Pickering, Thomas G., Nancy Houston Miller, Gbenga Ogedegbe, Lawrence R. Krakoff, Nancy T. Artinian, and David Goff. “Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.” Hypertension (May 22, 2008).
As we have been planning a multi-stakeholder pilot to demonstrate improved management of chronic conditions by Californians, this paper was just published, which adds compelling information to the discussion. Talk about interesting timing.
The paper is a compendium of research and information to date on the value of home blood pressure monitoring, which has not been previously integrated into the clinical practice of improving blood pressure control. The impact of poor control is reiterated: high blood pressure as accountable for 27% of total CVD events in women and 37% in men.
- 35% of hypertensive patients check their BP once a week, 64% of patients own a monitor.
- Arm monitors appear to still be the best choice through validation studies.
- There is often “poor” agreement between patient reported readings and readings stored in the monitors’ memory, with one study showing up to a 20% error rate.
- Patients are at risk for over-diagnosis (“white coat hypertension”) up to 20% of the time, and under-diagnosis (“masked hypertension”) up to 10 % of the time, resulting in over/unnecessary treatment, or undertreatment.
- Blood pressures measured outside of the doctor’s office in many cases is superior in predicting which patients are at risk for organ damage.
- It appears that more study is needed regarding the effectiveness of home blood pressure monitoring to guide treatment and ultimately support better control. As far as I can tell, none of the studies mentioned here assess the impact of coupling improved patient-health system communication (eg secure messaging with physicians or health system) with home blood pressure monitoring.*
- Medicare currently reimburses ambulatory (24 hour) blood pressure monitoring for patients with suspected white coat hypertension, and this monitoring has been shown to be cost-effective in reducing unnecessary treatment.
- Of extreme interest in our planning, this paper refers to studies assessing patient attitudes toward home monitoring, which appear favorable, but maybe less so when out of pocket expense is required – this is a follow-up/countermeasure item.
Beyond information about the value of home blood pressure monitoring, there are suggested protocols for integrating this monitoring into practice. This seems like a great springboard to integrate this into patient access to their own clinical information, along with potential connections to the health system and other patients.
Based on the information presented, there seems to be a case for employing “connected” blood pressure monitoring for accurate diagnosis of blood pressure and response to treatment. Given that Medicare already reimburses ambulatory blood pressure monitoring for white coat hypertension, there may also be a case to extend, as a pilot, reimbursement for home monitoring for diagnosis and initial management of blood pressure outside of physician visits. This ties well to the data that most patients with high blood pressure are insured and seeing physicians, with only 35% control, making this approach a worthy alternative.
From a biological plausibility perspective, it makes sense that measuring an ongoing physiological state (average blood pressure throughout the day) in its native environment, over time, has a likelihood of being more accurate than a few point measurements done outside of the environment where people live and work (the doctor’s office).
The opportunity for the proposed project here is to integrate the benefits of home monitoring with a sustainable workflow inside and outside of the health system, using technology available today, to improve patient and family involvement in their care. Of interest, the Agency for Healthcare Quality and Research is promoting the idea of patient involvement in care as a quality and safety improvement strategy for patients. This work could extend the strategy to more stakeholders, including employers and the health system itself.
Conflict of Interest Analysis
I think this should be part of a review of any paper, given the information being published about sponsored research (here’s some examples).
The lead author has a significant relationship with device maker Omron, and has received speakers fees from pharmaceutical manufacturer Boerhinger-Ingelheim and Omron. Another author has received speaker’s fees from Merck and serves in a consultant/advisory board capacity for Pfizer and CV Therapeutics.
There was discussion previously about support to the American Heart Association by device makers.
These associations could result in over-exhuberant promotion of home blood pressure monitoring devices and treatment (i.e. it’s unlikely that a device manufacturer would have an interest in less devices being sold), and need to be taken into account when reviewing this piece. This might be reflected especially in areas where the data is/was equivocal about benefits, yet conclusions are framed in the positive or hopeful.
One of the issues in the discussion of device/medication promotion is that new treatments are compared to placebo instead of to current practice. The information presented here compares the treatment of interest to current practice, which has room for improvement. With that in mind, I think the information here is contributory to the work we’re considering and will be used to update the A3 accordingly.
A Disclosure of My Own
I should point out that I assisted in the planning of the Group Health blood pressure study mentioned above from an operations/informatics perspective, and was not funded under the grant and am not a co-author of that study, which is not connected to this work. I am currently funded by the California Healthcare Foundation.
Comments welcome, of course.