How blood pressure readings taken at home can reduce a patient’s anxiety and lead to better health outcomes.
Home blood pressure monitoring is a cost-effective solution for better BP management, early detection of potential problems, and patient convenience, according to experts.
In the following interviews, Repertoire asked several experts to explain the rationale behind home blood-pressure monitoring and some messages sales reps might share with their clinical customers about it.
Increasing Patient Engagement
Editor’s note: Home blood pressure (BP) monitoring is a cost-effective solution for better BP management, early detection of potential problems, and patient convenience. Repertoire asked Julie Roth Jakubowski, MD, FACP, Head of Medical Affairs, Front Line Care, Baxter to explain the rationale behind home blood-pressure monitoring and some messages sales reps might share with their clinical customers about it.
Repertoire: Why is home blood pressure (BP) monitoring essential? What’s wrong with just having BP measured during your annual checkup at the primary care doc’s office?
Dr. Julie Jakubowski: Home BP monitoring is essential because blood pressure can fluctuate and may differ appreciably when measured in the office or at home. Higher out-of-office blood pressure is associated with increased cardiovascular risk resulting from underdiagnosis, misdiagnosis, undertreatment, overtreatment and misuse of antihypertensive medications.1
This fluctuation can occur when measured during an annual checkup at the primary care doctor’s office. Some of the common reasons for blood pressure measurement fluctuation found in office based measurement are: masked hypertension (i.e., office readings suggestive of normal BP but above normal BP outside of office settings) and white coat hypertension, which is characterized by elevated office readings but normal readings when measured outside the office. 2 – 5
Home BP monitoring allows patients to actively participate in the management of their BP and has been shown to improve adherence to antihypertensive medications.6 Therefore, home BP monitoring and recording of blood pressure readings can provide your healthcare professional with valuable information to determine if you truly have high blood pressure and, if you do, what your treatment options are and whether your treatment plan is working.7
Repertoire: Among the doctor’s patient base, who are the most likely candidates for home BP monitoring and why?
Dr. Jakubowski: The American Heart Association recommends home monitoring for all people with high blood pressure to help the doctor determine whether treatments are working or adjustments should be made to medication or treatments1. It’s important to note that home monitoring, or self-measured blood pressure, is not a substitute for regular visits to your physician. The best way to determine if a patient is a good candidate and will comply with home blood pressure monitoring is to include strategies shown that will result in higher levels of compliance with home blood pressure monitoring.
It has been found that engaging the patient and, if possible, the family, in a team-based care approach results in greater compliance. This involves engaging with patients on the importance of home blood pressure monitoring as it relates to their overall heath and the benefits of controlling hypertension. Additionally, providing education and training to patients and their families on how to take a proper blood pressure measurement and recording the results to share with their doctor, including when to contact the office, helps establish a shared sense of control and compliance in their overall health.8
Repertoire: What are the barriers to making home BP monitoring effective or practical? How can
the patient and doctor address those challenges?
Dr. Jakubowski: The main barriers are:
- Concerns over the validity of test results, reliability and quality of home blood pressure devices.
- Patient motivation and adherence to regularly check their blood pressure at home.
- Concerns over forgetting to check their blood pressure and that skipped readings could testing results.
- Technique concerns, which may be worsened by experiencing inconsistent blood pressure measurement techniques at the doctor’s office.
- Cost for a home BP monitor.9
These barriers can be addressed by:
- Providing guidance on selecting a monitor that has been validated with appropriately sized upper arm cuffs. (See: www.validatebp.org www.ama-assn.org/system/files/2020-11/smbp-cuff-selection.pdf10)
- Providing education on the importance and adherence of home blood pressure monitoring.
- Providing education on proper preparation, positioning, instructions on how often to test and how to record results.
- Training on how and when to communicate results back to the doctor’s office.
- Verification of patients’ understanding of resources available.
For patients who are concerned about the cost of owning a validated blood pressure monitor for home use, the medical team can explain how the monitor can decrease overall costs associated with better management of hypertension and reduce potential adverse health outcomes.
Repertoire: Anything to add about how healthcare professionals can most effectively integrate home BP monitoring into their workflow?
Dr. Jakubowski: A way to help integrate home BP monitoring into an office workflow is to identify a support staff member who can teach patients how to use monitors, validate devices, and review action plans and blood pressure logs. In addition, developing a protocol to address frequency of office visits, handle inquiries from patients about home monitor concerns, etc., will help integrate this important benefit to both the office and the patient for long-term health benefits.12
Better Readings, Better Care
Repertoire: Why is home blood pressure monitoring essential? What’s wrong with just having your BP measured during your annual checkup at the primary care doc’s office?
