Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

Home blood pressure monitoring reduced costs without compromising blood pressure control

ACP J Club. 1993 Mar-April;118:59. doi:10.7326/ACPJC-1993-118-2-059


Source Citation

Soghikian K, Casper SM, Fireman BH, et al. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Med Care. 1992 Sep;30:855-65.


Abstract

Objective

To determine whether home blood pressure (BP) monitoring by patients with uncomplicated hypertension can reduce medical costs and services without compromising BP control.

Design

A cost-effectiveness analysis in a 1-year, randomized controlled trial.

Setting

4 medical centers of a health maintenance organization.

Patients

467 nonhospitalized patients with hypertension of varying severity without complications that would preclude home BP monitoring or require frequent visits to a physician were referred. 430 patients were randomized, and 91% were included in the analysis.

Intervention

215 patients were randomized to the home BP group and trained in the use of the electronic device, Tycos Self Check model 7052-08, and instructed to return twice-weekly BP measurements by mail. Physicians were encouraged to use the self-measured BP reports to monitor their home BP patients instead of scheduling visits. 215 patients were assigned to usual care and were referred back to their physicians.

Main cost and outcome measures

Costs of BP home monitoring prorated over 5 years; costs and use of outpatient medical services for hypertension derived from the California Workers' Compensation Institute Medical Fee Schedule; changes from baseline in BP; and patient satisfaction with care.

Main results

Adjusted mean changes in BP did not differ between the groups at follow-up but tended to favor home BP especially for men (difference in systolic BP, -3.2 mm Hg [95% CI -6.7 to 0.2 mm Hg]; difference in diastolic BP, -1.6 mm Hg [CI -3.6 to 0.4 mm Hg]). Patients in both groups were satisfied with their care (home BP, 93% vs usual care, 90%). Home BP patients made 1.2 fewer hypertension-related office visits than usual care patients (CI 0.8 to 1.7 visits) but had 0.8 more telephone contacts (CI 0.4 to 1.1 contacts) per year. Mean annual cost of services for management of hypertension, adjusted for demographic factors, baseline BP, and previous use of services, was lower for the home BP group ($89/patient vs $125/usual care patient; CI for difference, $16 to $59). When home-monitoring costs were included, the mean cost was $117 for the home BP group (P > 0.2).

Conclusion

Home blood pressure monitoring provided satisfactory patient care and was slightly less expensive than conventional care for uncomplicated hypertension.

Sources of funding: Robert Wood Johnson Foundation and Kaiser Foundation Hospitals.

For article reprint: Dr. K. Soghikian,Division of Research, Kaiser Permanente Medical Care Program, 3451 Piedmont Avenue, Oakland, CA 94611-5463, USA. FAX 510-450-2073.


Commentary

Most practice environments struggle with controlling costs while maintaining or enhancing the quality of care. Substituting home BP monitoring with close follow-up and regular reporting is attractive if BP control, patient and provider satisfaction, and overall costs are as good as with doctor visits. The report by Soghikian and colleagues supports all 3 claims.

More than 15 years of similar data bolster confidence in the authors' conclusions. Although some training is required, most patients can learn the required techniques (1), especially for arm relaxation and slow cuff deflation. Electronic devices obviate the need for testing patients' hearing (2). Patients appear to appreciate the added reassurance of home monitoring as well as active participation in the process. Although home monitoring results are generally reproducible and sensitive to changes in BP, the accuracy of home devices must not be assumed (3). Frequent home device validation and occasional recalibration are necessary. Home BP units may overestimate pressures among obese or heavily muscled patients.

Home BP values are of limited use for deciding which patients need antihypertensive treatment because the studies of therapeutic efficacy are based on office measurements and reproducibility patterns are diverse. Over the short term, home monitoring offers modest prediction of untreated patients' spontaneous trend toward lowered BP in the office (4). Compared with health education alone, home monitoring may yield lowered BP (5) and reduce dropout rates from treatment (6). One small series reported increased rather than decreased physician visits among self-monitored patients (7). Overall, the existing evidence encourages home monitoring as a valuable part of antihypertensive care.

Peter Rudd, MD
Stanford Medical CenterStanford, California, USA


References

1. Armstrong R, Barrack D, Gordon R. Patients achieve accurate home blood pressure measurement following instruction. Aust J Adv Nurs. 1995;12:15-21.

2. Stergiou GS, Voutsa AV, Achimastos AD, Mountokalakis TD. Home self-monitoring of blood pressure: is fully automated oscillometric technique as good as conventional stethoscopic technique? Am J Hypertens. 1997;10:428-33.

3. Merrick RD, Olive KE, Hamdy RC, Landy C, Cancellaro V. Factors influencing the accuracy of home blood pressure measurement. South Med J. 1997;90:1110-4.

4. Nesbitt SD, Amerena JV, Grant E, et al. Home blood pressure as a predictor of future blood pressure stability in borderline hypertension. The Tecumseh Study. Am J Hypertens. 1997;10:1270-80.

5. Binstock ML, Franklin KL. A comparison of compliance techniques on the control of high blood pressure. Am J Hypertens. 1988;1:192-4S.

6. Stahl SM, Kelley C, Neill PJ, Grim C, Mamlin J. Effects of home blood pressure measurement on long-term BP control. Am J Public Health. 1984;74:704-9.

7. Zarnke KB, Feagan BG, Mahon JL, Feldman RD. A randomized study comparing a patient-directed hypertension management strategy with usual office-based care. Am J Hypertens. 1997;10:58-67.