Incorporating a free smartphone app featuring AI-driven health coaching, blood pressure monitoring, and behavioral incentives into a hospital’s existing clinical workflows helps patients make meaningful reductions in blood pressure, findings that suggest that digital apps may offer an effective means of extending care beyond the clinic when incorporated into treatment plans.
In a study published in the Journal of General Internal Medicine, Rush University Medical Center clinicians described how a group of 425 patients already being treated for high blood pressure used a free smartphone app to make at-home condition management and adoption of healthy habits easier. Developed by Nuna, Inc., the app helps users track blood pressure readings and maintain a heart-healthy lifestyle via personalized reminders while also allowing healthcare providers a window into patients’ efforts in between visits.
“The group that incorporated the Nuna app into their care showed clinically significant improvements. While the study wasn’t designed to assess hard clinical outcomes, established research has shown a direct correlation between reductions of this magnitude and lower rates of heart attacks and strokes,” said Michael Gottlieb, MD, MBA, a Rush emergency medicine physician, vice chair of research, and the study’s co-lead author. “But well before we were able to process and assess the impact of the app as researchers, as physicians we were able to see –patient by patient – the power of a tool that empowers patients to manage their blood pressure every day.”
During the year-long study, patients being treated for high blood pressure at Rush who agreed to incorporate the use of the app as part of their care had their systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings tracked for six months and then compared to their baseline readings six months prior to starting to use the app. Their results were then compared with a control group of 425 demographically similar patients who did not use the app as part of their high blood pressure treatment. While the control group lowered blood pressure consistent with expected outcomes for their treatment, the group that also used the Nuna app had even greater reductions, especially among participants whose blood pressure numbers passed the threshold between readings deemed “uncontrolled” and not just “high.”
The data shows, for example, that among participants with uncontrolled stage 2 hypertension at baseline, their systolic blood pressure (the top number in reading), decreased by 13.6 mmHg among app users compared with 9.0 mmHg among controls. Kristin Pallok, MD, a Rush internal medicine specialist and study’s co-lead author noted that seeing such a marked difference in the progress made by the group that used Nuna compared to the control group is “very encouraging. The data reflects what patient after patient has been telling us: using the app has helped them take better control of their health.”
Hypertension – or high blood pressure– is among the nation’s most modifiable risk factors for cardiovascular disease, stroke, chronic kidney disease, and premature mortality, as nearly half of adults meet diagnostic criteria for hypertension. The Centers for Disease Control and Prevention estimates that uncontrolled high blood pressure costs the country nearly $200 billion in healthcare costs alone. But despite decades of advances in pharmacologic therapy and well-established evidence-based treatment guidelines, fewer than 25% of adults with hypertension achieve adequate blood pressure control.
“Nuna helps us understand what happens outside of the clinic walls. It’s not a snapshot in time like clinic visit, but rather a window into a patient’s daily routine and blood control progress,” said Pallok. “We know long-term damage in cardiovascular disease is an accumulation of your risk over time, and now we can communicate more proactive treatment adjustments faster. Instead of lowering a patient’s risk over a period of months, we can do it in weeks.” She added.
“The medication adherence and lifestyle changes needed to keep high blood pressure under control can be very difficult to sustain. While physicians would love to stay steadily engaged with patients, realistically we only see them every few months and then only have that day’s reading and patient recollection. It’s a shared frustration,” Pallok added.
“How could I ignore a friend like that?
Nuna users, many of whom had been attempting to control high blood pressure for years, praise how the app’s positive and consistent reminders help them adopt healthier habits, with many describing their regular usage in relationship terms.
Stanley R. is a 74-year-old patient whose doctor recommended the Nuna app after he suffered a transient ischemic attack (TIA or “mini-stroke”) and had long battled obesity. ”I’m in my 70s and really just used my cellphone to make calls. But then it helped me make monitoring my blood pressure a daily habit,” he recalled. While not part of the study, he has grown to rely on the app for advice and reminders. “Changing what I eat and buy at the store took time. But I would get daily reminders, and then I even learned to ask questions while at the store about which foods were right for me. It’s with me…and how could I ignore a friend like that?”
