The main complaints about the program from both subjects and the health coach were on performance. They wanted the application to load faster and to save data faster.
Discussion
This study provides encouraging evidence that technology-supported apprenticeship can dramatically improve the outcomes, cost, and experience of care in the management of hypertension.
A 26.3 mm Hg average decrease in systolic blood pressure for intervention subjects in 3 months is significantly better than the standard of care and the best of the best in published interventions. [1,11–14]. The same is true for a rate of 100% of patients achieving goal blood pressure < 140/90 mm Hg.
We believe several factors contribute to the success of our program: (1) supporting subjects in the mission of leading their care, (2) rich real-time feedback for self-reflection, (3) emphasis on short-term goals, (4) promise of medication reduction with goal achievement, and (5) social support and accountability that come with having a continuously available coach who had immediate data access.
Other studies have had web communication components, self-titration components, and coaching components. In a progressive study by McManus [11], subjects in the intervention group self-tracked their blood pressure and self-titrated their hypertension medications while control subjects received routine care. Self-managing patients achieved a decrease in systolic blood pressure of 17.6 mm Hg over 12 months while controls only achieved a decrease of 12.2 mm Hg. Self-managing patients were more aggressive in adding new medications and did not have increased incidence of side effects. A study by Green [12] showed that subjects with home blood pressure monitoring, a web training course, and web-based pharmacist coaching achieved a 14.2 mm Hg decrease in systolic blood pressure over 12 months and that 56% reached goal blood pressure (< 140/90 mm Hg). Subjects who received routine care only achieved a 5.3 mm Hg decrease in systolic blood pressure and only 31% reached goal blood pressure. Margolis [13] and Magid [14] conducted studies similar to Green's with pharmacist-led care. In Margolis’ study, 71.8% of inter-vention subjects study achieved goal at 6 months with a mean decrease in systolic blood pressure of 21.5 mm Hg. These results were impressively stable at 18 months [13]. In Magid’s study, 54.1% of intervention subjects achieved goal at 6 months with a mean decrease in systolic blood pressure of 20.7 mm Hg [14].
The technology-supported apprenticeship model was inspired by the exceptional results of these studies, but we believe that it represents a significant step forward in patient engagement. In these studies, the tools were typically more burdensome than empowering, the titration more prescriptive than motivational, and the coaching more timed and paternalistic than continuous and nurturing. Technology-supported apprenticeship relies on more powerful tools for collaboration and aspires for the patient to lead the care rather than the clinician. It has the potential to produce greater self-efficacy, which results in better outcomes at lower cost.
Cost Implications
The 100% rate of attainment of systolic blood pressure < 140 mm Hg in our intervention subjects has the poten-tial to contribute to substantial cost savings through reducing complications. The cost of complications per patient per year is approximately $1275, and attainment of goal blood pressure on average results in approximately 35% decrease in complications [2,7–9] Therefore, it is reasonable to expect at least $446 savings in downstream costs per patient per year with this intervention. This has notable public health implications given that there are approximately 32 million patients in the United States with diagnosed hypertension that is uncontrolled [1]. Cost saving at scale could be more than $14 billion.