Journal of Telemedicine and Telecare

Assessing the impact of telemedicine interventions on

systolic and diastolic blood pressure reduction: A systematic
review and meta-analysis
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Journal: Journal of Telemedicine and Telecare

Manuscript ID JTT-24-08-029
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Manuscript Type: Research

Date Submitted by the

10-Aug-2024
Author:
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Complete List of Authors: moulaei, khadijeh; Kerman University of Medical Sciences, ;

Parhizkar Roudsari, Peyvand ; Tehran University of Medical Sciences
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Hosseini, Mobina ; Qazvin University of Medical Sciences

Anabestani, Mehrdad ; Karaj Islamic Azad University
Moulaei, Reza ; Tehran University of Medical Sciences
Sabet, Babak ; Shahid Beheshti University of Medical Sciences
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Afrash, Mohammad Reza ; Smart University of Medical Sciences

Telemedicine, systolic blood pressure, diastolic blood pressure, blood

Keyword:
pressure

ScholarOne, 375 Greenbrier Drive, Charlottesville, VA, 22901

Page 1 of 23 Journal of Telemedicine and Telecare

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Assessing the impact of telemedicine interventions on systolic and diastolic
5 blood pressure reduction: A systematic review and meta-analysis
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Khadijeh Moulaei1, Peyvand Parhizkar Roudsari2, Adel Shahrokhi sardoo3, Mobina Hosseini4,
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9 Mehrdad Anabestani5, Reza Moulaei6, Babak Sabet7, Mohammad Reza Afrash 8*
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11 1. Department of Health Information Technology, School of Paramedical, Ilam University of
12 Medical Sciences, Ilam, Iran
13 2. Tehran Heart Center, Cardiovascular Disease Research Center, Tehran University of Medical
14 Sciences, Tehran, Iran
15 3. School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
16 4. Master of Counseling in Midwifery, Qazvin University of Medical Sciences٫ Qazvin, Iran
17 5. Doctor of Veterinary Medicine, Islamic Azad University of Karaj, Karaj, Iran
18 6. School of Medicine, Tehran University of Medical Sciences, Tehran, Iran .
19 7. Department of Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
20 8. Department of Artificial intelligence, Smart University of Medical Sciences, Tehran, Iran.
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22 *Corresponding Author: Department of Artificial intelligence, Smart University of Medical Sciences,

