Outcomes of Team-Based Digital Monitoring of Patients With Multiple Chronic Conditions: Semiparametric Event Study

Remote patient monitoring (RPM) has emerged as an effective strategy for controlling hypertension by enabling patients to collect and transmit blood pressure (BP) data outside the clinic and supporting proactive care team interventions. While its benefits for hypertension management are well established, less is known about its effectiveness in patients with multiple chronic conditions (MCC), who experience higher morbidity, mortality, and costs.

This study aimed to evaluate the impact of an electronic health record (EHR)-integrated, team-based RPM program on patients with hypertension, alone or co-occurring with ischemic heart disease, type 2 diabetes, or both. This study aimed to determine whether referral to the program was associated with reductions in systolic blood pressure (SBP) across these patient groups.

We analyzed EHR data from patients referred by their primary care physicians to the University of California San Diego Health's Digital Health Program between October 2020 and July 2022. Eligible patients had hypertension, either alone or accompanied by at least 1 coexisting condition, such as ischemic heart disease or type 2 diabetes. Participants received a Bluetooth-enabled BP cuff and ongoing support from a multidisciplinary team, including nurse care managers and a pharmacist. A semiparametric event study design was used to estimate changes in SBP over 24 months, comparing prereferral and postreferral outcomes. To understand the program's impact, outcomes were analyzed for the full cohort of all referred patients and then scaled to reflect the average change in SBP among the program participants.

Among patients who had been referred to the program, those with hypertension only experienced an average reduction of 9.70 (SE 0.80) mm Hg in SBP by the end of the analysis horizon of 1 year. Patients with hypertension and either diabetes or ischemic heart disease experienced a reduction of 6.61 (SE 1.12) mm Hg, and those with all 3 conditions experienced a reduction of 6.60 (SE 1.72) mm Hg. The average reductions in SBP among active participants were 16.83 mm Hg, 13.22 mm Hg, and 16.01 mm Hg, respectively.

A team-based, EHR-integrated RPM program was associated with clinically meaningful SBP reductions among patients with MCC. The program leveraged existing EHR workflows for referral and monitoring and provided technical and clinical support to patients. These findings suggest that EHR-integrated RPM services can achieve substantial improvements in BP in high-risk populations. As reimbursement for RPM expands, such models represent a promising strategy for addressing hypertension and the disproportionate burden of MCC at the population level.