Self-Measured Blood Pressure Monitoring: An AHA/AMA Policy Statement

Self-measured blood pressure (BP) monitoring at home may be a cost-effective way to improve the diagnosis and management of patients with hypertension, according to a joint policy statement from the American Heart Association (AHA) and American Medical Association (AMA), which was published in Circulation.

“Self-measured BP monitoring is an evidence-based approach for measuring out-of-office BP and is considered to be part of the routine diagnosis and management of hypertension,” noted the statement authors. “The addition of self-measured BP monitoring to office BP monitoring is cost-effective compared with office BP monitoring alone or usual care among individuals with high office BP. BP may differ considerably when measured in the office and when measured outside of the office setting, and higher out-of-office BP is associated with increased cardiovascular risk independent of office BP.”

The policy statement reviewed the effectiveness of self-measured BP monitoring, identified existing barriers to the widespread implementation of its use, and provided recommendations to address those barriers.

Use of self-measured BP monitoring is frequently reported by patients and providers. Several national and international hypertension guidelines, scientific statements, and position papers endorse self-measured BP monitoring for the diagnosis and management of patients with high BP. Self-measured BP monitoring can prevent the misclassification of hypertension in patients with elevated in-office BP (white-coat hypertension) and those without elevated in-office BP (masked hypertension).

Most guidelines and policy statements recommend using a mean BP ≥135/85 mmHg as the threshold defining high BP on self-measured BP monitoring. This threshold corresponds to a mean office BP level of 140/90 mmHg. The 2017 Hypertension Clinical Practice Guidelines used ≥130/80 mmHg as the threshold for high BP in self-measured BP monitoring as it corresponds to the recommended threshold in the guideline of 130/80 mmHg for defining high BP in the office setting.

Validated self-measured BP monitoring devices that use the oscillometric method are preferred and a standardized BP measurement and monitoring protocol should be followed. A common recommendation for self-measured BP monitoring is 2 measurements taken at least 1 minute apart in the morning and evening, optimally for 7 days, with a minimum of 3 days.

Studies have shown that the use of self-measured BP monitoring alone, compared with usual care, leads to moderate reductions in systolic and diastolic BP at 6 months, which are no longer observed at 12 months. “There is also evidence for moderate reductions in systolic BP and diastolic BP and for improved BP control at 12 months when self-measured BP monitoring is accompanied by co-interventions, and the benefits on BP increase with the intensity of the co-interventions,” noted the statement authors.

A number of barriers currently prevent the widespread use of self-measured BP monitoring and include the following:

• Patient barriers include performing overly rigid protocols for a long period of time, lack of education about the benefits of self-measured BP monitoring, lack of feedback and recognition from providers, and out-of-pocket costs for conducting self-measured BP monitoring.
• Provider barriers include concerns about the inaccuracy of devices, low adherence to self-measured BP monitoring schedules by patients, concerns about patient anxiety associated with self-measured BP monitoring, increased burden on practices and staff, requirement for additional time to interpret readings, and lack of reimbursement for devices.
• Healthcare system barriers include the lack of systems for self-measured BP readings to be transferred from devices to electronic health records and lack of infrastructure to implement co-interventions.

The AHA/AMA committee made the following recommendations to address these barriers:

• Educating patients and providers about the benefits of self-measured BP monitoring and the optimal approaches for self-measured BP monitoring.
• Establishing clinical core competency criteria to ensure that high-quality self-measured BP monitoring is supported in clinical practice.
• Incorporating co-interventions that increase the effectiveness of self-measured BP monitoring, including behavioral change management and counseling, communication of treatment recommendations back to patients, medication management, and prescription and adherence monitoring.
• Creating systems for self-measured BP readings to be transferred from devices to electronic health records.
• Improving public and private health insurance coverage of validated self-measured BP monitoring devices prescribed by a healthcare provider.
• Reimbursing providers for costs associated with training patients, transmitting BP data, interpreting and reporting BP readings, and delivering co-interventions.

“These barriers can be surmounted in large part by effective education and integration of patients, providers, and healthcare systems,” noted the statement authors. “Patients and providers recognize that effective reduction of high BP is a team effort. Self-measured BP monitoring for hypertension provides the needed link between the limited care in clinics and the true locus of risk and benefit: the patient’s life outside of the clinic where self-monitoring is crucial.”

A financial investment in building and supporting infrastructure for self-measured BP monitoring is needed to ensure successful widespread implementation of its use, according to the researchers. “This includes improving education and training, building health information technology capacity, incorporating self-measured BP readings into clinical performance measures, supporting co-interventions, and enhancing reimbursement,” they noted.

Potential healthcare cost savings are associated with self-measured BP monitoring as well, including a reduction in office follow-up visits resulting from improved BP control; avoidance of possible overtreatment in patients who have self-measured BP that is lower than their office BP measurement, including those with white-coat hypertension; a reduction in cardiovascular events; improvement in quality of life; and a reduction in lost wages and earnings.

Some private and commercial payers and Medicaid plans currently provide coverage for self-measured BP monitoring. The writing committee endorsed the following reimbursement strategy:

• The patient is reimbursed for the purchase of a validated self-measured BP monitoring device prescribed by his/her provider.

• The provider is reimbursed for costs associated with training patients, including provider and staff time, transmission of BP data, interpretation of BP readings, reporting, and costs of delivering co-interventions.

“Although office BP measurement has been the primary method for diagnosing and managing hypertension, accumulating evidence has indicated that self-measured BP monitoring has potential health and economic benefits,” the research group concluded. “Currently, out-of-office BP monitoring, including self-measured BP monitoring, is used to confirm the diagnosis of hypertension and to improve BP control in individuals with hypertension. Therefore, there should be investment in creating and supporting the infrastructure for expanding self-measured BP monitoring and increasing coverage for patient- and provider-related costs.”

Reference

Shimbo D, Artinian NT, Basile JN, et al. Self-measured blood pressure monitoring at home: A joint policy statement from the American Heart Association and American Medical Association. Circulation. 2020;142:e42-e63.