23 Tehran, Iran. [email protected], [email protected]
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27 Abstract
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Background: Hypertension, characterized by high blood pressure, poses a significant risk for
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30 cardiovascular diseases, stroke, and heart attack. Managing it is particularly challenging in areas
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32 with limited healthcare access and for patients who cannot attend regular in-person visits.
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34 Telemedicine interventions offer a promising solution by improving patient adherence and
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facilitating timely treatment adjustments. This study aims to systematically evaluate the impact of
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37 these telemedicine interventions on reducing systolic and diastolic blood pressure.
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39 Methods: A comprehensive search of PubMed, Scopus, and Web of Science was conducted to
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41 identify relevant studies. Two independent reviewers screened and selected eligible articles,
42 extracting key data using a standardized form. The quality of the included studies was assessed
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44 with the Mixed Methods Appraisal Tool (MMAT). A random effects model was used to combine
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46 the results, with treatment effects measured using standardized mean differences (Hedges's g).
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Consistency of findings was evaluated through statistical tests, including the Q test and I² statistic,
49 to assess heterogeneity. Data analysis was conducted using Stata statistical software version 17.0.
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52 Results: Of the 2700 articles retrieved, 35 studies were selected for inclusion in the analysis. Using
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54 a random-effects model, the overall effect size was Hedges's g = -0.22 (95% CI: -0.30 to -0.15; p-
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value < 0.001), indicating a small but meaningful reduction in blood pressure (systolic and
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3 diastolic). Telemedicine interventions had a greater impact on systolic blood pressure (Hedges's
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5 g = -0.27, 95% CI: -0.39 to -0.15; p-value < 0.001) compared to diastolic blood pressure (Hedges's
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7 g = -0.17, 95% CI: -0.26 to -0.07; p-value < 0.001), though both reductions were clinically relevant.
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10 Conclusion: This study demonstrates that telemedicine interventions significantly reduce both
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systolic and diastolic blood pressure, with a more pronounced effect on systolic pressure. The
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13 overall effect size indicates a small but meaningful improvement in hypertension management.
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15 These findings highlight the potential of telemedicine as an effective strategy for enhancing patient
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17 outcomes in hypertension care.
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Keywords: telemedicine, systolic blood pressure, diastolic blood pressure, blood pressure
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22 Introduction
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25 High blood pressure is a key risk factor for ischemic heart disease, stroke, other cardiovascular
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26 diseases (CVDs), chronic kidney disease, and dementia. It is one of the leading preventable causes
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28 of CVD-related deaths and disease burden worldwide, affecting most regions across the globe 1.
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30 Globally, elevated blood pressure is estimated to contribute to 7.5 million deaths, representing
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approximately 12.8% of all fatalities. This condition accounts for 57 million disability-adjusted
33 life years (DALYs), or 3.7% of the total DALYs. High blood pressure is a significant risk factor
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35 for coronary heart disease and both ischemic and hemorrhagic stroke 2. Blood pressure patients
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37 face many challenges that make effective management of the disease difficult. One of the most
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important challenges is the need for continuous and accurate follow-up of blood pressure 3, which
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40 is difficult for many patients, especially in situations where access to medical centers is limited 4.
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42 Moreover, despite significant advancements in developing new, effective, and safe
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44 pharmacological and non-pharmacological treatments, hypertension remains inadequately
45 controlled in real-world practice. In fact, less than 50% of hypertensive patients receiving
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47 treatment reach the recommended blood pressure (BP) targets, with even lower rates of BP control
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49 observed in patients classified as high or very high risk 4, 5. Additionally, Patients struggle to visit
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healthcare centers regularly due to high travel and treatment costs, long distances, and time
52 constraints from work or personal commitments. These challenges can delay diagnoses, control
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54 and treatment, negatively affecting health outcomes 6.
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3 To overcome these challenges, digital technologies such as telemedicine and digital therapies are
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5 rapidly advancing in clinical medicine and hold the potential to enhance care quality and the
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7 effectiveness of drug treatments. By offering timely, personalized interventions tailored to the
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needs of hypertensive patients and improving treatment adherence, these technologies can
10 significantly impact patient outcomes 7. Yatabe et al.,8 believed that telemedicine utilizing internet-
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12 based communication could reduce barriers to initiating and maintaining hypertension treatment,
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14 potentially helping to prevent cardiovascular disease. Telemedicine also offers significant benefits
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for blood pressure management by enhancing accessibility to healthcare services, allowing patients
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17 to consult with healthcare providers from home, which is particularly advantageous for those with
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mobility issues or living in remote areas 5, 9. It facilitates continuous monitoring through digital
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21 devices, enabling timely adjustments to treatment plans based on real-time data. Furthermore,
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22 telemedicine promotes patient engagement and education, fostering adherence to medication and
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24 lifestyle changes. This approach not only reduces the need for in-person visits but also improves
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26 the overall management of hypertension, leading to more effective systolic and diastolic blood
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pressure reduction 9. The findings of the umbrella review by Timpel et al.10, show that telemedicine
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29 enhances clinical outcomes for patients with hypertension and diabetes.

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32 To our knowledge, no meta-analysis has specifically evaluated the impact of telemedicine

33 interventions on both systolic and diastolic blood pressure reduction. Existing research includes
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35 systematic reviews and meta-analyses on various aspects of telemedicine, such as its effects on
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37 systolic blood pressure in stroke patients 11, hypertension management in low- and middle-income
38 12, 13.
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countries and blood pressure reduction in chronic disease populations Additional studies
40 address clinical outcomes 14, diabetes management 15, and nurse-led telehealth interventions 16.
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42 Therefore, our study aims to fill this gap by systematically reviewing and analyzing the impact of
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44 telemedicine interventions on both systolic and diastolic blood pressure reduction.
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46 Methods
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Study design
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51 We adhered to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses
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53 (PRISMA) guidelines in preparing this study. Our meta-analysis encompasses published
54 randomized controlled trials (RCTs) examining the impact of telemedicine interventions on the
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56 reduction of both systolic and diastolic blood pressure, with no restrictions on publication dates.
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3 Data sources and search strategies
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6 We employed the PubMed, Scopus, and Web of Science databases to perform a systematic search
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for published studies, without any limitations on publication dates. The search strategy was
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9 collaboratively crafted by two researchers and later reviewed and approved by a third researcher
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11 to ensure its rigor and comprehensiveness. The specific keywords and search strategies utilized in
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13 this process are detailed below:
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15 ("hypertension" OR "hypotension" OR "hypertensive" OR "blood pressure" OR "high blood
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17 pressure" OR "Arterial Pressure" OR "Venous Pressure") AND ("self-management" OR "self
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care" OR "self management" OR "self monitoring" OR "self-monitoring" OR "self-care") AND
20 ("telemedicine" OR "telehealth" OR "eHealth" OR "e-health" OR "mHealth" OR "m-health" OR
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22 OR "mobile health" OR "Text Messaging" OR "Smartphone")

