Digital health technologies, such as remote monitoring and telemedicine, hold significant promise for improving patient outcomes and reducing healthcare costs. However, these innovations could inadvertently worsen existing health disparities if adoption rates are lower among underserved communities.
In a recent working paper, “Equity and Efficiency in Technology Adoption: Evidence from Digital Health” (NBER Working Paper 32992), researchers Itzik Fadlon, Parag Agnihotri, Christopher Longhurst, and Ming Tai-Seale investigated a remote patient monitoring program for cardiovascular risk management at UC San Diego Health (UCSDH). The program involved 2,512 patients with poorly controlled hypertension, referred by their primary care physicians (PCPs) between October 2020 and July 2022. Participants received free Bluetooth-enabled blood pressure devices, transmitting data to UCSDH clinical staff for daily monitoring.
After one year, the average systolic blood pressure decreased by 9.8 mmHg (from a pre-intervention baseline of 134 mmHg) among those referred to the program. Given that only 53 percent of the referred patients actively participated, the impact on systolic blood pressure for the participants themselves was substantial, with an estimated reduction of 18.5 mmHg. Within the first year, referred patients were 15 percentage points more likely to achieve healthy blood pressure levels (below 120 mmHg). The program also reduced the share of referred patients at high risk for severe cardiovascular events by 4.4 percentage points, representing a 12.4 percent decrease from the baseline.
Furthermore, the intervention demonstrated significant cost savings. By three quarters after referral, quarterly healthcare costs dropped by $385 per patient, a 40 percent decline from a predicted level of $1,004.
The researchers attributed these positive outcomes to better-tailored medication regimens and an improvement in patient behaviors. Participants showed a temporary increase in the number of unique prescription orders, especially during the initial quarter, which suggests an effort to find more effective medications. Moreover, in a subsample of 204 referred patients for whom information on smoking behavior was available, the intervention was linked to a sustained reduction in smoking, indicating positive changes in health behaviors.
Despite these encouraging results, the study revealed unequal gains. By the end of the study, White patients experienced almost double the blood pressure reduction (15.81 mmHg) compared to Black and Hispanic patients (8.74 mmHg). Similarly, patients from more affluent communities achieved greater reductions (14.85 mmHg) than those from less advantaged areas (8.62 mmHg).
A potential explanation for these disparities is the difference in continued participation over the 18-month study period. Participation rates among Black and Hispanic patients were 4 percentage points lower than those for White patients, suggesting potential barriers to consistent engagement with the program.
The study also highlighted the influential role of primary care physicians in patient participation. Patients of high-performing PCPs, based on their tier within a pay-for-performance system, had a 10.5 percentage point higher average participation rate throughout the study than patients of the lowest-performing PCPs. Additionally, longer physician-patient relationships were associated with increased program participation. Strengthening these relationships may be a strategy for promoting broader and more equitable engagement with digital health technologies.
— Leonardo Vasquez