Neal Weingart, President and CFO, American Diagnostic Corp.: There are three measurements you can count on at any physician office visit: weight, temperature, and blood pressure. Blood pressure is ubiquitous because it’s such an important metric in our overall health profile. But it’s tricky, too, because small variations in technique can cause large variances in measurements, even on the same patient. So the readings you get in the office are really just one data point that doesn’t tell us very much overall.
Steve Kelly, Vice President of Sales, American Diagnostic Corp.: And it’s not just technique that’s at play. White Coat Hypertension – the phenomenon where patients tend to have higher blood pressure in the presence of health care workers, particularly physicians – is very real. With all these factors, it can be a challenge to make treatment decisions based exclusively on the in-office numbers.
In these cases, doctors will usually recommend at-home monitoring.
Repertoire: How does monitoring at home complement measurement in a clinical setting?
Kelly: There’s a big difference between monitoring your blood pressure at home and having a reading taken in a busy physician’s office. Research confirms that readings are more accurate if you take five to ten minutes to relax before starting a measurement, for instance, but that’s just not practical in a clinical setting.
Weingart: And that’s just one variable. We know that measurements should be taken on a bare arm, that feet should be flat on the floor, that the back should be supported, and that the measurement arm should be positioned at heart level on a cushion or a table. Each of these alone can affect a reading by 5-40 mmHg (millimeters of mercury), so imagine the cumulative impact. It’s so much easier to manage the overall environment at home.
Kelly: It’s also easier to take daily readings at home, which allows you to see trends instead of isolated readings. And trends are essential to successful management of blood pressure conditions like hypertension.
Repertoire: Have cases of high blood pressure worsened among the U.S. health population in recent years?
Weingart: High blood pressure, or hypertension, is defined as a systolic blood pressure greater than 130 mmHg or a diastolic blood pressure greater than 80 mmHg. And the numbers are staggering.
- According to the CDC, nearly half of adults in the U.S. – about 116 million people – have hypertension or are taking medication for hypertension.
- Every year, Americans make more than 56 million physician office visits where essential hypertension is the primary diagnosis.
- Around one million emergency department visits are attributed to essential hypertension.
On top of that a large observational study published in the Circulation, the Journal of the American Heart Association, found a small, but consequential, rise in average blood pressure during the early peak of the Covid-19 pandemic in 2020. Average systolic blood pressure – the top number in the blood pressure reading – increased by about 2 millimeters of mercury (mmHg), while average diastolic pressure – the bottom number – also rose slightly.
Kelly: It’s an unfortunate trend overall, but it’s also a tremendous opportunity for patient education and engagement. Helping patients get set up to monitor blood pressure at home is relatively fast and easy and allows them to actively participate in the treatment process.
Repertoire: What questions can distributor reps ask their clients to ensure they have the most up to date equipment?
Kelly: Reps can start the conversation by asking, “How important is it to you that patients monitor their blood pressure at home?” Depending on the response, you can make sure doctors understand how valuable these devices are to managing conditions like hypertension. Then provide expert recommendations for the models that will be best suited for both the practice and their patients.
The connectivity piece is essential to the conversation, too, so follow-up questions should touch on how they want patients to share the data they collect at home. Solutions could be as easy as setting up a dedicated email address where readings should be sent electronically between visits or having patients bring their phones to appointments to show reading data or trend graphs.
Weingart: In the end, doctors will be getting more and better information on the status of patients, which will lead to more effective treatment plans.
References:
1 Shimbo, D, et al. Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association, AHA Journal, 22 June 2020;142:e42–e63
2 Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71: e127-248. DOI: 10.1016/j.jacc.2017.11.006
3 Verdecchia P, Angeli F, Reboldi G. Masked and white-coat hypertension. Moving to African-Americans. J Am College Cardiol 2015; 66(20): 2170-2172. DOI: 10.1016/i.jacc.2015.09.008
4 Tientcheu D, Ayers C, Das SR, et al. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension. J Am College Cardiol 2015; 66(20): 2159-2169. DOI: 10.1016/i.jacc.2015.09.007
5 Gorostidi M, Vinyoles E, Banegas JR, de la Sierra A. Prevalence of white-coat and masked hypertension in national and international registries. Hypertens Res 2015; 38: 1-7. DOI: 10.1038/hr.2014.149
6 Centers for Disease Control and Prevention. Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2014.
7 https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/common-high-blood-pressure-myths.
8 Trefond, J et al. Home blood pressure monitoring and adherence in patients with hypertension on primary prevention treatment: a survey of 1026 patients in general medicine in the Auvergne region, BMC Prim Care, 2022; 23: 131.
9 Carter, E. et al, Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study, Am J Hypertens. 2018 Jul; 31(8): 919–927.
10 https://www.ama-assn.org/delivering-care/hypertension/bp-monitoring-you-can-count-list-validated-devices-grows
11 https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20047889
12 https://www.nyc.gov/assets/doh/downloads/pdf/csi/hyperkit-hcp-bpselfmon-guide.pdf