A Rush community health worker suggested “Daniel,” a young man with extremely high blood pressure and other health challenges, begin using the app. After a few weeks, he replied in an app survey that “his new friend, Nuna” had coaxed him into daily walks and giving up salt.
Several patients commented on how the medical insight the app provides gives them more control of their health, with one saying, “I understand what my conditions are doing to my body, and how I can better control them.”
Rush has expanded the use of the Nuna app to more than 1,700 patients now using it to help them manage high blood pressure, prediabetes, diabetes, and related cardiometabolic comorbidities.
Rush and Nuna CEOs team up to extend care team beyond the hospital’s four walls
Rush and Nuna’s partnership began when Jini Kim, Nuna’s CEO and co-founder, met Dr. Omar Lateef, President & CEO of Rush University System for Health and Lateef described a frustration familiar across the industry: despite strong quality scores on blood pressure control, Rush struggled to reach targets among its historically difficult-to-engage patient populations. Kim recognized this problem. “Nuna was founded to improve outcomes through value-based care, but outcomes were limited by physicians’ reach outside of the clinic,” Kim stated. “We knew that we needed to address this gap.”
Nuna built the “health coach in your pocket” to serve as the visit between visits, translating the care plan into small daily actions reinforced by AI-generated feedback, visible progress, and gamification. The app prioritized engagement by combining multiple principles of behavioral economics – efforts that proved effective with 87% of patients still using the app at six months and roughly three-quarters continuing to use it weekly.
“We’re incredibly proud of the patient engagement we’ve seen with our app, especially in an industry with median retention rates of less than 30 days,” Kim reflected. Further, the study found that weekly users of the app had roughly 2.5 times the odds of achieving controlled blood pressure at six months compared to less frequent users. “A care plan doesn’t work in just a clinic,” Kim noted. “It has to work in a kitchen, at a pharmacy counter, on a Tuesday night. We built Nuna to be there for those moments, and to make sure the care team hears about them. These results show what you can do when you extend a care team beyond clinic walls.”
Nuna, Inc, did not provide any funding for the study nor was involved in decisions about which statistical analyses to include.
Scalable solution: extending clinician’s reach, not workload
Given how pervasive controlling high blood pressure is nationally and how the easy-to-use digital app’s adoption is scalable, the paper’s authors also suggest that Rush’s collaborative work with Nuna can serve as an example of innovative and effective ways to address chronic diseases that shorten lives and cost billions of dollars to control. “Having data such as this is going to change how we view preventative medicine and conduct treatments for cardiometabolic diseases,” Pallok noted. “As payers and health systems increasingly prioritize value-based care and population health management, interventions of this type may represent a practical strategy to improve outcomes without proportionally increasing clinician workload.”
Nuna’s Kim agrees: ”As demand for chronic condition support surges, health systems can’t simply hire their way to better outcomes. What we demonstrated at Rush is that an AI-based tool can extend a care team’s reach to thousands of patients without proportionally adding to that team’s burden. This is a blueprint for any health system looking to deliver better, more sustainable care at scale.”
The Centers for Medicare and Medicaid Innovation (CMMI) have also seen the potential of technology to increase access and manage chronic conditions. Recently, CMMI released the ACCESS model that focuses on reimbursement for technology companies supporting chronic conditions, of which hypertension is one. Nuna, as a participant in this model, hopes that other like-minded health systems and Accountable Care Organizations take advantage of this novel payment approach, to scale this technology across a broad population to improve healthcare in the US.
Noting that very early in the study 20 percent of the participants who used the app were able to bring their high blood pressure under control, Lateef says he is proud and excited about the promise Nuna has shown at the health system. “Twenty percent is a huge number in healthcare. If you take 20 patients with uncontrolled hypertension and make it controlled, you decrease strokes, and you decrease heart attacks, you cut the number of years robbed from people’s lives. But as a physician and a community partner, we know these 20 people by name, we’ve met their families, and have been welcomed into their neighborhoods.”
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