On October 7th, the US Department of Health & Human Services published the Surgeon General’s Call to Action to Control Hypertension. The report uses a blood pressure threshold of 130/80 mm Hg as its definition of control. The manuscript includes a goal to optimize patient care for hypertension control and sector-specific recommendations to influence hypertension.
Healthy lifestyle changes that could influence blood pressure control include:
- Losing weight
- Reducing sodium intake (more specifically, following the Dietary Approaches to Stop Hypertension [DASH] diet promoted by the National Heart, Lung and Blood Institute)
- Increasing physical activity, and
- Quitting smoking
The report suggests referring individuals with multiple cardiovascular disease risk factors for intensive behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention. The authors identified nine elements of a comprehensive treatment protocol for hypertension management (abstracted from the Million Hearts initiative co-led by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services):
|Accurate blood pressure measurement||Optimal blood pressure targets||Atherosclerotic cardiovascular disease risk calculation|
|Team-based care approach||Lifestyle modification referral pathways||Medication initiation and intensification guidance|
|Consider medication costs and formularies||Supportive strategies for medication adherence||Follow-up intervals|
Kaiser Permanente Northern California
The report specifically highlighted the Kaiser Permanente Northern California experience. Key elements were:
- Hypertension registry
- Clinic-level performance feedback
- Treatment algorithm
- Medical assistant visits for blood pressure measurement
- Single-pill combination therapy
The group created their own guideline development team with primary care physicians, specialty physicians, pharmacists and evidence-based methodologists. The team developed a simplified drug treatment algorithm with a single, specific drug with a recommended dose in nearly all situations. This simplification decreased practice variation and increased operational efficiencies.
These visits occurred two-four weeks after a blood pressure medication adjustment. These visits had no copayment. The medical assistant informed the primary care physician who might then direct treatment intensification or follow-up as needed. The medical assistants received periodic assessment of blood pressure measurement technique competency.
In 2005, the group included lisinopril-hydrochlorothiazide into its evidence-based guidelines.
Fourteen years after the Kaiser Permanente hypertension program was launched, blood pressure control rates increased from 44% to 90%. Heart attacks dropped 24% and stroke mortality dropped 42%.
Self-monitoring of blood pressure
Back in 1992, a group randomized about 400 individuals to home blood pressure monitoring or usual care. The home blood pressure monitoring group returned their readings to the study investigators by mail. The monitoring group also received instructions about what to do with unusually high or low blood pressure readings. The mean adjusted cost for physician visits, telephone calls and laboratory tests associated with hypertension care was $88.76 per patient per year, 29% less than the usual care group (95% CI: $16.11-$54.74). The home monitoring system cost about $28 per patient per year.
A 2017 systematic review and individual patient data meta-analysis of self-monitoring of blood pressure found that self-monitoring reduced systolic blood pressure (-3.2 mm Hg [millimeters of mercury], 95% CI -4.9 to -1.6 mm Hg). The researchers classified co-interventions into three levels: automated feedback or support, active intervention, and significant tailored support (including regular 1:1 contact). The blood pressure improvement point estimates for each co-intervention level were better than usual care or self-monitoring with no feedback. With each progressive level, the blood pressure reduction was greater. The most intensive interventions reduced the systolic blood pressure by an average of six mm Hg. This translates into a 20% reduction in strokes.
In 2014, a group of researchers from Miami and Indiana published a cost-benefit analysis of home blood pressure monitoring from the payer’s perspective. They modeled two commercial populations (20-44 years of age, 45-64 years of age) and a Medicare Advantage population. Their base-case analysis is listed below:
|Population||Return on Investment|
|20-44 years of age||0.94|
|45-64 years of age||0.85|
|65 years of age and older||3.75 (19.34 by year 10)|
The model found a positive return on investment among the under-65 groups when home blood pressure monitoring was limited to diagnosing hypertension, but a negative return on investment among individuals 65 years and older (attributed to fewer false-positives and avoiding unnecessary lifelong treatment [i.e., higher specificity] in a population with a low hypertension prevalence). The model found the opposite effect in the populations when restricted to treating hypertension (higher hypertension prevalence reduces the expected savings from the tool’s higher specificity, but older people are more likely to avoid a hypertension-related event due to home blood pressure monitoring).
In 2018, Mills et al. reviewed 100 articles with 121 comparisons across 55,920 participants to determine the comparative effectiveness of various implementation strategies of blood pressure reduction in patients with hypertension by direct comparison. They found all patient-level and multilevel implementation strategies were associated with reduced systolic blood pressure:
- Home blood pressure monitoring – reduced systolic blood pressure by 2.2 mm Hg (CI, 1.0 to 3.5 mm Hg)
- Multilevel strategies without team-based care – reduced systolic blood pressure by 3.9 mm Hg (CI, 1.3 to 6.5 mm Hg)
- Health coaching – reduced systolic blood pressure by 4.3 mm Hg (95% CI, 2.6 to 5.9 mm Hg)
- Team-based care with physicians and non-physician providers titrating medications – reduced systolic blood pressure by 5.7 mm Hg (CI, 3.6 to 7.9 mm Hg) and 6.6 mm Hg (CI, 4.2 to 9.0 mm Hg), respectively
Strategies targeting provider-level barriers to blood pressure control did not statistically significantly reduce blood pressure compared with the control group.
