1. Introduction

The use of telemedicine technologies, such as mobile phones and other audio-visual smart devices, has significantly transformed disease management and improved access to ambulatory and subspecialty care for patients in disadvantaged populations [1–3]. Mobile health (M-health), as a subset of telemedicine, involves the use of mobile phones and other wireless technologies in health care. Wireless technologies in M-health enable easier access to caregivers, better disease monitoring, and ultimately higher health status [4]. Recent developments in M-health have introduced new opportunities for improving access to healthcare, enabling better self-management of chronic diseases, facilitating access to information, promoting healthy eating habits and increasing physical activity levels [4]. The COVID-19 pandemic has led to a rapid expansion in the use of telemedicine and M-health [5]. Patients often opt for remote appointments via communication technology when a physician is unavailable or during pandemics such as COVID-19 [1]. These appointments provide comparable outcomes to face-to-face care and result in higher levels of satisfaction for both healthcare professionals and patients [5]. During the COVID-19 pandemic, the use of smartphones and low-cost wireless devices linked to smartphone applications has facilitated the collection and dissemination of accurate data among patients and physicians, thereby limiting reporting errors [6].

The main purpose of telemedicine is to educate of consumers about preventive health care, disease monitoring, treatment support, epidemic tracking, and chronic disease management [7, 8]. Advanced technologies such as Bluetooth and motion detection sensors (such as accelerometer and gyroscope) have led to the creation of numerous applications, particularly for chronic diseases including diabetes [4], heart disease [9], kidney problems [10], and especially hypertension [4]. This allows patients with chronic diseases to access medical services more easily than in the pre-technology era [11].

Hypertension, also known as high blood pressure (BP), is a significant public health concern and the most common chronic disease in primary care [12]. It affects over one billion people worldwide [10]. In 2020, researchers reported a decline in both awareness of condition and effective management of hypertension among patients over the past decade [13]. The COVID-19 pandemic has worsened the problem, as the number of referrals of patients with hypertension to health care facilities have decreased by over 25% [14]. Failure to manage hypertension can result in various complications, including heart failure, cardiovascular disease, stroke, kidney disease, and ultimately death [10, 15].

However, hypertension can be effectively controlled with medication, diet and lifestyle changes, [16]. Patients with non-communicable diseases, such as hypertension, are particularly vulnerable to COVID-19. Therefore, disease management is of paramount importance during this pandemic [3]. additionally, the pandemic has posed challenges to the care of patients with chronic diseases, particularly hypertension [17]. These patients were at risk of not receiving essential care due to quarantine limitations [10]. Therefore, the health care system should develop new approaches to prevent, diagnose and treat of non-communicable diseases [18]. One such strategy is the use of telemedicine platforms, which can help address important gaps in hypertension management, including access to care, medication adherence and patient engagement with an efficient, effective and patient-centered approach [14]. the use of telemedicine is not without its own set of challenges. The first of these is related to the quality of the internet connection and the subsequent difficulties encountered when implementing technology. The second is related to lack of physical examinations [19]. In addition, issues such as individual, racial and ethnic factors, as well as a lack of health and digital literacy must be considered [20]. Furthermore, the lack of full health insurance coverage and reimbursement, constitutes a significant barrier to the wider adoption of telemedicine [21].

Telemedicine and M-health have become a practical and attractive solutions for improving hypertension management and saving time and money for patients, caregivers and physicians. They are also technological solutions for preventing the spread of disease, screening patients, improving the quality of care, and providing real-time follow-up for patients with hypertension [6]. Telemedicine offers the opportunity to control and prevent the progression of the disease by continuously monitoring BP, encouraging medication adherence, promoting proper diet, and lifestyle changes [22]. Studies conducted during the COVID-19 pandemic have shown the effectiveness of telemedicine in controlling hypertension, indicating the understanding of society, physicians, and patients of its potential to overcome the challenges associated with the pandemic. These studies offer valuable insights for developing effective strategies to promote the regular and meaningful use of telemedicine. The Covid-19 pandemic presented a significant challenge for patients with hypertension in terms of accessing to care. But on the other hand, telemedicine has opened up opportunities for the healthcare system that were previously underutilized. Therefore, the aim of this study is to conduct a systematic review of the applications and outcomes of telemedicine for managing hypertension during the COVID-19 pandemic.

