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Telemonitoring improved BP control
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At-home telemonitoring combined with pharmacist management helped to achieve and maintain control of systolic and diastolic BP vs. usual care, according to data from a cluster-randomized study recently published in JAMA.
“Only about half of patients with high BP in the United States have their BP controlled,” researchers wrote. “Practical, robust and sustainable models are needed to improve BP control in patients with uncontrolled hypertension.”
HyperLink, a multicenter clinical trial, included 450 adults with an uncontrolled BP ≥140 mm Hg/90 mm Hg or ≥130 mm Hg/80 mm Hg if the participant had diabetes or chronic kidney disease (45% women; 82% white; mean age, 61.1 years) at 16 clinics. Karen L. Margolis, MD, MPH, of HealthPartners Institute for Education and Research in Minneapolis, and colleagues randomly assigned the participants to usual care (n=222) or a telemonitoring intervention with pharmacist case management (n=228). Those in the intervention group transmitted six weekly BP measurements online with a home monitor and had two weekly telephone consultations with pharmacists for the first 6 months until reaching 6 weeks of sustained BP control. Consultations were then reduced to once a month. Calls occurred bimonthly during months 7 to 12, after which telemonitoring ended and usual care ensued. Researchers reported that the measurements were transmitted 73% of the time during the first 6 months and 88% of the phone visits occurred.
Karen L. Margolis
A model for control
In the intervention group, 71.8% (95% CI, 65.6-77.3) had controlled BP at 6 months, 71.2% (95% CI, 62-78.9) at 12 months and 71.8% (95% CI, 65-77.8) at 18 months. In the usual care group, 45.2% (95% CI, 39.2-51.3) had controlled BP at 6 months, 52.8% (95% CI, 45.4-60.2) at 12 months and 57.1% (95% CI, 51.5-62.6) at 18 months. Among the 362 participants who attended the 6-, 12- and 18-month assessments, 50.9% (95% CI, 36.9-64.8) of those in the intervention group had controlled BP at all visits vs. 21.3% (95% CI, 14.4-30.4) of the usual care group.
The mean difference in systolic BP between the two groups was –6.6 mm Hg (95% CI, –10.7 to –2.5) at 18 months and the mean difference in diastolic BP was –3 mm Hg (95% CI, –6.3 to 0.3), favoring the intervention group. The mean number of antihypertensive medication classes increased from 1.6 (95% CI, 1.4-1.8) at baseline to 2.2 at 6 months in the intervention group (95% CI, 2-2.4) and from 1.4 (95% CI, 1.2-1.6) to 1.6 (95% CI, 1.4-1.8) in the usual care group.
“Patients in the telemonitoring intervention group were more satisfied with certain aspects of their care and were more confident in their own ability to manage their hypertension,” Margolis told Cardiology Today. “These findings suggest that new models of care that let patients work together with their health care team from home are very promising for managing hypertension and possibly other long-term conditions.”
A call for change
In response to the study’s results, David J. Magid, MD, MPH, of the Kaiser Permanente Institute for Health Research and the University of Colorado, Denver, and Beverly B. Green, MD, MPH, of the Group Health Research Institute and the University of Washington, Seattle, said adjustments are necessary to make home BP monitoring more feasible.
Beverly B. Green
“Home monitoring enables more frequent measurements in settings familiar to the patient, reducing misclassification due to white-coat or masked hypertension and prompting more timely action to address elevated BP,” Magid and Green wrote in an accompanying editorial. “Nonetheless, widespread adoption of home BP monitoring supported by team care has not occurred in the United States and it is not likely to occur spontaneously.”
Magid and Green said health insurers should offer benefit coverage for BP monitors; that health care providers receive reimbursement for home monitoring services; and that quality assurance assessments of hypertension care include home BP measurements.
“If home BP monitoring and team-based care were implemented broadly, hypertension management would be easier for patients, and the magnitude of BP reductions brought by this change could lead to substantial reductions in cardiovascular events and mortality,” Magid and Green wrote.
For more information:
Magid DJ. JAMA. 2013;310:40-41.
Margolis KL. JAMA. 2013;310:46-56.
Disclosure: See the study for a full list of the researchers’ disclosures. Magid and Green report no relevant financial disclosures.
Perspective
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Randall Mark Zusman, MD
The study by Margolis et al. clearly points to the advantages of BP telemonitoring and frequent contact between hypertensive patients and health care professionals. The disappointingly low rate of BP control among hypertensive patients in the United States and around the world, despite recognition of the role of high BP as a risk factor for stroke, MI, renal failure and congestive HF, points to the need to do better. But, the failure to control BP values is a complex problem which is, in part, addressed by this study. I would suspect that patients in the telemonitoring intervention group were more compliant with their drug regimen and certainly received more guidance, support and reassurance as a result of their multiple contacts with the participating pharmacists. Unfortunately, wider application of this strategy will require many changes to the way we follow these patients as outlined both in the JAMA manuscript and the accompanying editorial. This strategy is time- and person-intensive, and dedicated personnel will need to be identified and funding made available to sustain such programs. No doubt there will be a substantial ‘return on investment’ associated with the improvement in BP control, in terms of lower risk for stroke, MI and so on, but an initial financial commitment on the part of the insurance industry will be essential to success.
Until that comes to be, I encourage my patients to monitor their BP at home (although not to the point of compulsion; some patients will measure their BP up to 24 times per day). Doing so helps them to be part of the therapeutic process and seeing a change in BP values reinforces the importance of compliance with their drug regimen, as well as maintaining the lifestyle changes which are so important to BP (as well as cholesterol, weight and blood glucose) control. The short-term benefit to the patient is a lowered BP; the long-term benefit is hopefully reduced risk for major adverse cardiac and vascular events (stroke, MI, HF, renal failure, etc.). There are dozens of currently available antihypertensive medications and novel techniques — renal denervation, for example — being developed for better BP control; by engaging increased patient participation in their own care and by increasing the frequency of patient-health care professional interaction, better rates of BP control are inevitable.
This study confirms the benefits of such a strategy and will hopefully influence policymakers to support the widespread use of a telemonitoring program.
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