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Stroke is a common, harmful disease with high recurrence and mortality rates. Uncontrolled blood pressure is an important and changeable risk factor for stroke recurrence. Telemedicine and mobile health (mHealth) interventions may have the potential to facilitate the control of blood pressure among stroke survivors, but their effect has not been established.
This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to estimate the effects of telemedicine and mHealth interventions on the control of systolic blood pressure among stroke survivors.
The research literature published up to June 28, 2020, and consisting of RCTs related to telemedicine and mHealth interventions was searched in PubMed, EMBASE, Web of Science, and the Cochrane Library. The Cochrane risk of bias tool (RoB 2.0) was used to evaluate the quality of the studies. The Cochran
In total, 9 RCTs with a total sample size of 1583 stroke survivors met the inclusion criteria. Compared with the usual care, telemedicine and mHealth had a significantly greater impact on the control of systolic blood pressure (MD –5.49; 95% CI –7.87 to –3.10;
In general, telemedicine and mHealth reduced the systolic blood pressure of stroke survivors by an average of 5.49 mm Hg compared with usual care. Telemedicine and mHealth are a relatively new intervention mode with potential applications for the control of systolic blood pressure among stroke survivors, especially those with hypertensive stroke.
Stroke is a common, harmful disease and a main cause of death and disability worldwide. It has the characteristics of high morbidity, disability, recurrence, and mortality [
Noncommunicable diseases are the main causes for the increase in the incidence of stroke. Approximately 90.5% of global stroke diseases can be attributed to modifiable risk factors, among which hypertension is the most common for first and recurrent strokes but is modifiable [
Therefore, some researchers have tried to reduce the risk of recurrent cerebrovascular events through interventions to improve blood pressure after a stroke or transient ischemic attack. Telemedicine and mobile health (mHealth) interventions have a potential role in this endeavor. An increasing number of studies have been conducted on the use of telemedicine and mHealth interventions to manage systolic blood pressure in stroke survivors [
This study follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [
We included all studies that met the following requirements: the study’s design was an RCT, participants were diagnosed with a stroke (hemorrhagic stroke or ischemic stroke) or transient ischemic attack, interventions were provided for patients using telemedicine (with telemedicine defined as the provision of health services at a distance using a range of technologies, such as telephone, telemonitoring, etc [
Studies were excluded from the meta-analysis if any of the telemedicine and mHealth intervention or usual care management was independently discussed, or if the original research data were incomplete or unusable and useful data could not be obtained by contacting the original author.
The data were retrieved from the selected studies. The extracted data included study information (author, publication year, country), study characteristics (study population, sample size), participants’ characteristics (age, gender, baseline systolic blood pressure), intervention information (intervention mode, intervention interval), and main outcome indicators (systolic blood pressure). The required data were extracted independently by 2 researchers (ML and TW) and cross-referenced to avoid potential extraction errors. All disagreements were discussed with a third researcher to reach a consensus.
Two independent researchers used the Cochrane risk of bias tool (RoB 2.0) [
Stata version 14.0 (StataCorp) was used for the meta-analysis. The Cochran
A total of 13,998 studies were retrieved using the search strategy. After screening, 9 studies were included in the meta-analysis, comprising a total of 1583 patients: 798 in the mHealth intervention group and 785 in the usual care group. The literature screening process and results are shown in
Flow diagram of the selection of studies. mHealth: mobile health; RCT: randomized controlled trial.
The basic characteristics of the included studies are presented in
Cochrane risk-of-bias tool for randomized controlled trials (RoB 2.0).
Study | Bias arising from the randomization process | Deviations from intended interventions | Bias due to missing outcome data | Bias in measurement of the outcome | Bias in selection of the reported result | Overall risk of bias |
Adie et al (2010) [ |
Low | Low | Low | Low | Low | Lowa |
Hanley et al (2015) [ |
Some concerns | Some concerns | Low | Low | Low | Some concernsb |
Kerry et al (2013) [ |
Low | Low | Low | Low | Low | Low |
Lakshminarayan et al (2018) [ |
Low | Some concerns | Low | Low | Low | Some concerns |
Mackenzie et al (2013) [ |
Low | Some concerns | Low | Low | Some concerns | Some concerns |
Sarfo et al (2018) [ |
Low | Low | Low | Low | Low | Low |
Wan et al (2018) [ |
Low | Low | Low | Low | Low | Low |
Wang et al (2020) [ |
Low | Low | Low | Low | Low | Low |
Ögren et al (2018) [ |
Low | Some concerns | Some concerns | Low | Low | Some concerns |
aLow: when present in this column, this indicates the study is judged to be at low risk of bias for all domains for this result.
bSome concerns: when present in this column, the study is judged to raise some concerns in at least one domain for this result, but not due to a high risk of bias for any domain.
