Improving treatment adherence in hypertension patients: a randomised controlled trial

Background. Arterial hypertension remains one of the leading causes of cardiovascular complications and mortality worldwide. A key factor in effective AH management is high adherence to medication therapy; however, adherence levels remain insufficient. In recent years, digital technologies, including mobile applications designed to enhance treatment adherence, have been actively developing, yet data on their effectiveness remain limited.

Aim. To evaluate the impact of the mobile application CardioExpert.kz on treatment adherence and blood pressure control in patients with primary hypertension within a randomized controlled trial.

Materials and methods. The study included 633 patients with primary hypertension who were randomized into two groups: a control group (standard treatment) and an experimental group (using the mobile application). The primary efficacy indicators were changes in systolic and diastolic blood pressure levels, as well as treatment adherence assessed using the MMAS-8 scale. Results and discussion. After 1 month of observation, the experimental group showed a significant reduction in systolic (-10.74±20.89 mmHg) and diastolic blood pressure (-2.52±12.84 mmHg) compared to the control group (р<0.001).

Additionally, a statistically significant improvement in medication adherence was recorded (р<0.001).

Conclusions. The use of a mobile application demonstrated a positive effect on blood pressure control and adherence to treatment in patients with hypertension. However, further studies with a longer follow-up period are needed to assess the long-term effectiveness of digital technologies in hypertension management.

1. Ashoorkhani M., Bozorgi A., Majdzadeh R., Hosseini H., Yoonessi A., Ramezankhani A., Eftekhar H. Comparing the effectiveness of the BPMAP (Blood Pressure Management Application) and usual care in self-management of primary hypertension and adherence to treatment in patients aged 30–60 years: study protocol for a randomized controlled trial. Trials. 2016; 17 (1): 511. https://doi.org/10.1186/s13063-016-1638-0

2. Burnier M. Drug adherence in hypertension. Pharmacological Research. 2017; 125: 142-149. https://doi.org/10.1016/j.phrs.2017.08.015

3. Canoy D., Nazarzadeh M., Copland E., Bidel Z., Rao S., Li Y., Rahimi K. How Much Lowering of Blood Pressure Is Required to Prevent Cardiovascular Disease in Patients With and Without Previous Cardiovascular Disease? Current cardiology reports. 2022; 24 (7): 851- 860. https://doi.org/10.1007/s11886-022-01706-4

4. Chazova I.E., Zhernakova Y.V. Diagnosis and treatment of arterial hypertension [Guidelines]. Systemic Hypertension. 2019; 16 (1): 6-31. https://doi.org/10.26442/2075082X.2019.1.190179

5. Chowdhury R., Khan H., Heydon E., Shroufi A., Fahimi S., Moore C., Stricker B., Mendis S., Hofman A., Mant J., Franco O.H. Adherence to cardiovascular therapy: a meta-analysis of prevalence and clinical consequences. European Heart Journal. 2013; 34 (38): 2940-2948. https://doi.org/10.1093/eurheartj/eht295

6. Culig J., Leppée M., Boskovic J., Eric M. Determining the difference in medication compliance between the general patient population and patients receiving antihypertensive therapy: A case study. Archives of Pharmacal Research. 2011; 34 (7): 1143–1152. https://doi.org/10.1007/s12272-011-0712-0

7. Dayer L., Heldenbrand S., Anderson P., Gubbins P.O., Martin B.C. Smartphone medication adherence apps: Potential benefits to patients and providers. Journal of the American Pharmacists Association. 2013; 53 (2): 172-181. https://doi.org/10.1331/JAPhA.2013.12202

8. Dunbar-Jacob J., Mortimer-Stephens M.K. Treatment adherence in chronic disease. Journal of Clinical Epidemiology. 2011; 54 (12): 57-60. https://doi.org/10.1016/S0895-4356(01)00457-7

9. Heisler M., Choi H., Rosen A.B., Vijan S., Kabeto M., Langa K.M., Piette J.D. Hospitalizations and Deaths Among Adults With Cardiovascular Disease Who Underuse Medications Because of Cost. Medical Care. 2010; 48 (2): 87-94. https://doi.org/10.1097/MLR.0b013e3181c12e53

