Multilevel mobile health program to improve rural hypertension

高血压(HTN)是心血管疾病的主要可改变原因。卫生局局长的2020 控制高血压的行动呼吁阐明了多层次战略的关键相关性，以解决 影响HTN控制的社会决定因素和获得护理的机会。农村个人经历了额外的 农村卫生鸿沟的挑战：与提供者的地理距离、社会孤立、有限的社会 资源匮乏，卫生知识知晓率低。我们已经开发并验证了基于智能手机的 用于家庭血压监测(HBPM)的程序，称为MyBP，并展示了 MyBP成功地促进了对HBPM的依从性，改善了血压控制，并提高了患者 订婚。我们现在将MyBP改编为虚拟代理，称为MyBP Coach，并利用我们的经验 与此类药物一起提供纵向的健康教育、移情指导、监测和适应性 为农村心血管疾病患者提供以患者为中心的指导。在这里，在一位病人的建议下 委员会，我们为农村个人提供MyBP Coach作为个性化课程来推广和支持 HBPM；HTN教育；用药依从性；HTN管理的非药物策略； 为临床接触做好准备；加强问题解决和参与。我们将评估6- 月MyBP Coach干预在一项单中心、平行组临床试验中，随机选择334名 HTN控制不佳(2次门诊时收缩压150-199或舒张压95-119毫米汞柱)至(1)HBPM 使用MyBP Coach；或(2)控制，由HBPM和带有一般健康应用程序的智能手机组成 (WebMD)。对于干预和控制，我们向临床医生提供HBPM摘要以改善HTN 对农村患者的管理。我们将关注高血压的治疗强化和调整 在为期12个月的试验中服用药物；并跟踪(A)坚持服用6-和12- 每月覆盖的天数比例和(B)遵守HBPM的6个月。我们的目标是：(1)检查效果 MyBP Coach在6个月时对BP进行干预，并在12个月时评估其效果的可持续性；(2) 评估干预对BP药物和HBPM依从性的影响；以及(3)确定 干预对患者报告的结果的影响，包括生活质量、参与度和社交 与世隔绝。我们的试验利用了我们在整个农村地区的医疗系统基础设施，这是一种常见的电子医疗 我们庞大的医疗保健系统的记录，以及建立的农村临床合作伙伴关系。我们结合了各种方法 我们以前申请招募健康和数字有限、地理位置偏远的农村个人 扫盲，进行远程评估，并提供类似的基于智能手机的资源和指导。 预期结果：在这个项目中，我们将评估一种可扩展的、以患者为中心的干预措施，以改善BP 控制、用药和HBPM依从性，以及患者报告的结果。如果被证明是成功的，这一点 可以广泛传播干预措施，以改善对控制不佳的HTN农村患者的护理。

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.