Telemonitoring with pharmacist management improves and maintains BP control

The HealthPartners Institute for Education and ResearchJul 3 2013

An intervention that consisted of home blood pressure (BP) telemonitoring with pharmacist management resulted in improvements in BP control and decreases in BP during 12 months, compared with usual care, and improvement in BP that was maintained for 6 months following the intervention, according to a study in the July 3 issue of JAMA.

"High blood pressure is the most common chronic condition for which patients visit primary care physicians, affecting about 30 percent of U.S. adults, with estimated annual costs exceeding $50 billion. Decades of research have shown that treatment of hypertension prevents cardiovascular events; and many well-tolerated, effective, and inexpensive drugs are readily available. Although BP control has improved during the past 2 decades, it is controlled to recommended levels in only about half of U.S. adults with hypertension," according to background information in the article. "Several recent studies suggest that a combined intervention of telemedicine with nurse- or pharmacist-led care may be effective for improving hypertension management, but none included postintervention follow-up. Also, previous studies excluded patients with comorbidities [other illnesses] and more severe hypertension."

Karen L. Margolis, M.D., M.P.H., of the HealthPartners Institute for Education and Research, Minneapolis, and colleagues conducted a study to determine the effect and durability of home BP telemonitoring with pharmacist case management in patients representative of the range of comorbidity and hypertension severity in typical primary care practices. The randomized clinical trial included 450 adults with uncontrolled BP recruited from 14,692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St. Paul, with 12 months of intervention and 6 months of postintervention follow-up.

Eight clinics were randomized to provide usual care to patients (n = 222) and 8 clinics were randomized to provide a telemonitoring intervention (n = 228). Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly. The primary measured outcome was control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg (<130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. Secondary outcomes were change in BP, patient satisfaction, and BP control at 18 months (6 months after intervention stopped).

Among the 380 patients attending both the 6- and 12-month visits, the proportions of patients with controlled BP at both visits were 57.2 percent in the telemonitoring intervention group and 30.0 percent in the usual care group. At 18 months, BP was controlled in 71.8 percent of the telemonitoring intervention group and 57.1 percent of the usual care group. Among the 362 patients attending all clinic visits at 6, 12, and 18 months, the proportions of patients with controlled BP at all visits were 50.9 percent in the telemonitoring intervention group and 21.3 percent in the usual care group.

"Self-efficacy questions indicated telemonitoring intervention patients were substantially more confident than usual care patients that they could communicate with their health care team, integrate home BP monitoring in their weekly routine, follow their medication regimen, and keep their BP under control. Telemonitoring intervention patients self-reported adding less salt to food than usual care patients at all time points, but other lifestyle factors did not differ," the authors write.

"If these results are found to be cost-effective and durable during an even longer period, it should spur wider testing and dissemination of similar alternative models of care for managing hypertension and other chronic conditions."
(JAMA. 2013;310(1):46-56; Available pre-embargo to the media at http://media.jamanetwork.com)

Editor's Note: This study is supported by a grant from the National Heart, Lung, and Blood Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

There will also be a digital news release available for this study, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, July 2 at this link.

Editorial: Home Blood Pressure Monitoring

In an accompanying editorial, David J. Magid, M.D., M.P.H., of the Kaiser Permanente Colorado Institute for Health Research, Denver, and Beverly B. Green, M.D., M.P.H., of the Group Health Research Institute, Seattle, write that "for home BP monitoring to become part of routine practice, changes to the current system of reimbursement and performance measurement will be needed."

"First, to minimize patient barriers to participation, health insurers must follow the lead of the Veterans Health Administration and provide benefit coverage for BP monitors. Second, clinicians and health care organizations must be reimbursed for services related to home BP monitoring, which are currently not covered by Medicare and many other payers; otherwise, clinicians in fee-for-service systems are unlikely to voluntarily give up reimbursements for hypertension-related office visits. Third, home BP measurements must be included in quality assurance assessments of hypertension care. Currently, the National Committee for Quality Assurance performance measure for BP control considers only BP measurements made in the clinic, even though home BP measurements correlate as well or better with 24-hour ambulatory BP measurements and are more predictive of cardiovascular outcomes than clinic measures."