Introduction
Hypertension is among the most progressive and widespread health problems that contributes to significant negative outcomes including increased mortality as well as morbidity rates especially among the African-Americans. Typically, African-Americans usually develop the disease in their early stages of life, have higher blood pressure levels on average and experience various severe hypertension-related illnesses as compared to the other racial groups (Ferdinand, 2013). Although hypertension is untreatable, the illness can be effectively managed through the use of medications and establishing the relevant lifestyle changes. Nonetheless, management of hypertension is suboptimal among the African-Americans due to various factors such as poor adherence to medications as well as treatment regimens whereby this can largely be attributed to lack of self-efficacy and self-care techniques. This underscores the need to come up with evidence based approaches to enhance the self-efficacy as well as self-management techniques among the group in order to foster optimal management of the disease among this vulnerable group. With regard to this, telemonitoring is an effective approach that could be used to effectively monitor the health of hypertensive African-American patients as well as enhance their self-management and self-efficacy techniques in order to foster their adherence to medications and treatment regimens (Trudel et al., 2007).
PICOT question
As such, guided by the PICOT question “Are adult African American patients (P), who are monitored remotely (I) compared with those that are not monitored (C) at a decreased risk of hypertensive complications and noncompliance (O) over a six-month period after initiation of antihypertensive medications (T)?” this paper seeks to conduct a systematic review with the purpose of determine the amount and quality of evidence available to support this proposed modality of care delivery for hypertension patients particularly African-Americans.
With regard to this, a systematic review was conducted using the Cochrane collaboration and PubMed databases that helped in identifying the existing literature relating to the topic and determine the quality of evidence available to support the proposed intervention. Analyzing the quality as well as the amount of evidence that supports the intervention is a crucial step that helps in validating the applicability of the modality into clinical practice whereby this promotes the integration of the proposed intervention into nursing practice.
Description of the systematic review
Essentially, a systematic review helps in collecting and analyzing various research studies relating to the topic or clinical question whereby this helps in gathering the relevant and valid evidence that supports the intervention. In order to identify and analyze the relevant evidence, a comprehensive systematic review was carried out using specific databases specifically the Cochrane collaboration and PubMed. Notably, the systematic review was guided by the PICOT question that helped in collecting the relevant evidence that provides valid and sufficient answers pertaining to the question. In relation to this, a comprehensive search strategy was utilized whereby this helped in focusing on the topic and collecting pertinent evidence. The search strategy embarked on the PICOT question in developing the pertinent key word as well as phrases that were utilized in conducting a literature search. Among the key words utilized in the search included; telemonitoring, hypertension, noncompliance, African-Americans and antihypertensive medications.
Subsequently, the key words were combined so as to develop phrases that helped in narrowing the literature search towards the clinical question. Among the key phrases included in the literature search included; “remote monitoring of hypertensive patients”, “effectiveness of telemonitoring among African-Americans with hypertension”, “use of remote monitoring in decreasing the risk of hypertensive complications and non-compliance”. On the other hand, the scope of the review was limited to studies conducted within the last ten years whereby this helped in collecting valid and applicable evidence that could be used in effectively addressing the clinical problem. Based on the clinical question the review was limited to studies conducted in the United States and the larger Europe. Subsequently, an error analysis was conducted on the identified reviews in order to evaluate the validity of the evidence. With regard to this, the methodologies used in the studies were effectively analyzed whereby this helped in assessing the risk of biasness in the studies such as selection of participants. This helped in selecting studies with minimal biasness thereby enhancing the validity as well as applicability of the evidence. In addition, the heterogeneity of the study results was effectively assessed in order to avoid selecting studies that had erroneous conclusions in regard to the intervention. More importantly, the study design utilized in the reviews was effectively assessed in order to avoid duplication of systematic errors made previously. Thus, most of the studies selected were those that investigated the objective measures since they are usually associated with minimal biasness. Overall, assessing the validity of the studies as well as heterogeneity of the study results helped in collecting valid evidence that could be applied in addressing the clinical problem.
Critically analyzing the selected studies is an essential approach that helps in evaluating the viability as well as reliability of the studies and determining the quality of evidence provided by the articles in regard to supporting the proposed intervention (Grove, Burns & Gray, 2012). In addition, this enables the researcher to come up with valuable inferences that can be used in guiding the implementation of the suggested change into clinical practice.