After adjustment for important covariates and all implementation strategies simultaneously using generalized estimating equations, the researchers found the three multilevel strategies were the most effective for reducing systolic blood pressure. Team-based care with medication titration by a non-physician had the greatest reduction in systolic blood pressure (change, −7.1 mm Hg [CI, −8.9 to −5.2 mm Hg]), followed by team-based care with medication titration by a physician (−6.2 mm Hg [CI, −8.1 to −4.2 mm Hg]) and multilevel strategies without team-based care (−5.0 mm Hg [CI, −8.0 to −2.0 mm Hg]). The electronic decision-support systems strategy was associated with a statistically significant reduction in systolic blood pressure (change, −3.7 mm Hg [CI, −5.2 to −2.2 mm Hg]), but provider training and audit and feedback were not.
McManus et al. published a parallel, randomized controlled trial in 142 practices across the United Kingdom that randomized eligible patients into self-monitoring blood pressure (monitor one’s own blood pressure in their nondominant arm twice each morning and evening for the first week of each month with each patient’s general practitioner to use self-monitored measurements to titrate antihypertensive medication), self-monitoring with telemonitoring (self-monitoring with electronic prompts and automated alerting of providers when the week’s average blood pressure was elevated) or usual care. Neither participants nor investigators were masked to group assignment. After 12 months, systolic blood pressure was:
- 140.4 mm Hg (standard deviation 16.5) in the usual care arm,
- 137.0 mm Hg (16.7) in the self-monitoring arm, and
- 136.0 mm Hg (16.1) in the telemonitoring arm.
Both interventions were associated with a lower change in blood pressure at 12-months compared to usual care. There were no significant differences between the self-monitoring arm and the telemonitoring arms. Patients in the telemonitoring group had more increases in the defined daily doses (DDD, 2.69 [standard deviation 1.82]) than self-monitoring (2.42 [1.75]) or usual care (2.27 [1.65]). There was no difference in self-reported adherence, quality-of-life or primary care visits among the three groups.
TASMINH4 shows the opportunities and challenges of remote management of hypertension. Reducing barriers to collect blood pressure measurements within patients’ homes can lead to more aggressive medication titrations, but those titrations do not necessarily lead to higher rates of self-reported adherence or fewer primary care visits. I believe the clinicians (physicians, nurses or pharmacists) tasked with adjusting antihypertensive medications will need to have a relationship with both patients and the patients’ primary care providers to increase trust among all three groups. In addition to trusting the prescribing group, the patient will also need to understand the value to controlling blood pressure based on what their own preferences.
Where Health IT Might Make a Difference
Based on the presented literature, I think health IT could help address blood pressure in the following ways:
- Promoting behaviors for primary prevention
- Encouraging behaviors to reduce the risk of developing complications
- Tracking self-measured blood pressure
- Calculate cardiovascular disease risk with information about modifying that risk (information and peer behaviors)
- Promote medication adherence (prescribing once-a-day medications with little or no copayments, automated reminders, and reinforcing the value of a medication with minimal short-term benefit)
- Enable communication with a care team to support medication intensification or referrals (potentially replacing face-to-face encounters with virtual ones)
Health IT with different displays for primary (prevent disease or injury), secondary (reduce impact of disease or injury that has already occurred) and tertiary (soften the impact of ongoing illness or injury) prevention could help patients, providers and payers recognize a benefit for managing health using much more personalized tools than what have been studied so far. I do not think we need more tools to diagnose heart disease earlier. We need tools to help patients make healthier choices and sustain those choices long-term. Health IT that can meet patients and providers where they are (limited health literacy or access to the Internet, limited electronic medical record functionality) is more likely to be adopted by groups that are most likely to benefit from the technology. We could consider peer behaviors and patient perceptions of their own identity to help shift behaviors to support more heart-healthy lifestyles, including greater medication adherence.
Although controlling blood pressure is important, using health IT to manage a patient’s overall cardiovascular risk profile is more likely to be meaningful to patients. Health IT could allow providers and payers to re-imagine how cardiovascular risk is managed with more assessments within a patient’s home and fewer office visits. The technology could support behaviors ranging from maintaining a healthy weight to performing cardiac rehabilitation after a heart attack. These interventions may require novel payment and care delivery support processes to be sustainable long-term.