Eduardo Sanchez, M.D., M.P.H., Chief, Center for Health Metrics and Evaluation
Stakeholders must invest in building and supporting infrastructure that expands self-measured blood pressure monitoring, according to a new policy statement from the American Heart Association and American Medical Association.
The statement, released on Monday, is rooted in the high potential for self-measured BP monitoring to improve the diagnosis and management of high blood pressure.
High blood pressure, or hypertension, is one of the most important modifiable cardiovascular disease risk factors and affects 45.6% of U.S. adults. Hypertension is systolic BP of 130 mm Hg or higher, diastolic BP of 80 mm Hg or higher, or taking antihypertensive medication, according to the AHA’s 2017 Hypertension Clinical Practice Guideline.
Hypertension is typically diagnosed and managed by measuring a person’s blood pressure in clinical settings. Self-measured BP monitoring may be used to confirm an office-based diagnosis, track out-of-office BP and/or evaluate BP response to hypertension treatment.
Several U.S. and international guidelines and other authoritative bodies endorse using self-measured BP monitoring for these purposes. Many outline best practices such as using validated, automated devices with properly sized cuffs and following a standardized protocol for measuring and monitoring.
Self-measured BP monitoring is cost effective compared with office BP monitoring alone or with usual care among people with high office BP. Its effect for improving BP control is optimized when combined with co-interventions such as patient education and training, behavior change counseling or medication management—each of which can be delivered via telehealth modalities.
In addition, self-measured BP monitoring can help diagnose white-coat hypertension (having high BP measurements in the office, but not out of the office in people not on blood pressure medication) and masked hypertension (having high BP measurements out of the office, but not in the office in people not on blood pressure medication). For people taking blood pressure medicine, these are called white-coat effect or masked uncontrolled hypertension, respectively.
It’s important to monitor for these conditions because they can lead to unnecessary treatment in those with white coat or undertreatment and higher risk for CV events (heart attacks, strokes and heart failure) and death in those with masked hypertension or masked uncontrolled hypertension. The only way to identify white coat or masked hypertension is to measure BP both in and out of the office.
Although patients and providers in the U.S. report use of self-measured BP monitoring, it should be adopted as a more common practice. We must also close the gap in knowing how many use best practices to ensure that blood pressure measurement is done properly.
- Assure self-measured BP monitoring is recommended for the right patients.
- Teach patients how to correctly use measuring devices.
- Communicate with patients to assess the effect of treatment and make adjustments based on BP readings.
Evidence-based recommendations are generally slowly adopted in clinical practices and by patients, which delays the benefits of self-measured BP monitoring. Overcoming delays requires investing in infrastructure to support self-measured BP monitoring and increasing coverage for patient- and provider-related costs.
“Infrastructure” includes education and training so patients learn the benefits of self-measured BP monitoring and how to use validated monitoring devices correctly. It also ensures that providers are reimbursed to give timely, appropriate feedback.
Investment in infrastructure also involves enhanced health information technology capacity to enable readings from “connected” self-measuring devices to be digitally transmitted to electronic health records. And infrastructure support includes incorporating self-measured BP readings into clinical performance measures, developing co-interventions and enhancing reimbursement.
Some private and commercial payers and Medicaid plans cover costs for self-measured BP monitoring, including equipment and reimbursement for provider time. But lack of reimbursement remains a common barrier.
Getting blood pressure to a safe zone is not a “one and done” clinical intervention. It takes a team – with the patient as captain and the health care provider as coach – to lower high blood pressure and act quickly, when indicated, to keep it at controlled levels.
The bottom line: Investing in infrastructure to support optimized self-measured blood pressure monitoring is key to a world of longer, healthier lives.