMASK[22]	Primary care	Mobile phone	Self-management to improve BP and medication adherence after kidney transplant	12	0.0
Ochsner[48]	Home	Digital medicine	Medication management and lifestyle change	3	NR
DHFS[29]	Pharmacy; urban	mHealth system	Medication management; self-management to improve BP	2	0.0
REACH[50]	Urban	Internet	e-counselling and motivation in self-care	12	17.0
Pill Phone[51]	Urban	Mobile phone	Medication reminder	6	4.0
NR (SMS)[52]	Hospital;NR	SMS	Enhancement of adherence to non-pharmacological treatment; self-management	3	NR
eSahha[32,53,54]	Primary care; rural	SMS	Effect of eHealth tools on accessibility to health services; detection and referrals rates in rural settings	12	NR
mWellcare[41]	Primary care; rural	mHealth system	Management of the chronic conditions; long-term monitoring and follow-up	12	10.1
DREAM‐GLOBAL[30]	Primary care; rural	SMS	Health services delivery, mobile health technologies and patient engagement	2	14.1
MESMI[55]	Primary care; urban	Multifactorial intervention	Self-monitoring and medicine review	7	6.3

NR: Not report; BP: Blood pressure; NA: Not applicable; HINTS: Hypertension Intervention Nurse Telemedicine Study; CPS: Clinical pharmacy specialists; DMO: Digital medicine offering; eHSM: eHealth self-management; SMASK: Smartphone Medication Adherence Saves Kidneys; DHFS: Digital health feedback system; SMS: Short Message Service; DTxs: Digital therapeutics; MESMI: Medication Self-Management Intervention.

Table 3 Comparison of findings between digital health interventions

DHI	Key findings (impact of DHI)
	Perception about devise use		Clinical assessment and care	Practice and self-management
mPower Heart[23]	73% of physician agreed with the mDSS suggestion		SBP of the intervention group was reduced by 14.6 mmHg from the baseline. Detected newly hypertension 3152 cases (52%)	Empowered nurse for management of hypertension, promoted evidence-based practices and overcoming the clinical inertia
NR (Mobile)[39,45]	The application was used 10305 times and encouraged participants to change health behaviours		Reduction in BP for the intervention group was 2.7 mmHg from the baseline but was not significance. No significant differences in health care resource utilization	Significant differences in health self- management and health behaviour change but no difference in medication adherence between groups
HINTS[27,31,42,44,47]	Most of the participants reported that the HINTS was useful		SBP of the intervention group was reduced by 6.5 mmHg from the baseline. Significant reduction in SBP for combined intervention group at 12 mo but not significant difference at 18 mo	Patients receiving medication management achieved a clinically significant reduction in SBP relative to those not receiving medication management
DMO[43,49]	Participants with lower adherence benefited more from seeing the reminder messages		SBP of the intervention group was reduced significantly by 9.0 mmHg from the baseline. The intervention group had a greater proportion of meeting goal compared with usual care group	Medication dose reminders were associated with the improving medication adherence, especially in lower adherence group. Mean medication adherence was 86% and mean on-time adherence was 69.7%
	Perception of DHI	Clinical assessment and care		Practice and self-management
DTxs[25,26]	Cost effectiveness at total 3-year program	Significant reduction of SBP was 11.5 mmHg and 17.6 mmHg for stage 2 hypertensive participants		Substantial cost savings by reducing the use of conventional medications
eHSM[24]	NR	SBP of the intervention group was reduced by 11.4 mmHg from the baseline which was greater than the control group		The intervention group showed significantly greater improvement in self-efficacy and self-care behaviour than the control group at 24 wk post-intervention
mHealth[46]	NR			Participants who completed 4 or more phone calls did not had a statistically significant decrease in SBP compared to those who completed fewer calls
CPS[28]	NR	A mean SBP reduction was 26.00 mm Hg		84% of hypertensive participants were discharged after achieving their goal and tobacco cessation was achieved in 42% of targeted patients
NR (Internet)[40]	NR	SBP of the intervention group was reduced by 7.5 mmHg from the baseline but was not significant		The expert-driven group was more effective than the control group
SMASK[22]	NR	SBP of the intervention group was reduced by 9.6 mmHg from the baseline		Establishing and sustaining control of SBP was greater in the intervention group than the control group (11%)
	Perception of DHI	Clinical assessment and care		Practice and self-management
Ochsner[48]	NR	Reduction in BP for the intervention group was 14.0 mmHg from the baseline and 71% of intervention group met target blood pressure control		Mean patient activation was increased by 2.2%. The proportion of patients with low patient activation decreased by 9% and excess sodium consumption was decreased by 24% in the intervention group
DHFS[29]	Participants had positive experience and found the DHFS was helpful	SBP of the intervention group was reduced by 7.9 mmHg from the baseline		Participated pharmacists found the program helped in targeting specific recommendations and creating a collaborative experience with their patients
REACH[50]	NR	SBP of the intervention group was reduced by 10.1 mmHg from the baseline		NR
Pill Phone[51]	Majority of participants (96%) reported a high level of satisfaction	SBP of the intervention group was reduced significantly by 9.0 mmHg from the baseline		92% of participants were engaged in the pre- and post-Morisky medication adherence intervention
NR (SMS)[52]	The intervention group had a positive response toward the SMS service	SBP of the intervention group was reduced by 8.0 mmHg from the baseline		The regular reminders were found very useful in enhancing medication adherence, and educational SMS improved adherence to use of medicines on time
	Perception of DHI	Clinical assessment and care		Practice and self-management
eSahha[32,54]	94% of participants perceived the SMSs as useful and easy to read and understand	SBP of the intervention group was reduced significantly by 1.9 mmHg from the baseline. The refugee camps group had a significantly higher response rate than those in rural areas group		76.9% of participants using SMS through behavioural modifications to improve medication adherence. The appointment showup was associated with knowledge of referral reasons and the employment status
mWellcare[41]	68% of doctors accepted decision support recommendation for hypertension	SBP of the intervention group was reduced by 15.9 mmHg from the baseline but was not significant		The intervention group reported significantly greater adherence to medication more than the control group, but no significant difference in changes for tobacco and alcohol use
DREAM‐GLOBAL[30]	NR	SBP of the intervention group was reduced by 5.3 mmHg from the baseline but was not significant. The success in BP control was 37.5% in active group and 32.8% in the passive group		Within the first 2 mo of follow-up, 9 of the participants were able to consistently control the blood pressure
MESMI[55]	All participants reported satisfaction with the intervention	SBP of the intervention group was reduced by 6.9 mmHg from the baseline but was not significant		No difference in medication adherence between groups. Participants enjoyed being more actively engaged in their self-management

