The Paradox of Access: Why Remote Hypertension Management Struggles with Engagement
Despite the universal recommendation of home blood pressure monitoring (HBPM) as a cornerstone of hypertension management, a significant ‘engagement gap’ persists in clinical practice. While remote patient monitoring (RPM) programs have been lauded as the future of chronic disease management, new data suggests that simply providing tools and human support may not be enough to overcome the inherent burdens of self-monitoring. A recent retrospective cohort study conducted within the Mass General Brigham healthcare system provides a sobering look at real-world patient engagement levels, revealing that a substantial portion of the population remains unreached by current intervention models.
Highlights
- Nearly one-third (32.7%) of patients enrolled in a remote hypertension program showed zero engagement with HBPM at the baseline phase.
- Only 34.8% of participants demonstrated high engagement, defined as 24-28 measurements per week.
- The study highlights that even with the removal of financial barriers (free devices) and the addition of personalized support (health navigators), adherence remains suboptimal.
- Innovation in passive or less burdensome monitoring technologies is likely required to achieve the population-level benefits of remote hypertension management.
Background: The Pillar of Hypertension Management
Hypertension remains the leading modifiable risk factor for cardiovascular disease, stroke, and renal failure globally. Clinical guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) increasingly emphasize HBPM over office-based readings to avoid ‘white coat hypertension’ and to capture a more representative profile of a patient’s blood pressure throughout the day.
Remote hypertension management programs were designed to bridge the gap between periodic clinic visits and daily self-management. By utilizing digital health tools, these programs aim to facilitate real-time data sharing, allowing for more rapid medication titration and lifestyle intervention. However, the effectiveness of these programs is entirely dependent on the patient’s willingness and ability to consistently perform measurements—a requirement that involves significant behavioral activation and time commitment.
Study Design and Population
This retrospective cohort study, published in JAMA Cardiology, analyzed data from a remote hypertension management program at Mass General Brigham in Boston. The study period spanned from September 2018 to June 2022, involving 3,390 adults with uncontrolled hypertension.
Intervention and Support
Participants were provided with free, automated, Bluetooth-enabled HBPM devices. Beyond equipment, the program offered a robust support structure including:
- Education on proper measurement techniques.
- Ongoing personalized support from healthcare navigators via telephone and secure messaging.
- Algorithm-guided medication titration overseen by clinical pharmacists and physicians.
Primary Measures
Engagement was measured as the frequency of weekly HBPM uploads. The researchers categorized engagement into four tiers:
- No engagement: 0 measurements per week.
- Low engagement: 1-11 measurements per week.
- Intermediate engagement: 12-23 measurements per week.
- High engagement: 24-28 measurements per week.
Key Findings: A Spectrum of Engagement
The study population had a median age of 61 years, with a slight majority of female participants (57.8%). A high burden of comorbidity was present, with 40.4% of patients having atherosclerotic cardiovascular disease (ASCVD) and 29.4% having diabetes. Despite the high-risk nature of this cohort and the resources provided, the results revealed a striking disparity in engagement levels.
The Engagement Gap
At the baseline assessment, 1,107 patients (32.7%) fell into the ‘no engagement’ category, meaning they did not record a single measurement despite being enrolled in the program. This finding is particularly significant because these patients had already consented to participate and had been provided with the necessary hardware.
Further breakdown of the data showed:
- Low engagement: 484 patients (14.3%).
- Intermediate engagement: 618 patients (18.2%).
- High engagement: 1,181 patients (34.8%).
While approximately one-third of the patients were highly diligent, the fact that nearly half of the cohort (47%) showed either no or low engagement suggests that the current ‘active’ monitoring model is not sustainable for a large segment of the population.
Clinical Implications: Moving Beyond Access
The Mass General Brigham study challenges the assumption that ‘access’—defined as providing devices and education—is the primary bottleneck in hypertension control. If 32.7% of patients do not engage even when the device is free and a navigator is calling them, the barriers must be deeper than financial or educational.
The Burden of Measurement
Taking a blood pressure reading correctly is a multi-step process. It requires the patient to sit still for five minutes, keep their feet flat on the floor, ensure their arm is supported at heart level, and refrain from talking or using a mobile device. Doing this twice in the morning and twice in the evening, as often recommended, is a significant ‘time tax’ on patients, especially those with busy work schedules or caregiving responsibilities.
Behavioral and Psychological Factors
For some patients, the act of monitoring can induce anxiety (the ‘obsessive’ monitoring effect) or, conversely, serve as a constant reminder of their illness, leading to avoidance. Additionally, digital literacy and the technical challenges of pairing Bluetooth devices can create friction that discourages use, even among those who are initially motivated.
Expert Commentary
Experts in digital health and cardiology suggest that these findings should prompt a shift in how we design remote monitoring interventions. While health navigators are valuable, they cannot physically perform the measurement for the patient. The study authors, led by Dr. O. Unlu and colleagues, suggest that ‘innovative methods of BP monitoring that are more convenient and less burdensome’ are essential.
This points toward the development and validation of passive monitoring technologies, such as wearable sensors, cuffless devices, or even smartphone-based optical sensing (transdermal optical imaging). If blood pressure data could be collected without requiring the patient to stop their daily activities, the ‘no engagement’ group might be significantly reduced.
Conclusion: Redefining Remote Care
In conclusion, the Mass General Brigham cohort study demonstrates that current remote hypertension management programs face a major hurdle in patient engagement. While these programs are effective for the one-third of patients who are highly engaged, they leave a substantial portion of the uncontrolled hypertensive population behind.
For clinicians, the takeaway is twofold: first, identify the ‘non-engagers’ early and investigate the specific barriers they face—whether they are technical, physical, or psychological. Second, the medical community must advocate for and help validate next-generation monitoring tools that minimize patient effort. Until monitoring becomes a ‘background’ activity rather than a ‘foreground’ chore, the full potential of remote hypertension management will remain unfulfilled.
References
1. Unlu O, Zelle D, Cannon CP, et al. Patient Engagement With Home Blood Pressure Monitoring. JAMA Cardiol. 2026; doi: 10.1001/jamacardio.2025.5196.
2. Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension. 2019;73(5):e35-e66.
3. Omboni S, McManus RJ, Bosworth HB, et al. Managing Hypertension in the Digital Era: Small Steps or a Giant Leap? Circ Res. 2021;128(7):1041-1057.