10. Ho P.M., Rumsfeld J.S., Masoudi F.A., McClure D.L., Plomondon M.E., Steiner J.F., Magid D.J. Effect of Medication Nonadherence on Hospitalization and Mortality Among Patients With Diabetes Mellitus. Archives of Internal Medicine. 2006; 166 (17): 1836. https://doi.org/10.1001/archinte.166.17.1836

11. Jha D., Gupta P., Ajay V.S., Jindal D., Perel P., Prieto-Merino D., Jacob P., Nyong J., Venugopal V., Singh K., Goenka S., Roy A., Tandon N., Patel V., Prabhakaran D. Protocol for the mWellcare trial: a multicentre, cluster randomised, 12-month, controlled trial to compare the effectiveness of mWellcare, an mHealth system for an integrated management of patients with hypertension and diabetes, versus enhanced usual care in India. BMJ Open. 2017; 7 (8): e014851. https://doi.org/10.1136/bmjopen-2016-014851

12. Jusipov А.К., Atarbayeva V.Sh., Koshumbayeva K.M. Hypertension prevalence in the different regions of Republic of Kazakhstan. Therapevticheskiy Vestnik. 2007; 2 (14): 33-34.

13. Kim J.Y., Wineinger N.E., Steinhubl S.R. The Influence of Wireless Self-Monitoring Program on the Relationship Between Patient Activation and Health Behaviors, Medication Adherence, and Blood Pressure Levels in Hypertensive Patients: A Substudy of a Randomized Controlled Trial. Journal of Medical Internet Research. 2016; 18 (6): e116. https://doi.org/10.2196/jmir.5429

14. Kim M. T., Hill M.N., Bone L. R., Levine D. M. Development and Testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Progress in Cardiovascular Nursing. 2000; 15 (3): 90-96. https://doi.org/10.1111/j.1751-7117.2000.tb00211.x

15. Kumar N., Khunger M., Gupta A., Garg N. A content analysis of smartphone–based applications for hypertension management. Journal of the American Society of Hypertension. 2015; 9 (2): 130-136. https://doi.org/10.1016/j.jash.2014.12.001

16. Mancia G., Kreutz R., Brunstr M., Burnier M., Grassi G., Januszewicz A., Lorenza Muiesan M., Tsioufis K., Agabiti-Rosei E., Abd Elhady Algharably E., Azizi M., Benetos A., Borghi C., Brguljan Hitij J., Cifkova R., Coca A., Cornelissen V., Kennedy Cruickshank J., Cunha P.G., Kjeldsen S.E. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). Journal of hypertension. 2023; 41 (12): 1874-2071. https://doi.org/10.1097/HJH.0000000000003480

17. Max R. Causes of death globally: what do people die from? https://ourworldindata.org/causes-ofdeath-treemap

18. Mazzaglia G., Ambrosioni E., Alacqua M., Filippi A., Sessa E., Immordino V., Borghi C., Brignoli O., Caputi A.P., Cricelli C., Mantovani L.G. Adherence to Antihypertensive Medications and Cardiovascular Morbidity Among Newly Diagnosed Hypertensive Patients. Circulation. 2009; 120 (16): 1598-1605 https://doi.org/10.1161/CIRCULATIONAHA.108.830299

19. Morawski K., Ghazinouri R., Krumme A., McDonough J., Durfee E., Oley L., Mohta N., Juusola J., Choudhry N.K. Rationale and design of the Medication adherence Improvement Support App For Engagement – Blood Pressure (MedISAFE-BP) trial. American Heart Journal. 2017; 186: 40-47. https://doi.org/10.1016/j.ahj.2016.11.007

20. Morisky D.E., Ang A., Krousel-Wood M., Ward H.J. Retracted: Predictive Validity of a Medication Adherence Measure in an Outpatient Setting. The Journal of Clinical Hypertension. 2008; 10 (5): 348-354. https://doi.org/10.1111/j.1751- 7176.2008.07572.x

