Multilevel mobile health program to improve rural hypertension

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Hypertension (HTN) is the leading modifiable cause of cardiovascular disease. The Surgeon General’s 2020 Call to Action to Control Hypertension articulated the critical relevance of multilevel strategies to address the social determinants and access to care that affect HTN control. Rural individuals experience the additional challenges of the rural health divide: geographic distance from providers, social isolation, limited social resources, and high rates of low health literacy. We have developed and validated a smartphone-based program for home-based blood pressure monitoring (HBPM), termed MyBP, and have demonstrated the success of MyBP to promote adherence to HBPM, improve blood pressure (BP) control, and enhance patient engagement. We now adapt MyBP as a virtual agent, termed MyBP Coach, and leverage our experience with such agents to provide longitudinal health education, empathic guidance, monitoring, and adaptable patient-centered coaching to rural individuals with cardiovascular disease. Here, guided by a patient advisory committee, we provide MyBP Coach to rural individuals as a personalized curriculum to promote and support HBPM; HTN education; medication adherence; non-pharmacologic strategies for HTN management; preparation for the clinical encounter; and enhanced problem-solving and engagement. We will evaluate the 6- month MyBP Coach intervention in a single-center, parallel group clinical trial, randomizing 334 patients with poorly controlled HTN (systolic BP 150-199 or diastolic BP 95-119 mm Hg at 2 ambulatory visits) to (1) HBPM with MyBP Coach; or (2) the control, consisting of HBPM and a smartphone with a general health application (WebMD). For both intervention and control, we provide HBPM summaries to clinicians to improve HTN management for rural patients. We will follow treatment intensification and adjustment of hypertensive medications over the 12-month trial; and track (a) adherence to antihypertensive medication with 6- and 12- month proportion of days covered and (b) 6-month adherence to HBPM. Our aims are: (1) Examine the effect of the MyBP Coach intervention on BP at 6 months and assess the sustainability of its effects at 12 months; (2) Evaluate the effect of the intervention on adherence to BP medications and HBPM; and (3) Determine the effect of the intervention on patient-reported outcomes including quality of life, engagement, and social isolation. Our trial leverages our health system’s infrastructure across rural PA, a common electronic health record of our large health care system, and established rural clinical partnerships. We incorporate methods previously applied by us to recruit geographically isolated rural individuals with limited health and digital literacy, conduct remote assessments, and provide similar smartphone-based resources and instruction. Expected Results: In this project we will evaluate a scalable and patient-centered intervention to improve BP control, medication and HBPM adherence, and patient-reported outcomes. If proven successful, this intervention can be broadly disseminated to improve the care of rural patients with poorly controlled HTN.