Evidence-based quantitative article that contains an evidence-based randomized trial.
The article below is one of the most appropriate evidence-based quantitative study that incorporates an evidence-based RCT (Randomized Control Trial) to evaluate the effectiveness of the proposed intervention.
Margolis, K. L., Asche, S. E., Bergdall, A. R., Dehmer, S. P., Groen, S. E., Kadrmas, H. M., & O’Connor, P. J. (2013). Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. Jama, 310(1), 46-56.
Summary of the case study
The study “Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial” by Margolis et al. (2013), sought to evaluate the effectiveness of home BP (Blood Pressure) telemonitoring combined with pharmacist management in improving the control of BP. In addition, the study assessed whether the patients could maintain BP control even after withdrawing the intervention. According to the study, in the United States a considerable number of hypertensive patients including African-Americans have uncontrolled BP whereby this results to various severe hypertension-related complications as well as increased mortality. In addition, uncontrolled BP usually leads to increased hospital visits and readmissions mainly due to exacerbation of the illness thereby resulting to increased health expenditures. As such, the researcher emphasizes the need to develop sustainable evidence-based approaches that could help in improving the control of blood pressure among hypertensive patients. With regard to this, the study focused on evaluating the effectiveness of telemonitoring in enhancing BP control in order to provide valid evidence that could foster the incorporation of the intervention into clinical practice. The study utilized a randomized control trail study design that used two groups (i.e. the control or usual care group and the intervention or telemonitoring group) to compared the effectiveness of telemonitoring in regard to BP control. The key outcome of the study was to lower the systolic and diastolic BP to less than 140 mmHg and 90 mmHg respectively. Moreover, the secondary outcomes of the study included patient satisfaction as well as maintain control of the patients BP even after withdrawing the intervention.
The study found out that telemonitoring led to a significant improvement in relation to BP control among patients in the telemonitoring group compared to those who received usual care (control group). In relation to this, about 57.2% of the patients in the intervention group achieved an optimal BP control as compared to 30.0% of patients in the control group after six and twelve months (Margolis et al., 2013). Moreover, the study established that 71.8% of participants drawn to the telemonitoring group achieved an optimal BP control while 57.1% had their level of blood under control during the post-intervention period i.e. six months after the withdraw of the intervention. In regard to systolic BP, the study established that the telemonitoring group had a higher decrease as compared to the group that received usual care. The intervention group had a systolic decrease of -10.7 mmHg, -14.3 mmHg and -7.3 mmHg at six months, twelve months and eighteen months respectively while the control group had a decrease of -9.7 mmHg, -6.0 mmHg and -6.6 mmHg during the same period. Furthermore, the intervention group had a higher decrease in the diastolic BP as compared to the control group.
Overall, the study established that home telemonitoring of blood pressure combined with case management by the pharmacist had better control of the patients’ level of blood pressure as compared to the usual care that did not involve remote monitoring of the patients. More importantly, the study established that this trend persisted even after withdraw of the intervention particularly during the post-intervention period that lasted for six months.
Study approach
The study embarked on a quantitative study approach that utilized a RCT (Randomized Control Trial) study design in assessing the effectiveness of the intervention (Margolis et al., 2013). Thus, the study utilized a suitable approach that enabled the investigator to come up with valid and relevant findings. In relation to this, the participants who met the study’s eligibility criteria were randomized either into the intervention (telemonitoring) group or the control (usual care) group. As such, this helped the researcher to effectively compare the outcomes of the two groups and subsequently come up with valuable inferences. The study was conducted in sixteen clinics whereby the participants in the two groups were randomly assigned to each clinic. However, the clinics were matched based on their size as well as clinical level in regard to BP control in order to ensure consistency in the randomization process. Each of the participant in the intervention group was given a home BP monitor specifically an automated oscillometric that was used to store and subsequently transmit the patient’s data relating to their BP levels to the affiliated clinic and healthcare professional. The participants in the intervention group were educated on various aspects relating to hypertension, trained on how to use the telemonitoring system for blood pressure and provided with individualized goals on BP control. During the study period, the pharmacist communicated to patients in the intervention group via telephone visits and emphasized on medication adherence as well as lifestyle changes. Moreover, the pharmacist made the relevant adjustments in medications based on the information obtained in regard to the patient’s BP level. On the other hand, the participants in the control group received the usual care without any form of remote monitoring. The study utilized measurable outcomes such as the level of blood pressure including the changes in the systolic as well as diastolic BP. The study also utilized the appropriate instruments to measure other outcomes such as self-efficacy and the level of patient satisfaction among the two groups (Polit & Beck, 2013).