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24 Study selection criteria
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27 Inclusion criteria
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29 We included only randomized controlled trials (RCTs) to ensure the highest level of evidence.
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31 Studies were selected if they involved patients with essential hypertension (elevated systolic and/or
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diastolic blood pressure) and investigated telemedicine interventions (e.g., mobile apps, video
34 consultations, remote monitoring, SMS) aimed at managing blood pressure. Studies had to report
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36 changes in systolic or diastolic blood pressure as primary outcomes, include a control group
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38 receiving standard care or an alternative intervention, and have any length of follow-up. Only
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English-language studies were considered to maintain language uniformity and accessibility.
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42 Exclusion criteria
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44 We excluded conference abstracts, research protocols, pilot studies, duplicate reports, and non-
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46 peer-reviewed materials to ensure the inclusion of fully validated research. Studies with
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48 incomplete or irrelevant data on blood pressure outcomes, those not primarily focusing on
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telemedicine interventions, or those involving non-telecommunication-based interventions were
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51 excluded. Additionally, research not involving patients with essential hypertension, or non-
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53 randomized controlled trials, observational studies, case reports, and reviews were omitted to focus
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55 solely on high-quality RCT evidence.
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3 Study selection
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6 The records retrieved from multiple databases were imported into EndNote V.X9.3.3 software for
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management. After the initial import, duplicate entries were identified and removed. Two
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9 independent researchers then performed a double-blind review of the remaining titles, abstracts,
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11 and additional relevant content, systematically excluding studies that did not meet the pre-
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13 established inclusion criteria. The reasons for excluding each study were meticulously
14 documented. Next, the full texts of potentially eligible studies were examined to ensure they met
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16 all inclusion criteria. Studies that were found not to be eligible upon full-text review were
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18 excluded, with the reasons for their exclusion noted. In cases where the information in the studies
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was ambiguous or insufficient for a clear decision, the literature was subjected to a second round
21 of screening. This process included attempts to contact the authors via email to obtain any missing
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23 or unclear information critical to the study's inclusion.
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Any disagreements between the two reviewers regarding study eligibility were resolved through
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27 discussion. If consensus could not be reached, a fourth investigator was consulted to provide a
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31 Data collection and extraction process
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33 For the purpose of ensuring accurate and systematic data collection, the research team developed
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35 a comprehensive and standardized data extraction form using Microsoft Excel version 2019
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37 (Microsoft Corp., Redmond, WA, USA). This form included a broad range of variables necessary
38 for the analysis. The data fields captured included the author(s), publication year, country of study,
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40 population diagnosis, mean (and SD) age in the control and treatment groups, sample size
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42 (including breakdown by gender), as well as details on the telemedicine intervention and control
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conditions, including type and duration. Additionally, the form recorded specific information on
45 the impact of telemedicine interventions on systolic and diastolic blood pressure reduction,
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47 including mean and standard deviation (SD) values for both the experimental and control groups.
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49 The data extraction process involved two independent researchers who thoroughly reviewed the
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51 original articles and selected studies that met the predetermined inclusion criteria. These
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53 researchers then independently extracted and entered the data into an Excel spreadsheet. To ensure
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consistency and accuracy, the extracted data was subsequently reviewed by a third and a fourth
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3 investigator. In cases where discrepancies arose between the two primary researchers, discussions
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5 were conducted to reach a consensus. If disagreements could not be resolved through discussion,
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7 the third or fourth investigator was consulted to provide a final decision.
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9 Quality assessment
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12 To evaluate the methodological quality and risk of bias of each included study, two authors
13 independently utilized the Mixed Methods Appraisal Tool (MMAT, version 2018: Hong et al.,
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15 2018). The MMAT is a comprehensive risk-of-bias tool specifically designed for assessing mixed
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17 methods, qualitative, and quantitative research. This tool evaluates studies across five key
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domains: the clarity and relevance of the research questions, the appropriateness of the study
20 design and methodology, the validity and reliability of data collection and analysis, the
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22 presentation and interpretation of results, and the overall rigor of the study.
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24 Data synthesis and analysis
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26 Data synthesis and analysis were conducted using STATA version 17.0 software. To assess
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28 potential study bias, we employed several methods: a funnel plot, Egger's test, and Begg's test. The
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30 funnel plot visually represents the probability of publication bias by examining asymmetry; greater
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asymmetry in the plot suggests a higher likelihood of bias in smaller studies. Both Egger's and
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33 Begg's tests provide statistical evaluations of this bias.
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To evaluate heterogeneity among the effect sizes of the included studies, we used the I² statistic,
37 which measures the percentage of variance in effect sizes due to heterogeneity rather than chance.
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39 The degree of heterogeneity was also formally tested using the Q statistic. An I² value of 25%
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41 indicates low heterogeneity, 50% indicates moderate heterogeneity, and 75% suggests high
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heterogeneity.
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45 We calculated standardized mean differences using Hedges' g to compare the treatment and control
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groups. Additionally, meta-regression analysis was performed to explore whether study-specific
48 variables moderate the observed heterogeneity. Given the expected variability among studies, a
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50 random effects model was utilized to calculate a 95% Confidence Interval (CI) for the effect sizes.
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52 All analyses were carried out using STATA version 17.0 to ensure robust and accurate results.
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54 Results
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3 Study Selection
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6 The systematic literature search and study selection process is illustrated in Figure 1. Our
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comprehensive search strategy resulted in a total of 2700 possibly pertinent papers. 1764 different
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9 papers were thoroughly assessed against our established inclusion and exclusion criteria after
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11 duplicates were eliminated. After a thorough screening process, 35 papers which met all eligibility
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13 standards were selected to be included in our evaluation.
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17 PubMed Scopus Web of Science
18 (n=814) (n=1251) (n=635)
Identification

