The Effect of Veteran Race and Socioeconomic Status on Enrollment in Remote Patient Monitoring for Hypertension: Retrospective Observational Cross-Sectional Study

TL;DR

Black veterans are more likely to enroll in a remote monitoring program for hypertension compared to White veterans, despite overall low enrollment rates.

Contribution

This study is the first to examine the probability of initial enrollment in a Veterans Health Administration remote patient monitoring program for hypertension.

Findings

Black veterans were 65% more likely to enroll in RPM compared to White veterans.

Asian American or Pacific Islander veterans were 17% less likely to enroll in RPM compared to White veterans.

There was no significant association between socioeconomic status and RPM enrollment.

Abstract

Black veterans and veterans from lower socioeconomic backgrounds are more likely to have uncontrolled hypertension. One potential explanatory factor is reduced access to specific treatments that result in improved chronic disease management. In the Veterans Health Administration (VHA), veterans with hypertension may enroll in a remote patient monitoring (RPM) program, which consists of patient education, daily home blood pressure (BP) monitoring, health coaching, and case management. Barriers for socioeconomically disadvantaged patients may exist for similar programs in other health systems; however, the VHA is an integrated health care system, and these barriers may differ for veteran populations.

The objective of this study was to assess the relationship between veteran race and neighborhood socioeconomic status and the likelihood of enrolling in the VHA RPM program.

The study sample included VHA-enrolled veterans with a diagnosis of hypertension (average BP >130/80 mm Hg on ≥2 BP readings) between fiscal years 2020 and 2023. We ran random-effects logistic regression models to assess the relationship between veteran race and Area Deprivation Index and RPM enrollment each year, controlling for potential demographic and clinical confounders. For sensitivity analysis, we limited our sample to veterans with stage 2 hypertension (BP >140/90 mm Hg) and on antihypertensive medication.

Overall use of RPM was low, with only 4.1% (56,553/1,390,995; 95% CI 4%-4.1%) of veterans being enrolled in RPM. Black veterans, who represented 26.6% (n=35,096) of all veterans, were more likely (odds ratio [OR] 1.65, 95% CI 1.59-1.70) to enroll in RPM compared to White veterans. Asian American or Pacific Islander veterans were less likely to enroll (OR 0.83, 95% CI 0.74-0.94). We found no meaningful association between Area Deprivation Index and RPM enrollment (OR 1.00, 95% CI 0.99-1.00). When limiting our sample to those with stage or grade 2 hypertension, we found a similar association (OR 1.61, 95% CI 1.50-1.72) between Black race and RPM enrollment but no significant association with Asian or Pacific Islander race (OR 1.02, 95% CI 0.80-1.29).

Prior research on RPM in veterans has examined duration or outcomes of RPM enrollment but not the probability of initial enrollment. We found higher enrollment rates in the VHA RPM program among Black veterans but slightly lower enrollment among Asian American or Pacific Islander veterans. Higher enrollment among Black veterans and among those with higher comorbidity burden suggests that the VHA RPM program is successfully reaching those who could most benefit, despite low overall enrollment. Given the low enrollment in RPM, future research should focus on improving uptake among veterans who could additionally benefit from the program. Non-VHA systems, particularly those serving low-income or socioeconomically disadvantaged areas, should explore subsidized or free RPM programs for eligible patients similar to the VHA’s no-cost model for veterans.

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