2. Material and methods

The study followed to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. These guidelines provide a minimal set of evidence-based elements for reporting systematic reviews and meta-analyses and include a four-phase flow chart that has been approved as a standard by health science organizations and journals [23].

2.3 Selection process

The Mesh protocol was utilized to conduct a comprehensive search across all relevant databases. Subsequently, the findings were entered into Endnote software version 20. To eliminate any duplicates, we used the software’s duplicate elimination feature, followed by manual removal of any remaining duplicates by the first author. We then reviewed the article titles to discard any that did not align with the study’s objective. The articles’ abstracts underwent scrutiny to exclude any irrelevant ones. Two reviewers, H A and N CH, evaluated each study based on the title and abstract. They included approved studies and excluded rejected ones. If only one reviewer thought a study was good enough, the third reviewer (MH) decided. We then looked at all the articles that met the criteria and wrote up our findings in line with the PRISMA 2020 guidelines (Fig 1).

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Fig 1. PRISMA flow chart of the study selection process.

https://doi.org/10.1371/journal.pone.0306347.g001

3. Findings

Following the initial search, 3727 articles were retrieved. After reviewing the titles and abstracts, 33 articles were examined in full text. Of these, four full texts were unavailable, leaving 29 articles included in the present study (S1 Checklist). Additionally, all qualifying studies achieved the necessary quality score (S2 Appendix).

The majority of the studies (N = 15, 51.8%) were cohort studies that compared patients whose hypertension was managed using telehealth with a control group. A small number of clinical trials (N = 3, 10.3%) were conducted due to the epidemic and quarantine conditions, as well as the desire of physicians and patients to avoid in-person visits to prevent the transmission of infection. About one-third of the reviewed studies were observational articles (N = 11, 37.9%). Of the studies analyzed, 14 (48.3%) were conducted in 2022. The sample size of the studies ranged from 20 to 1,223,560 visits, and the age of the patients ranged from 18 to 88 years. Cohort studies lasted from four days to four and a half years, observational studies lasted from six months to six years, and RCTs lasted from three to four months (Table 1).

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Table 1. Characteristics extracted from the included studies.

https://doi.org/10.1371/journal.pone.0306347.t001

Out of the 29 studies reviewed, 6 articles (20.7%) focused only on hypertension control, while 23 articles (79.3%) examined hypertension as a comorbidity with other diseases. Three distinct strategies were employed to facilitate communication between providers and patients. The majority of studies reviewed employed exclusively proprietary platforms (n = 11) or in conjunction with public platforms (n = 3). A second approach involved the use of public platforms, such as public social messengers or email, exclusively (n = 5) or in conjunction with proprietary platforms(n = 3) or phone calls (n = 5). The final strategy involved the use of telephone calls, either exclusively(n = 6) or as an adjunct to public platforms (n = 3). Two studies did not provide any information regarding the communication mechanism. It is notable that six studies employed two strategies concurrently (public platforms in conjunction with proprietary platforms or telephone calls).

15 studies (51.7%) utilized both face-to-face and virtual meetings, including video calls, to regularly compare in-person blood pressure readings with those taken remotely by the patients themselves. The study identified 88 unique concepts, 15 initial themes, and six final themes related to the outcomes of using telemedicine in hypertension management (Table 2). 21 articles reported the effect of telemedicine on hypertension control, seven articles discussed measuring and recording BP, nine focused on medication management, three addressed mental health, five discussed care continuity, and finally 15 examined the acceptance and use of telemedicine among hypertension patients.

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Table 2. Outcomes of telemedicine implementation for hypertension management in COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0306347.t002

4. Discussion

This study investigates the applications and outcomes of telemedicine in managing hypertension amidst the COVID-19 pandemic. As health systems around the world struggle to meet user needs, telemedicine has emerged as the most effective way to reduce risks for healthcare workers and patients during the pandemic. Although it was previously used to some extent in developed countries, its use has now expanded exponentially. The increasing popularity of this healthcare approach is due to its prioritization of safety and convenience [42].