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23 Records identified through
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27 Records after duplicates
Screening

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31 Records excluded after evaluation of
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32 Records after screening title and abstract

33 (n=250) (n=160)
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Eligibility

36 Full-text articles excluded (n=55)

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38 Full-text articles assessed -Lack of complete and comprehensive
39 for eligibility (n=90) information in studies (n=50)
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-Research protocol or protocol study
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(n=5)
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Included

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Articles included in the
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review (n=35)
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Fig1. PRISMA flowchart of screened and included studies to assess the effect of Telemedicine
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49 interventions on on systolic and diastolic blood pressure reduction
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52 Quality assessment
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3 Using the Mixed Methods Appraisal Tool, the methodological quality of the included studies was
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5 rigorously evaluated (MMAT). The results of the quality appraisal approach are fully presented in
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7 Appendix A.
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9 Study characteristics
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11 Table 1 provides a comprehensive overview of the key characteristics of the studies included in
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13 this systematic review and meta-analysis.
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3 Table 1: Characteristics of the included studies to assessing the impact of telemedicine interventions on systolic and diastolic blood
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5 pressure reduction.
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7 Reference Year Country Population diagnosis Mean (SD) Mean (SD) Intervention in control intervention in Sample Session's
8 age in age in group treatment group size length\ or
9 control treatment (M/F) Study
10 group group Period
11 2008 South Patients with 54.6 (11.0) 53.2 (6.9) Lifestyle Short message service 49(26/2 8-weeks
12 17 Korea hypertension and recommendations (SMS) by cellular 3)

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13 obesity phone and Internet
14 2008 USA Individuals with heart 77.5 (not 74.2 (not Usual care Website 40(13/2 1-year
15 18 failure mentioned) mentioned) 7)

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16 2011 USA Individuals with Type 53.2 (8.4) 52(80) Usual care Mobile diabetes 62(31/3 12-Months
17 19 2 diabetes and management software 1)

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18 Glycated hemoglobin application and a web
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20 2012 Mexico Participants with high 57.1 (1.1) 58.0 (1.3) Usual care Telephone calls 200(not 6-weeks
21 20 SBPs (>=140 mm Hg mention
22 if nondiabetic and ed)