Sample size
The study utilized a convenient sample size that comprised of four hundred and fifty participants who had medical records in sixteen clinics that were affiliated to the study (Margolis et al., 2013). Thus, the sample size utilized was suitable for the study since it enabled the investigator to come up with reliable findings.
Sample population
The sample population comprised of hypertensive adult patients who had uncontrolled BP. Clinical records were utilized in identifying patients with elevated BP through assessing their BP level during their recent clinical visits. In addition, the population comprised on participants drawn from various racial backgrounds that included; the Whites, Hispanics and Blacks (Margolis et al., 2013). The mean age of the study population was sixty one years who included participants from various social-economic backgrounds. Patients with various health complications such as stroke and acute coronary syndrome were excluded from the study.
Thus, the review provides significant and valuable insights in regard to the effectiveness of remote monitoring in improving the BP control of hypertensive patients and minimizing their risk of developing hypertensive complications. In addition, the review shows that remote monitoring of hypertensive patients helps in enhancing the compliance of patients to treatment regimens and medications whereby this could help in preventing the progression of the disease and minimize the development of hypertension-related illnesses. Based on the evidence provided by the review, it is apparent that telemonitoring is an effective evidence-based approach that could help in fostering self-efficacy as well as self-management techniques especially among African-Americans. Subsequently, this would help in improving their adherence to treatment regimens and medications and minimize incidences of hypertension-related complications. Ultimately, effective implementation of this intervention would help to minimize the amount of health spending, and enhance the wellbeing of hypertensive patients.
Evaluation of outcomes
The study utilized measurable outcomes in evaluating the effectiveness of the intervention. Among the key outcomes included the patients’ level of blood pressure and scores relating to the patient satisfaction and self-efficacy. Thus, comparing the outcomes of the two groups helps in determining the effectiveness and the benefits of the intervention (Grove, Burns & Gray, 2012). Based on the study’s outcomes, it is apparent that telemonitoring is an efficient evidence-based modality that could help in addressing the clinical problem. Moreover, the study utilized an appropriate study design that helped the investigator to come up with valid and reliable findings thereby enhancing the study’s validity and reliability. Additionally, the study used a convenient sample size and population that helped in collecting reliable and generalizable data that could be used in addressing similar problems (Polit & Beck, 2013). More importantly, the study is in agreement with similar studies carried out on the topic whereby this enhances the reliability and applicability of the findings and the intervention.
With regard to biasness, the study utilized a suitable approach that used objective data thereby minimizing incidences of biasness. Furthermore, the participants, the researcher as well as the healthcare providers who participated in the study were blinded before the randomization process thereby reducing potential bias.
Level of evidence
The level of evidence provided by the review can be rated as level II since the study utilized a randomized control trial in obtaining the relevant evidence.
Conclusion
Apparently, uncontrolled hypertension is one of the key health problems that contributes to various severe complications and mortality with African-Americans forming the most affected group whereby this can be poor adherence to treatment regimens and medications mainly due to lack of self-efficacy and self-care techniques. Based on the evidence, telemonitoring is an effective evidence-based approach that could help in enhancing these techniques among the group and improve their adherence to treatment regimens and medications thereby minimizing progression of the illness.
References
Ferdinand, K. C. (2013). Improving approaches to hypertension treatment in African Americans: lessons learned from the Jackson Heart Study. The Journal of Clinical Hypertension, 15(6), 362-364.
Grove, S. K., Burns, N., & Gray, J. (2012). The practice of nursing research: Appraisal, synthesis, and generation of evidence. Elsevier Health Sciences.
Margolis, K. L., Asche, S. E., Bergdall, A. R., Dehmer, S. P., Groen, S. E., Kadrmas, H. M., & O’Connor, P. J. (2013). Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. Jama, 310(1), 46-56.
Polit, D. F., & Beck, C. T. (2013). Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams & Wilkins.
Trudel, M., Cafazzo, J. A., Hamill, M., Igharas, W., Tallevi, K., Picton, P., & Logan, A. (2007). A mobile phone based remote patient monitoring system for chronic disease management. Studies in health technology and informatics, 129(1), 167.
