Multi-trajectory modeling of home blood pressure telemonitoring utilization among hypertensive patients in China: A latent class growth analysis

Highlights

• Home blood pressure telemonitoring (HBPT) has great potential in improving blood pressure (BP) control.

• Our study provided insight into the potential of depicting the latent feature of telehealth use trajectories over time.

• With LCGA, we depicted the characteristics of HBPT use frequencies and unraveled the latent longitudinal self-monitoring behavioral trajectories.

• Our study identified the association between self-monitoring and BP control outcome, which shed light to further health improvement programs.

Abstract

Background

Home blood pressure telemonitoring (HBPT) has great potential in improving blood pressure (BP) control among patients with hypertension. However, the longitudinal use trajectories of HBPT have not been identified yet. In addition, there has been a lack of understanding of the relationship between developmental trajectories of HBPT and BP control over time. The primary goal of this study was to identify the longitudinal trajectories of using HBPT among hypertensive patients and to explore the relationship between longitudinal trajectories of HBPT use patterns and BP control.

Methods

A total of 122 hypertensive patients were enrolled consecutively in Xiling, Huayan, Baisha and Xueyuan communities in Yichang City, Hubei Province, China. Each patient was provided with a portable monitoring device which has unlimited data service at the time of enrollment. Socio-demographics (e.g. name, age, sex, marital status) were collected at baseline. Real-time data including systolic and diastolic blood pressure were automatically uploaded to cloud platform through devices. Latent class growth analysis was conducted to determine the latent trajectory of HBPT use. Joint trajectory method was used to correlate the longitudinal trajectories of HBPT utilization and BP control status.

Results

Five trajectories were identified which are persistently low (47.1%), moderate with decreasing (23.9%), sharply decreasing (11.2%), high with decreasing (11.3%) and persistently high with increasing (6.6%). There was no statistically significant difference among 5 trajectories in the baseline survey in terms of age, marital status, BP (both SBP and DBP) and BP control status. However, there was a strong positive correlation between the HBPT utilization pattern and BP control status over time.

Conclusions

The latent trajectories of HBPT utilization were identified in our study. However, no predictors of trajectory membership were identified. Nevertheless, we have demonstrated that HBPT was to some extent positively correlated with improved BP control, and this correlation still needs to be further proved.

Introduction

It was reported by WHO that chronic diseases were accounted for 68% of all deaths global wide and 79% of mortality in China [1]. Of all the chronic diseases in China, the burden of hypertension has been increasing in recent years with an age-standardized prevalence elevation by 1.4% per year from 2002 to 2012 [2]. Burden of Hypertension Survey indicated that 27.8% of Chinese adults are hypertensive [3]. However, the level of hypertension awareness as well as the proportion of effective treatment and BP control have remained low [4]. It was reported from the China Kadoorie Biobank Study that only 4.2% of the hypertensive patients had their blood pressure (BP) under control (BP < 140/90 mm Hg) [5].

BP control has been proved to be effective through a systematical approach, including clinical intervention, lifestyle modification and self-management [6]. Telemonitoring, such as education through telephone, texting and SMS and computer or smartphone based software, has potential to facilitate behavior change in BP patients, resulting in improved access to healthcare, better health outcomes and cost saving [[7], [8], [9], [10]]. Similar evidence was also demonstrated in China [11,12]. It was reported by a meta-analysis that telemonitoring could significantly lower systolic blood pressure (SBP) (mean 3.74 mmHg; 95% CI 2.19–2.58 mmHg) and diastolic blood pressure (DBP) (mean 2.37 mmHg; 95% CI 0.40–4.35 mmHg) [13]. Moreover, Morton et al. proposed that patients with chronic diseases who use digital devices to conduct self-management tend to feel supported [14]. However, adherence as well as effectiveness remains uncertain in the long run [8,10].

The majority of the published literature on HBPT assessment has been cross-sectional which provides little information on the developmental trajectories or use pattern of telemonitoring devices over time. In contrary to the traditional approach grouping subjects cross-sectionally, the latent class growth analysis (LCGA) is able to identify latent groups who share similar developmental trajectories over time [15,16]. LCGA has been widely used in the evaluation of mental health [17,18] and life course epidemiology etc. [[19], [20], [21]]. Goh et al. successfully identified three trajectories among patients utilizing telemonitoring with type 2 diabetes in Singapore with LCGA analysis, including minimal, intermittent-waning and consistent users [22]. However, the relationship between the developmental trajectories of the telemonitoring utilization frequency and clinical indicators (e.g., BP and plasma glucose levels) has not been studied yet.

HBPT has great potential in China with increasing numbers of smartphone users. It is important to understand the developmental trajectories or use pattern of HBPT over time for achieving long-term effectiveness and high adherence. We hence conducted a prospective cohort study of HBPT with hypertensive patients using to identify trajectories and reveal patterns of HBPT utilization. We firstly identify the longitudinal trajectories of HBPT utilization during 5-month follow-up period. We then explored the relationship between trajectories and patient’s characteristics such as socio-demographic, clinical indicators and HBPT use factors. Lastly, we assessed the correlation between longitudinal trajectories of HBPT utilization pattern and BP control outcome.