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23 >=130 mm Hg if
24 diabetic)
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21 2012 Netherlands Patients with a 59.2 (8.9) 60.7 (7.8) Usual care based on the Website 330(246 12-months
26 atherosclerosis in the 2006 Dutch cardiovascular /84)
27 coronary, cerebral, or risk management guideline
28 peripheral arteries
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22 2013 US Patients with diabetes 61.6 (11.4) 59.6 (12.1) Use of a similar tool Website 500(282 12-months
30 or chronic kidney suggested question to /218)
31 disease( with askabout preventive
≥140/≥90 mmHg) services (eg, cancer
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screening)
33 23 2014 Taiwan Patients with type 2 57.0 (7.5) 56.6 (7.7) Usual-care for education Internet based tele 95(54/4 6-months
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diabetes who had a session sessions by tele 1)
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glycosylated conference technology
36 hemoglobin (HbA1c)
37 24 2015 Italy Subjects with type 2 57.8 (8.9) 59.1 (10.3) Followed by general Telephone 302(153 12 months
38 diabete, Age >45 practitioner as usual care /149)
39 years, and>130/80
40 mm
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3 25 2016 South General adult 54.7 (11.6) 54.2 (11.6) Usual care SMS text-messaging 458(331 12-months
4 Africa population age >=21 /127)
5 years diagnosed with
6 hypertension
7 26 2016 Hypertensive patients 57.7 (8.7) 57.5 (8.6) A standard disease Web-based disease 95(30/6 6-month
8 management program management program 5)
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2016 Belgium People with type 2 62.4 (8.9) 63.8 (8.7) Usual care Telephone calls 574(353 18-months
10 27 diabetes /221)
11 28 2016 England Adults with a high risk 67.3 (4.7) 67.5 (4.9) Usual care Telephone calls 867 12-months
12 of cardiovascular (126/74

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13 disease 1)
14 29 2016 China People with diabetes 53.5 (12.4) 55.0 (13.1) Usual care Mobile application 100(57/ 3-month
15 43)

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16 30 2017 UK Patients with diabetes 55.8 ( 13.8 58.2 ( 13.6 Usual care Mobile telehealth 81(46/3 9-months
17 (MTH) 5)

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18 31 2017 USA Type 2 diabetes 49.1 (10.6) 47.8 (9.0) Usual care SMS 126(32/ 6-months
19 patients 94)

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20 32 2017 Saudi Patient with diabetes 39.71(9.39) 40.37(10.23) Standard medical care BJILSE program 200(100 6-months
21 Arabia mellitus patients (Short-text and audio- /100)
22 visual messages)

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23 33 2019 China Patient with both 59.5 (9.1) 59.5 (9.4) Usual care SMS 502(414 6-months
24 coronaryheart disease /88)
25 and diabetes mellitus
26 34 2019 Nigeria Patients with stroke 55.86(11.84) 58.58(11.49) A standardized version of SMS, and educational 400(254 12-months
27 the usual care video /146)
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35 2019 Pakistan Hypertensive patients Not Not Usual care SMS 120(not 3-Months
30 mentioned mentioned mention
31 ed)
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36 2019 India Patients with type 2 44.1(8.9) 42.4(8.5) Standard care SMS 248(168 24 months
diabetes /80)
33 37 2020 Turkey Patients with type 2 57.69 (9.15) 55.74 (8.57) Did not receive any SMS 101(48/ 6 months
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diabetes mellitus intervention during the 53)
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study.
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38 2020 USA Patients with 58.97 (8.37) 60.0 (9.49) Receiving the printed Web-based education 60(15/4 3-months
hypertension educational materials on and medication app 5)
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managing hypertension
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39 2020 China Hypertensive patients 53.42(8.78 52.35(9.46 the conventional mode Mobile application - 117(59/ 3-months
41 group WeChat 58)
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3 40 2021 Japan Participants aged ≥ 20 55.8 (12.8) 49.2 (12.8) Usual care Email, SMS 28(20/8 6- months
4 years, with obesity )
5 and/or metabolic
6 disorders
7 41 2021 Russia Patients with high 60.0 (4.0) 59.7 (4.9) Routine care with Telephone call 28(20/8 1-year
8 cardiovascular risk individual single-session 0)
9 counseling
10 42 2021 USA Patients with 51.38 (9.0) 61.90(18.79) received the technology- web-based education 18(5/13 12-weeks
11 hypertension based intervention alone. )
12 43 2021 China Patients with stroke 65.2 (8.2) 66.2 (8.2) Usual care and village An Android-based 28(17/1 12-

