Pharmacists key in home blood pressure telemonitoring, study finds

More than 70% of patients had lower blood pressures after 6 months of intervention

Patients who partnered with a pharmacist for home blood pressure (BP) telemonitoring, lifestyle advice, and medication changes reduced their BP and achieved better control of hypertension than did those receiving usual care, according to a study published in the July 3 issue of the Journal of the American Medical Association.

The research team, headed by Karen L. Margolis, MD, MPH, of the HealthPartners Institute for Education and Research in Minneapolis, recruited 450 adults with uncontrolled BP from 16 primary health care clinics in an integrated health system for 12 months of intervention and 6 months of postintervention follow-up. Pharmacists on the research team included Sarah E. Groen, PharmD, Holly M. Kadrmas, PharmD, and Krissa J. Klotzle, PharmD, all with HealthPartners in Minneapolis.

Intervention method and results

Pharmacists participating in the study met with patients for a 1-hour, in-person visit, during which they reviewed patients' relevant history, provided general information about hypertension, and instructed patients on using the home BP telemonitoring system. They gave patients an individualized home BP goal 5 mm Hg lower than their clinic BP goal.

Each patient received a home BP monitor that stored and transmitted BP readings to the pharmacist, who used an algorithm to adjust the patient’s BP medication and report the changes to the patient’s primary physician. Patients were instructed to transmit at least six BP readings from different times of the day to the pharmacist each week. During the first 6 months, patients and pharmacists talked by phone every 2 weeks until patients had their BP under control for at least 6 weeks, after which they talked monthly. For the next 7 to 12 months, patient–pharmacist telephone visits occurred every 2 months. During the calls, pharmacists emphasized lifestyle changes and medication adherence.

Among the 380 people who attended both the 6- and 12-month clinic visits, slightly more than 57% of those in the intervention group had controlled BP at both visits, compared with 30% in the usual care group, the study noted. After 6, 12, and 18 months, just over 70% of the intervention participants had their elevated BPs under control, compared with 42% to 58% in the group that received usual care.

Systolic BP dropped by an average of almost 11 mm Hg more for those receiving the study intervention compared with the usual care group at 6 months, and by almost 10 mm Hg more at 12 months. Six months after the study ended, those who had been in the intervention group had systolic BP readings an average of 6.6 mm Hg lower than the usual care group.

Costs to patients and pharmacists

Estimated per-patient cost to implement the program would be about $1,350 when patients receive up to 12 months of access to BP telemonitoring, according to the researchers. Costs may be reduced by targeting patients more effectively, negotiating volume discounts, and tailoring interventions, such as replacing telemonitoring with a standard home BP monitor after a patient has reached and sustained home BP goals, they suggested.

During the study, pharmacists logged all encounters with patients in a database. Pharmacy departments were reimbursed for pharmacy staff’s time spent interacting with patients, reviewing BP telemonitoring data and preparing for the telephone calls, and documenting the encounters using the monthly time logs. The price for the home BP telemonitoring was negotiated before the trial, with a fixed per-patient enrollment fee and a monthly telemonitoring rate based on the 12-month intervention period. The researchers excluded costs of patient time, pharmacy, laboratory tests, and nonstudy encounters.

Removing program barriers

To increase patient participation, health insurers should provide benefit coverage for BP monitors and reimburse clinicians and health care organizations for services related to home BP monitoring, according to an accompanying editorial by David Magid, MD, MPH, of Kaiser Permanente Colorado Institute for Health Research in Denver, and Beverly Green, MD, MPH, of the Group Health Research Institute in Seattle. Because such care is not currently covered by Medicare and many other payers, they wrote, “clinicians in fee-for-service systems are unlikely to voluntarily give up reimbursements for hypertension-related office visits.” They also recommended that home BP measurements be included in quality assurance assessments of hypertension care.

“If home BP monitoring and team-based care were implemented broadly, hypertension management would be easier for patients, and the magnitude of BP reductions brought about by this change could lead to substantial reductions in cardiovascular events and mortality, which is something patients, clinicians, and policy makers can take to the bank,” Magid and Green wrote.