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Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial
Study Questions:
Can a program that combines home blood pressure monitoring with pharmacist management improve blood pressure (BP) control?
Methods:
This was a cluster randomized clinical trial of 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, MN. The study included 12 months of intervention and 6 months of post-intervention follow-up. Eight clinics were randomized to provide usual care to patients (n = 222), and eight 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. Each intervention patient received a home BP monitor that stored and transmitted data to a secure website via modem. Pharmacists met with patients for a 1-hour, in-person visit, during which they reviewed the patient’s relevant history, covered general teaching points about hypertension, instructed the patients on using the home BP telemonitoring system, and provided patients with an individualized home BP goal 5 mm Hg lower than their clinic BP goal. During telephone visits, pharmacists emphasized lifestyle changes and medication adherence. They assessed and adjusted antihypertensive drug therapy based on an algorithm using the percentage of home BP readings meeting goal. Patients were instructed to transmit at least six BP measurements weekly (three in the morning and three in the evening). During the first 6 months of the intervention, patients and pharmacists met every 2 weeks via telephone until BP control was sustained for 6 weeks, and then frequency was reduced to monthly. During intervention months 7-12, telephone visits occurred every 2 months. After 12 months, patients discontinued use of the telemonitors, returned to the care of their primary physicians, and no longer received support from a study pharmacist. The main outcome of interest was control of systolic BP to <140 mm Hg and diastolic BP to <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 the intervention stopped).
Results:
A total of 450 adults were included in this study, of which 45% were women and 82% were white (mean age 61 years). Mean systolic BP at baseline was 148 mm Hg, and mean diastolic BP was 85 mm Hg. Many patients had comorbid conditions, including obesity (54%), diabetes (19%), chronic kidney disease (19%), or a history of cardiovascular disease (10%). At 6 months, BP was controlled in 71.8% (95% confidence interval [CI], 65.6%-77.3%) of the telemonitoring intervention group and 45.2% (95% CI, 39.2%-51.3%) of the usual care group (p < 0.001). At 12 months, BP was controlled in 71.2% (95% CI, 62.0%-78.9%) of the telemonitoring intervention group and 52.8% (95% CI, 45.4%-60.2%) of the usual care group (p = 0.005). At 18 months, BP was controlled in 71.8% (95% CI, 65.0%-77.8%) of the telemonitoring intervention group and 57.1% (95% CI, 51.5%-62.6%) of the usual care group (p = 0.003). Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (−10.7 mm Hg [95% CI, −14.3 to −7.3 mm Hg]; p < 0.001), at 12 months (−9.7 mm Hg [95% CI, −13.4 to −6.0 mm Hg]; p < 0.001), and at 18 months (−6.6 mm Hg [95% CI, −10.7 to −2.5 mm Hg]; p = 0.004). 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.
Conclusions:
The investigators concluded that home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of post-intervention follow-up.
Perspective:
Given the poor rates of BP control in this country, together with shortages of primary care providers, programs such as the one outlined in the paper can provide viable solutions for patients with hypertension.
Keywords: Life Style, Blood Pressure, Mucin-1, Medication Adherence, Blood Pressure Monitoring, Ambulatory, Cardiovascular Diseases, Obesity, Blood Pressure Determination, Blood Pressure Monitors, Pregnancy, Prolonged, Hypertension, Diabetes Mellitus, Renal Insufficiency, Chronic
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