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13 doctors maintained general smart phone 1) months
14 practices and Basic Public application
15 Health Services

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16 2022 China Hypertensive patients 61.50(10.17) 59.64 (9.76) Usual care provided by the Smartphone application 182(91/ 12-weeks
17 44 community health service 91)

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18 centres, including medical
19 follow-ups and health

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21 45 2022 Bangladesh Adults with CKD 57.97(15.03) 57.32(14.37) Usual care Mobile phone call 126(43/ 6-months
22 83)

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23 46 2022 Turkey Patients with T2DM 55.21 (8.72) 52.90 (8.96) No intervention SMS and a phone call 63(26/3 12-weeks
24 7)
25 47 2022 Hong Kong Older adults 77.4 (8.2) 77.6 (7.84) Usual care ( such as health Smartphone app 221(36/ 3-months
26 talks and recreational 185)
27 activities)
28 48 2022 China Patints with coronary 63 (7.38) 58.83 (9.11) Nursing telephone advice Mobile Application 60(26/3 3-months
29 cardiac risk factors 4)
30 2023 USA Patints with T2DM 58.60 (9.72) 59.12(10.62) Asynchronous Website 125(86/ 12-months
31 49 WebControl site 125)
32 50 2023 United Patints with chronic 61.0 (15.6) 56.5(15.7) Patient View home based Website, and 61(42/1 12-weeks
33 Kingdom kidney disease Website Telephone call 9)
34 51 2023 China Patients with 50.70(14.31) 50.90(14.21) Usual care WeChat-based Mobile 175 6-months
35 hypertension Application (88/87)
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3 Overall Effect Size
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6 The random-effects model yielded a significant overall effect size with a Hedges's g of -0.22 (95%
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CI: -0.30 to -0.15; p-value< 0.001), indicating a small but meaningful reduction in blood pressure
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9 due to telemedicine interventions. The test statistics for the effect size were highly significant, with
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11 a z-value of -5.62 and a p-value of 0.00, confirming the overall positive impact of telemedicine
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13 interventions on blood pressure reduction. The studies by MA et al. 44, and Yan et al. 43, showed
14 the greatest effect sizes among all the studies included in the analysis. On the other hand, the study
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16 by Still et al. 42 exhibited the smallest effect size (Appendix B).
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Effect size in systolic blood pressure studies
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21 The random-effects model revealed a significant overall effect size with a Hedges's g of -0.27
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23 (95% CI: -0.39 to -0.15; p-value< 0.001), indicating a small but clinically relevant reduction in
24 systolic blood pressure due to telemedicine interventions (Fig 2). The test statistics further
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26 confirmed the significance of the results, with a z-value of -4.45 and a p-value of 0.00. This
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28 suggests that telemedicine interventions lead to a small but significant reduction in systolic blood
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pressure. Individual studies reported varying effect sizes, with the most notable reductions
31 observed in studies such as Yan et al 43. Conversely, Still et all, 42 had the smallest effect size .
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44 Figure 2: Forest plot of studies assessing the effect of telemedicine interventions on systolic
45 blood pressure reduction
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Effect size in diastolic blood pressure studies
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51 The random-effects model indicated a significant overall effect size with a Hedges's g of -0.17
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53 (95% CI: -0.26 to -0.07), suggesting a small but clinically relevant reduction in diastolic blood
54 pressure attributed to telemedicine interventions (Fig 3). The test statistics further confirmed the
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3 significance of the results, with a z-value of -3.44 and a p-value of 0.00. The smallest and largest
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5 effect sizes were observed in the studies by Still et al. 42 and Yan et al. 43, respectively.
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47 Figure 3: Forest plot of studies assessing the effect of telemedicine interventions on diastolic
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blood pressure reduction
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52 Publication bias
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The funnel plots displayed a relatively symmetrical distribution of studies around the estimated
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56 overall effect size (θ_iv), suggesting minimal evidence of publication bias (Figure 4, 5). However,
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3 the regression-based Egger's test yielded p-values of 0.496 and 0.2496 for systolic and diastolic
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5 studies, respectively. This indicates no significant small-study effects, suggesting that smaller
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7 studies are not disproportionately influencing the overall effect size. A p-value greater than 0.05