Our results indicate that countries with high internet and smartphone penetration have conducted the most cases of telemedicine implementations for hypertension management. This suggest that health policy makers can utilize existing strong technical infrastructure to ensure the continuous delivery of services to their target population. In general, the use of telemedicine, and mobile health in particular, to deliver health services during the COVID-19 pandemic experienced explosive growth [43]. However, this growth was primarily observed in societies that had already stablished the necessary technical infrastructure, legal framework, and administrative rules. This potential has also been utilized for managing hypertension, enabling the provision of care, the continuation of care and follow-up care in a non-attendance setting [44].

There are three different approaches in implementing telemedicine for hypertension management. The first approach involves using a proprietary application or platform for continuous monitoring and care of hypertension. The second approach involves using commonly available communication applications, such as email, WhatsApp, WeChat, or suitable remote communication programs, to effectively communicate with participants and transfer data, training and/or providing necessary instructions. The third approach relied on telephone communication. It should be noted that this approach may not be appropriate in all situations and requires further evaluation.

To understand how each method affects the study’s results, we analyzed the data. This analysis showed that proprietary platforms focus on final clinical outcomes, while studies using telephone calls focus on intermediate outcomes. Studies based on public platforms also fall somewhere in the middle.

Of the 21 studies on blood pressure control, 11 used proprietary systems, 6 studies used public systems, and 4 studies used telephone. This indicates that in 75.6% of studies using proprietary systems, blood pressure control results have been reported. This rate reaches 54.5% and 44.4% in studies using public and telephone systems, respectively. In a similar vein, all three studies on mental health used proprietary systems.

On the other hand, more studies used telephone calls than proprietary platforms for measuring and recording data (50% vs. 33.3%). Proprietary platforms are more effective for managing blood pressure because they offer functionalities that are specifically designed for disease management. They can also measure blood pressure more accurately. In the context of the special conditions caused by quarantine and social distancing, simpler mechanisms such as public platforms and even telephone calls have also had a positive effect on blood pressure management. Studies have shown that basic telemedicine visits are as effective as face-to-face visits in controlling hypertension [45].

Of the 29 studies analyzed, 6 articles (20.68%) focused solely on hypertension control, while 23 articles (79.31%) examined hypertension in conjunction with other diseases. This suggests that, to a large extent, hypertension is often considered as a comorbid condition. However, elevated hypertension can be a fundamental cause of other serious conditions, such as heart disease and stroke.

It is important to note that the key factor in successfully replacing face-to-face visits with telemedicine is patient training [46]. In other words, the higher the quality of patient training, the greater the likelihood of telemedicine success. Almost half of the studies (N = 13, 44.8%) provided necessary training, such as instructions on how to use wearable devices or home hypertension measuring devices. The participants received instructions on how to communicate clinical information to physicians or support staff, as well as lifestyle modification methods to help manage their hypertension. Most of studies (N = 11, 37.9%) used virtual methods such as videos, workshops, books, articles, websites, and emails for training. These studies obtained significantly more useful results than those that did not educate patients or their companions.

In light of the rising prevalence of hypertension and the constraints of conventional care models, the implementation of novel interventions in patients’ homes may facilitate enhanced accessibility, quality, and outcomes [47].

This study identified six main themes regarding the outcomes of using telemedicine for hypertension management.

5. Limitation

The study has three limitations. Firstly, there was a lack of detailed examination of changes in systolic and diastolic blood pressure due to the heterogeneity and differing methodologies of the studies, also the review was not registered in Prospero. Secondly, the study did not aim to provide a detailed examination of the factors that affect the use of telemedicine tools, such as their level of complexity or connection with health information systems. Future studies could provide a new perspective on the use of these tools in hypertension management by conducting a detailed investigation of these factors. Additionally, the number of RCTs was limited, which may have impacted the strength of the evidence in this area. Despite their stronger methodology, RCTs were difficult to conduct due to the isolation and social distancing measures imposed by COVID-19.

6. Conclusion

Telemedicine allows patients with hypertension to have medical consultations more conveniently and comfortably and considered as valid as in-person visits. This study reports the outcomes of using telemedicine for BP management including BP control, BP measurement and recording, medication management, mental health, care continuity, and use and acceptance. Telemedicine offers the possibility of creating a connected network to support patients with high BP anywhere and anytime. High BP requires regular treatment and monitoring of BP, as well as adherence to physician’s recommendations. Limitations and issues may arise due to patients and healthcare staff being unfamiliar with telemedicine. These problems can be resolved through ongoing use and continuous feedback.

Supporting information