Forest plot of the systolic blood pressure of the telemedicine and mHealth group and usual care group. mHealth: mobile health; WMD: weighted mean difference.
We conducted subgroup analyses of the intervention mode. When the intervention mode consisted of telephone plus SMS text messaging or only telephone, the telemedicine and mHealth group showed a larger effect on the control of systolic blood pressure than did the usual care group, with an MD of –9.09 (95% CI –12.71 to –5.46;
We also performed subgroup analyses of the intervention interval and baseline systolic blood pressure (
Forest plot of the subgroup analysis of the mode of intervention. mHealth: mobile health; WMD: weighted mean difference.
Forest plot of the subgroup analysis of the intervention interval. mHealth: mobile health; WMD: weighted mean difference.
Forest plot of the subgroup analysis of the baseline systolic blood pressures. mHealth: mobile health; WMD: weighted mean difference.
Funnel plot inspection and the Egger test showed no publication bias (
Funnel plot of the systolic blood pressures. WMD: weighted mean difference.
Stroke is characterized by high recurrence and mortality rates [
As far as we know, this is the first systematic, quantitative analysis and summary of all available evidence of telemedicine and mHealth interventions for the management of systolic blood pressure in the population of stroke survivors. More importantly, we found that the stroke survivors in the telemedicine and mHealth group had better control of their systolic blood pressure than did the usual care group after receiving interventions that actively sent electronic messages (telephone calls, SMS text messages). This result may be expected because poor self-management and poor compliance are major problems affecting patients’ blood pressure control [
This meta-analysis included RCTs from different countries (the United States, the United Kingdom, Sweden, Ghana, and China), indicating that mHealth interventions may be applicable to people in different countries and different medical systems. Furthermore, the average baseline systolic blood pressure was 128.0-154.0 mm Hg, which indicates that the included studies targeted stroke survivors extensively for telemedicine and mHealth interventions. We found that among the stroke survivors with a baseline systolic blood pressure <140 mm Hg, there was no significant difference between the telemedicine and mHealth group and the usual care group. However, for stroke survivors with a baseline systolic blood pressure ≥140 mm Hg, the telemedicine and mHealth group had significantly better control of systolic blood pressure than did the usual care group. This is a major finding in stroke survivors with a baseline systolic blood pressure ≥140 mm Hg, which indicates that telemedicine and mHealth interventions may have greater benefits for stroke survivors with hypertension. If the proper intervention is conducted for an extended period, this may have a significant clinical impact.
Telemedicine and mHealth interventions are becoming an increasingly common way to support patients with chronic diseases in adhering to their medications and conducting self-management [
Our research has several limitations worth discussing. First, one of the main limitations is that the duration of the interventions included in the selected studies was relatively short. There was only 1 study over 12 months, and a lack of data from studies lasting more than 12 months makes it impossible to conduct subgroup analyses. Blood pressure control in stroke survivors may be a long-term process, requiring continuous lifestyle changes. It is important to understand the long-term (over 12 months) effectiveness and safety of telemedicine and mHealth interventions in stroke survivors. Thus, more research is needed for further analyses and verification. Second, compared with usual care, the telemedicine and mHealth intervention reduced the systolic blood pressure. Statistically speaking, the difference was significant, but its clinical significance still needs to be confirmed by further study. Third, as most of the included studies only provided limited information on the profiles of the participants, it was impossible to analyze the effects of some factors on the telemedicine and mHealth interventions, such as participants’ socioeconomic and educational status and combination of drugs, which still need to be explored further in future research.
Preliminary analysis shows that the telemedicine and mHealth interventions reduced the systolic blood pressure of stroke survivors by 5.49 mm Hg on average compared with patients who received usual care. Telemedicine and mHealth interventions may be an important strategy to promote the control of systolic blood pressure in stroke survivors, and this benefit may be even greater for patients with hypertensive stroke. We also found that telemedicine and mHealth interventions with active reminders via telephone calls or SMS text messages and an intervention interval ≤1 week may be more effective. In short, telemedicine and mHealth interventions are relatively new. If used correctly, they have potential application in the control of systolic blood pressure in stroke survivors, specifically those with hypertensive stroke.
Search strategy.
Characteristics of the 9 randomized controlled trials included in the study.
mean difference
mobile health
prediction interval
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
This study was funded by the Natural Science Foundation of Fujian Province of China (grant 2018Y0037) and the Fujian Medical Innovation Project of China (grant 2019-CX-19).
JZ initiated the study. ML and TW performed the data extraction and analyses. ML drafted the first version of the manuscript. JZ and ML critically reviewed the manuscript and revised it. All authors made a substantial contribution to the concept and design of the study, interpreted the data, and reviewed the manuscript.
None declared.