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9
supports the absence of bias related to study size.
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11 Similarly, Begg's test produced p-values of 0.205 and 0.1739 for systolic and diastolic studies,
12
13 respectively. This result further corroborates the findings from Egger's test, indicating no
14 significant evidence of publication bias based on the correlation between effect size and study
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16 precision.
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Figure 4: Funnel plot of studies assessing the effect of telemedicine interventions on systolic
38 blood pressure reduction
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3 Figure 5: Funnel plot of studies assessing the effect of telemedicine interventions on diastolic
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5 blood pressure reduction
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7
Heterogeneity among included studies
8
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The analysis revealed a heterogeneity statistic (I²) of 84.53% and 66.68% in systolic and diastolic
10
11 studies, respectively, indicating variability among the studies. This suggests that the differences in
12
13 effect sizes are likely not due to chance alone, and there may be underlying factors contributing to
14
15 this variability.
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17 The Q-test for heterogeneity resulted in values of Q(35) = 161.39 and Q(30) = 73.18 for systolic
18
19 and diastolic studies, respectively, with a p-value of 0.00. This statistically significant result
20
confirms that the studies included in the meta-analysis exhibit significant heterogeneity.
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23 Meta-regression analysis
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25 Meta-regression analysis identified type of disease as the only significant moderator of the effect
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27 of telemedicine interventions on systolic blood pressure reduction (effect size = 30.53, p = 0.002).
28
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29 This suggests that the effectiveness of telemedicine interventions in lowering blood pressure varies
30
depending on the type of disease being treated. Other potential moderators, such as gender, age,
31
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32 sample size, and type of telemedicine intervention, did not significantly influence the effect size
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34 (p-values from 0.064 to 0.904).
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36 In contrast, diastolic blood pressure analysis highlighted significant effects for gender (effect size
37
38 =47.40, p = 0.001) and type of disease (effect size=45.4, p = 0.002), while age, sample size, type
39
40 of telemedicine intervention, and follow-up duration did not show significant influence (p-values
41
from 0.412 to 0.771).
42
43
44 Table 2: Effect sizes for meta-analyses on moderators in systolic and diastolic studies
45
46 Systolic blood pressure moderators
47 Variables Effect size I2 (%) Variance z-value P-value
48 Gender 9.65 83.26 .08883 -1.85 0.064
49 Age 0.00 84.84 .103 -0.12 0.904
50 Sample size 0.00 84.93 .1008 0.37 0.710
51 Type of telemedicine intervention 0.00 84.30 .1024 -0.19 0.851
52 Type of disease 30.53 78.52 .0683 3.03 0.002
53 Follow up duration 0.00 84.86 .1025 0.43 0.666
54 Diastolic blood pressure moderators
55 Variables Effect size I2 (%) Variance z-value P-value
56 Gender 47.40 51.63 .02173 -3.20 0.001
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3 Age 0.00 69.27 .0472 0.59 0.555
4 Sample size 7.72 64.89 .03812 1.37 0.170
5 Type of telemedicine intervention 0.00 67.06 .04456 -0.29 0.771
6 Type of disease 45.47 51.28 .02253 3.14 0.002
7 Follow up duration 0.00 67.32 .04325 0.82 0.412
8
9
Discusion
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11 To evaluate the effectiveness of telemedicine interventions in managing hypertension, this meta-
12
13 analysis aimed to assess their impact on systolic and diastolic blood pressure reduction. The
14
15 findings from our systematic review and meta-analysis suggest that telemedicine interventions are
16
17
effective in reducing both systolic and diastolic blood pressure in patients with hypertension. The
18 overall effect size, although small, was statistically significant and clinically relevant, with a more
19
20 substantial reduction observed in systolic blood pressure compared to diastolic blood pressure.
21
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22 These findings align with previous studies, such as a meta-analysis that included 117 studies with
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24 over 68,000 participants, which similarly reported significant reductions in office systolic blood
25
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26 pressure across various intervention periods, modes of delivery, and settings 52. The study found
27
28
that digital health interventions (DHIs) for telemedicine significantly improved blood pressure
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29 management compared to usual care, with reductions in systolic blood pressure ranging from -3.21
30
31 mmHg to -4.81 mmHg, depending on the intervention type and patient population 52. Other meta-
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33 analysis of 55 randomized controlled trials involving 9,258 diabetes patients showed that
34
telemedicine was more effective than conventional care in improving treatment outcomes. This