DHI: Digital health intervention; NR: Not report; BP: Blood pressure; SBP: Systolic blood pressure; HINTS: Hypertension Intervention Nurse Telemedicine Study; CPS: Clinical pharmacy specialists; DMO: Digital medicine offering; eHSM: eHealth self-management; SMASK: Smartphone Medication Adherence Saves Kidneys; DHFS: Digital health feedback system; SMS: Short Message Service; DTxs: Digital therapeutics; MESMI: Medication Self-Management Interventio.

Table 4 Challenges in implementing digital health intervention for hypertensive patients

Challenges
Limited resources[23]
Technological issues[39]
Collaboration between stakeholders[39]
Discrepancy between BP values obtained from different setting[48] i.e., research setting, home and clinic and socioeconomic status, i.e., income status, education, socioeconomic, access to technology, tech-savvy and motivational biases
Self-limited rash at the wearable sensor site[43,49]
Imprecise message for reminder[51]
Interpatient variation in medication timeline and frequency[42]
Different email addresses, for example, participants who used Yahoo email were more likely to complete the intervention than users of other email domains[50]
Overlap in content of a DTx and conventional interventions[25,26]
Patients’ variable clinic visits and the lack of standardization of the blood pressure measurement[28]
Lack of expert-driven e-counselling protocol[40]
Sustainability of intervention, for example, SMASK patients returned the Bluetooth blood pressure devices and smartphones after the end of clinical trial[22]
Lack of clinical measurement[41]
SMSs sent were reached family members rather than the patients themselves[32,53,54]

BP: Blood pressure; DTx: Digital therapeutic; SMASK: Smartphone Medication Adherence Saves Kidneys; SMSs: Short Message Services.