e-Counselling tool enhanced efficacy of usual care for hypertension
e-Counseling for Self-Care Adherence Adds Therapeutic Benefit for Hypertension: The REACH Trial
Presented at ACC.17 by Rob Nolan
Several guidelines recommend pharmacotherapy with lifestyle counselling as the optimal strategy to reduce risk factors for CVD. Studies have shown that, in the context of hypertension, counselling for exercise and diet augments medical care with incremental reduction in blood pressure (BP). Within 12 months, reduction of 4.47 mmHg was seen in systolic BP (SBP) and of 2.29 between 12 and 24 months, achieved with moderate-to-high intensity programmes.
E-based interventions for hypertension have been shown to decrease BP in a range comparable to conventional lifestyle programmes. Heterogeneity of treatment effects across trials is a problem however, due to a diverse range of technology, variable theories of behaviour change, and absence of specified models of behavioural counselling.
The double-blind REACH trial aimed to assess whether e-counselling enhances BP control and CVD risk factor reduction at 12 months, for individuals with stage 1 or 2 hypertension (SBP/DBP 140-180/90-110 mmHg). The e-counselling protocol was ‘user-centered’ and collaborative, consisting of adapted components of evidence-based models of counselling.
After a baseline assessment, 264 patients were randomised to the web-based lifestyle counselling programme, or to the control situation of e-information provided on BP management. Before the 4-month assessment, weekly emails were sent, the next stage until the 8-month assessment consisted of bi-weekly emails, and until the 12-month assessments, monthly emails were sent. The emails to the e-Counseling group provided links to online multimedia and interactive tools to increase motivation and skills to begin and sustain a heart-healthy lifestyle. Emails to the control group linked to generic information about heart-healthy living and reducing high BP.
Primary outcomes were SBP/DBP, pulse pressure, measured with an automated office protocol, and non-HDL-c and Framingham Risk Index of 10-year absolute risk for CVD. Patients continued to receive usual care. Complete data was available for 97 control patients and 100 e-counselling patients.
- Change in SBP from baseline at 4 months was -5.6 mmHg (95%CI: -9 to -2) in controls, as compared with -8.2 mmHg (95%CI: -11 to -5) (P=0.35). At 12 months, the values were -6.0 mmHg (95%CI: -9 to -3) and -10.1 mmHg (95%CI: -13 to -8) (P=0.03).
- Change in pulse pressure from baseline at 4 months was -1.2 mmHg (95%CI: -4 to 1) in controls, as compared with -4.2 mmHg (95%CI: -6 to -2) (P=0.02). At 12 months, the values were -1.5 mmHg (95%CI: -4 to 1) and -4.3 mmHg (95%CI: -7 to -2) (P=0.04).
- Change in Framingham risk index from baseline at 4 months was -0.6% (95%CI: -1 to 0.1) in controls, as compared with -2.1% (95%CI: -3 to -1) (P=0.004). At 12 months, the values were -0.2% (95%CI: -1 to 2) and -1.9% (95%CI: -3 to -0.6) (P=0.01).
- Change in DBP from baseline at 4 months was -4.4 mmHg (95%CI: -7 to -2) in controls, as compared with -4.1 mmHg (95%CI: -6 to -2) (P=0.89).
- At 12 months, different changes in DBP from baseline were seen between males and females. In males, the values were -0.3 mmHg (95%CI: -2 to 2) in controls and -4.1 mmHg (95%CI: -6 to -2) (P=0.007). In females, the values were -6.0 mmHg (95%CI: -9 to -3) and -6 mmHg (95%CI: -9 to -3) (P=0.69).
- Change in non-HDL-c from baseline at 4 months was 4.5 mg/dL (95%CI: 0.4 to 9) in controls, as compared with -1.9 mg/dL (95%CI: -6 to 2) (P=0.03).
- At 12 months, different patterns in change in non-HDL-c from baseline were seen between males and females. In males, the values were 11.3 mg/dL (95%CI: 1.5 to 21) in controls and -4.3 mg/dL (95%CI: -13 to 5) (P=0.02). In females, the values were -0.7 mg/dL (95%CI: -9 to 7) and 4.6 mg/dL (95%CI: -4 to 13) (P=0.87).
These data show that the e-counselling programme enhanced efficacy of usual care for hypertension at 12 months. Clinically meaningful outcomes were seen, including a 10 mmHg lower SBP, which is associated with risk reductions of 20% of CVD events, 17% CHD, 27% stroke and 13% all-cause mortality. These findings provide support for a scalable phase III e-counselling trial for hypertension.
During the press conference, it was noted that in daily clinical practice, it is difficult to counsel patients adequately in a 10-minute appointment. This e-counselling method targeted at a motivational, evidence-based intervention, in a well-thought-out combination of factors, can therefore be a powerful additive approach in hypertension management. The physicians in the discussion panel agreed that it would be helpful to have an extra tool to improve compliance.
Dr. Nolan mentioned that future versions will include technology to track online which components of the programme worked best. After some additional work, they aim to make the core app freely available.
Subanalyses have not resulted in insights that may explain the gender differences observed.
Our coverage of ACC.17 is based on the information provided during the congress.