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36 effect was especially pronounced in patients with type 2 diabetes, where the effect size was nearly
37
38 twice as large as in those with type 1 diabetes 15. Furthermore, our results are supported by a meta-
39
40 analysis of 16 randomized clinical trials that specifically investigated telemedicine-based lifestyle
41 interventions. This study found that telemedicine significantly reduced both systolic and diastolic
42
43 blood pressure, with notable efficacy in interventions lasting six months or longer 13. Aditionally,
44
45 Lv et al.11, found that telemedicine and mHealth reduced systolic blood pressure in stroke survivors
46
47
by an average of 5.49 mm Hg compared to usual care. These interventions show promise for
48 managing systolic blood pressure in stroke patients, particularly those with hypertensive stroke.
49
50 11, 53
51 Various studies demonstrate that telemedicine enhances blood pressure management by
52 offering continuous monitoring and timely feedback, which facilitates better control of blood
53
54 pressure levels. It increases accessibility for patients in remote or underserved areas, ensuring they
55
56 receive consistent care without the need for frequent in-person visits 6. Other studies show that
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3 telemedicine improves treatment compliance by supporting patient adherence through reminders
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5 and direct communication with healthcare providers 54. Additionally, it reduces healthcare costs
6
7 by minimizing the need for travel and optimizing resource use. Increased patient engagement
8
9
through tracking tools and educational resources empowers individuals to actively participate in
10 their hypertension management, contributing to more effective blood pressure control 6.
11
12
13 Overall, these findings underscore the effectiveness of telemedicine in managing hypertension and
14 improving patient outcomes. The consistent positive impact observed across various studies
15
16 highlights the value of integrating telemedicine into routine care, particularly in settings where
17
18 traditional healthcare access is limited. Future research should focus on refining these
19
20
interventions, exploring factors that enhance their effectiveness, and determining their optimal
21 application across diverse patient populations and healthcare environments.
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22
23
24 Limitations of the Study
25
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26 Several limitations remain in this study. Firstly, only PubMed, Scopus, and Web of Science were
27 searched. Secondly, focusing solely on randomized controlled trials (RCTs) may exclude
28
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29 potentially valuable insights from non-RCT studies, which could offer additional perspectives on
30
31 the impact of telemedicine interventions. Additionally, reliance on studies published in English
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32
might introduce language bias, potentially overlooking relevant research published in other
33
34 languages. Future research could benefit from including a broader range of study types and
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35
36 databases and exploring studies in multiple languages to provide a more comprehensive
37
38 understanding of telemedicine's impact on blood pressure reduction.
39
40 Conclusion
41
42
In this study, we assessed the impact of telemedicine interventions on the reduction of systolic and
43
44 diastolic blood pressure. Our study demonstrates that telemedicine interventions have a
45
46 statistically significant and clinically relevant impact on reducing both systolic and diastolic blood
47
48 pressure in patients with hypertension. While the overall effect size is small, the reduction in blood
49 pressure is meaningful, with a more pronounced effect observed on systolic blood pressure. Given
50
51 the increasing prevalence of hypertension and the challenges associated with traditional in-person
52
53 care, telemedicine presents a viable solution for improving patient outcomes. These results
54
55
underscore the importance of integrating telemedicine into hypertension management strategies,
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3 especially in areas with limited healthcare access, to enhance patient adherence and facilitate
4
5 timely interventions. Future research should continue to explore the long-term effects and optimal
6
7 implementation strategies for telemedicine in managing hypertension.
8
9
10 Competing interests
11
12 The authors declare that there are no conflicts of interest.
13
14
Author contributions
15
16
17 KM, and MA conceived the study design. PP, and MA conducted title/abstract and full-text
18
19
screening. AS and MH performed the data extraction. KM, MA, BS, and RM wrote the manuscript
20 and all the authors contributed to reviewing the manuscript.
21
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22
23 Acknowledgments
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25 The authors would like to express their gratitude to the Central Library and Documentation
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26
27
Center of Smart University of Medical Sciences for granting access to the knowledge base
28 references required for this study.
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31 Funding
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33
Not applicable.
34
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36 ORCID IDs
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38
39 Khadijeh Moulaei: 0000-0002-5730-3972
40
41
42
43
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