Delayed adoption of home blood pressure monitoring: are policies hindering quality?

At a recent faculty meeting, my colleagues and I spent a considerable amount of time discussing ways to improve the performance of internal medicine clinics regarding clinical quality measurement (CQM) of hypertension. Some of them were associated with financial incentives. Our discussion included a plan to review the report and schedule a return visit for patients with elevated in-hospital blood pressure measurements, but I wondered if they were acting on the correct data. I did. Due to the many errors associated with blood pressure measurement in the office, clinical guidelines emphasize the importance of home blood pressure monitoring (HBPM) for the diagnosis and management of hypertension. However, the CQM specifications that determine performance could not include most home blood pressure measurements. We worked hard to improve the performance of clinical quality measurements, but wondered if we were actually improving the quality.

Clinical basis and guidelines for HBPM

Since the 1940s, inconsistencies in blood pressure assessments at home and in the office have been pointed out. Patient-related factors that lead to inaccurate measurements include acute dietary intake, acute alcohol, caffeine, nicotine use, or bladder distention. Procedure-related factors include unverified device use, improper patient positioning, improper cuff size, inadequate rest time, and conversation during measurement. lastly,”White coat effect“Can raise blood pressure in the office, but blood pressure at home is normal.

Increased evidence Systematic HBPM suggests that it provides a more reliable assessment of blood pressure compared to blood pressure in the office. In 2008, Joint statement HBPM is “known or suspected hypertension.” ESH), American Heart Association (AMA), and American Center for Disease Prevention and Management (CDC) Million Hearts® Initiative Currently, all strongly recommend HBPM. In 2021, the US Preventive Medicine Commission reaffirmed the 2015 “Screening for Adult Hypertension.” recommendation Obtain non-clinical measurements by either home or outpatient monitoring for diagnostic confirmation of hypertension before starting treatment. To ensure accurate HBPM AHA, AMA, ESHWhen CDC Both provide similar guidance on device selection, methods, and monitoring schedules, as summarized in Exhibit 1.

Chart 1: Guidelines for Home Blood Pressure Monitoring

Source: AHA / AMA Joint Statement on Self-Measured Blood Pressure Monitoring at Home..

Barriers to accurate HBPM adoption

Despite more than a decade of guidelines calling for HBPM adoption, blood pressure continues to be measured at most visits, and these potentially inaccurate measurements are commonly used in clinical decision making regarding hypertension. It will continue to be a measured value. Evidence-based HBPM penetration in the United States is low. Less than half of adults with high blood pressure Engaged in all types of monthly or higher HPBM, only about one-third of hypertensive patients report being told by their doctor to do HPBM.

Unfortunately, CQM and other policy regulations have taken time to incorporate approaches to promote evidence-based HBPM and may have contributed to low adoption. Medicare and Medicaid Service Center (CMS) CQM, “Management of high blood pressure“”, Which measures the proportion of hypertensive patients with blood pressure <140/90 mmHg during the monitoring period, was revised in 2022 to include blood pressure measurements taken by remote monitoring devices and transmitted to clinicians. While these changes are a step in the right direction, at least internal medicine clinics have not yet adopted a workflow for incorporating HBPM measurements into quality performance data. Importantly, the CQM specification also does not know if measurements were taken using a validated device or if an average home blood pressure submission was accepted. HBPM guidelines We recommend clinical decisions based on this calculation.

Remote patient monitoring code What has evolved over the past few years since it was introduced by the CMS in 2017 is also based on policies that are inconsistent with the guidelines. These codes are intended to motivate clinicians to employ remote monitoring, including HBPM. However, patients should send their blood pressure data to the clinician for at least 16 days a month. This is also a standard that contradicts the HBPM guidelines that require measurements for 3-7 days a month.

Another barrier to HBPM is the lack of extensive insurance coverage for blood pressure devices. A Verified Automatic home blood pressure monitors cost between $ 30 and $ 100.Medicare, as opposed to a blood glucose monitor Normally not covered Upper arm blood pressure measuring device for regular HBPM (excluding annual free-moving blood pressure measurement of patients) Suspected mask or lab coat hypertension.. There are few plans for private payers and Medicaid to offer HBPM coverage.

Accurate HPBM implementation

Despite its continued use, blood pressure measurements in the office for the diagnosis and management of hypertension have little usefulness. My vision of HPBM based on evidence is that instead of measurements in the office, all patients need access to a validated brachial blood pressure monitor of appropriate cuff size, ideally covered by health insurance. there is. Patients should be asked to perform HBPM monitoring sessions from time to time and take two measurements at 1 minute intervals for 3-7 days in the morning and evening. The healthcare provider or staff should educate the patient about the location and timing of the measurements, including the rest interval. Providers should make clinical decisions based on mean blood pressure for each monitoring period of 3-7 days. The CQM needs to be modified to accept the submission of averaged results, and the remote monitoring platform should be able to easily send this data to electronic health records. Remote patient monitoring incentives only require 3-7 days of monitoring.

There is clearly a need for improved blood pressure control in the United States. However, patients should use evidence-based HBPM to make clinical decisions based on accurate data, rather than reviewing reports of patients with high office measurements and errors. Need to be educated. Instead of maintaining an outdated status quo, it should be advocated that payers support these approaches. As we usher in an era where provider payments are tied to value, it’s important to remember that accurate data is an important factor in providing quality care.

Author’s note

Dr. Ritobin is Vice President of Research and Innovation at the PPRNet Foundation, a non-profit organization that promotes evidence-based primary care. Dr. Litvin is a co-founder of Stevara, LLC, a start-up company focused on developing technical solutions to improve the delivery of evidence-based health care, including BPCorrect, a remote home blood pressure monitoring platform. Dr. Litvin would like to thank Dr. Steven Ornstein for providing valuable feedback on this submission.