21. Mukhtarkhanova D., Poulter N.R., Beaney T., Kiru G., Toopchiani S., Junusbekova G., Tundybayeva M. K., Baglanova L., Leonovich T., Ismailov E. May Measurement Month 2021: an analysis of blood pressure screening results from Kazakhstan. European Heart Journal. 2024; Suppl. 26: 48-50. https://doi.org/10.1093/eurheartjsupp/suae058

22. Muntner P., Halanych J.H., Reynolds K., Durant R., Vupputuri S., Sung V.W., Meschia J.F., Howard V.J., Safford M.M., Krousel-Wood M. Low Medication Adherence and the Incidence of Stroke Symptoms Among Individuals With Hypertension: The REGARDS Study. The Journal of Clinical Hypertension. 2011; 13 (7): 479- 486. https://doi.org/10.1111/j.1751-7176.2011.00464.x

23. Panahi S., Rathi N., Hurley J., Sundrud J., Lucero M., Kamimura A. Patient Adherence to Health Care Provider Recommendations and Medication among Free Clinic Patients. Journal of patient experience. 2022; 9: 23743735221077523. https://doi.org/10.1177/23743735221077523

24. Rosendorff C., Lackland D.T., Allison M., Aronow W.S., Black H.R., Blumenthal R.S., Cannon C.P., de Lemos J.A., Elliott W.J., Findeiss L., Gersh B.J., Gore J.M., Levy D., Long J.B., O'Connor C.M., O'Gara P.T., Ogedegbe G., Oparil S., White W.B. Treatment of Hypertension in Patients With Coronary Artery Disease. Circulation. 2015; 131 (19): 435-470. https://doi.org/10.1161/CIR.0000000000000207

25. Roth G.A., Abate D., Abate K.H., Abay S.M., Abbafati C., Abbasi N., Abbastabar H., Abd-Allah F., Abdela J., Abdelalim A., Abdollahpour I., Abdulkader R.S., Abebe H.T., Abebe M., Abebe Z., Abejie A.N., Abera S.F., Abil O.Z., Abraha H.N., Murray C.J.L. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018; 392 (10159): 1736-1788. https://doi.org/10.1016/S0140-6736(18)32203-7

26. Svarstad B.L., Chewning B.A., Sleath B.L., Claesson, C. The brief medication questionnaire: A tool for screening patient adherence and barriers to adherence. Patient Education and Counseling. 1999; 37 (2): 113-124. https://doi.org/10.1016/S0738-3991(98)00107-4

27. Whittle J., Schectman G., Lu N., Baar B., MayoSmith M.F. Relationship of Scheduling Interval to Missed and Cancelled Clinic Appointments. Journal of Ambulatory Care Management. 2008; 31 (4): 290-302. https://doi.org/10.1097/01.JAC.0000336549.60298.1d

28. Williams B., Mancia G., Spiering W., Agabiti Rosei E., Azizi M., Burnier M., Clement D.L., Coca A., de Simone G., Dominiczak A., Kahan T., Mahfoud F., Redon J., Ruilope L., Zanchetti A., Kerins M., Kjeldsen S.E., Kreutz R., Laurent S., Brady A. 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2018; 39 (33): 3021-3104. https://doi.org/10.1093/eurheartj/ehy339

29. World Health Organization. Death rate from cardiovascular diseases. https://ourworldindata.org/grapher/death-rate-from-cardiovascular-disease-agestandardized-ghe

30. Xiong S., Berkhouse H., Schooler M., Pu W., Sun A., Gong E., Yan L.L. Effectiveness of mHealth Interventions in Improving Medication Adherence Among People with Hypertension: a Systematic Review. Current Hypertension Reports. 2018; 20 (10): 86. https://doi.org/10.1007/s11906-018-0886-7

31. Zhou B., Carrillo-Larco R.M., Danaei G., Riley L.M., Paciorek C.J., Stevens G.A., Gregg E.W., Bennett J.E., Solomon B., Singleton R.K., Sophiea M.K., Iurilli M.L., Lhoste V.P., Cowan M.J., Savin S., Woodward M., Balanova Y., Cifkova R., Damasceno A., Ezzati M. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet. 2021; 398 (10304): 957-980. https://doi.org/10.1016/S0140-6736(21)01330-1