Consideration of Out‐of‐Office Blood Pressure Monitoring in Hypertension Management

Clinical decision-making in the management of hypertension is typically based on blood pressure (BP) measurements obtained during a face-to-face office visit. Treatment decisions are complicated by evolving BP targets, medical comorbidities, potential drug-drug interactions, and discrepancies between home and clinic-obtained BP measurements. Evidence for the last of these complexities can be found in studies showing that clinic-based BP measurements are highly variable, likely misclassify BP control for a significant portion of patients,1-3 and lack the sensitivity and specificity to be the sole source of BP measurement to determine management decisions.4 Moreover, self-obtained BP measurements are reproducible,5 lower cost,6, 7 and allow for measurement across time and life circumstances, thus increasing validity.8 In addition, home-based BP measurements are a stronger predictor of adverse outcomes in hypertension than those obtained in the clinic-setting9-11 and assist with achieving BP targets.12 While ambulatory BP recordings (ie, continuous BP devices that record at regular intervals over 24 hours) may be more useful for initial diagnosis and differentiating between masked and white-coat hypertension,13 home-based BP measurement can be an acceptable alternative that may be more feasible in many circumstances.14 Promoting the patient's role in hypertension management is not unique to home BP measurement; self-titration of hypertension medications shows promise in certain high-risk populations.15 In order to make adequately informed and clinically appropriate treatment decisions, clinicians must integrate BP measurements obtained outside the clinic visit, specifically those obtained at home. Incorporating home BP values could ideally look like this: a patient with hypertension on a two-drug regimen uses a home BP measurement device regularly validated based on evidence-based guidelines.16 Based on the literature,1 he takes BP measurements 5 to 6 times over the 2 weeks preceding a routine primary care follow-up appointment as prescribed during a structured device-specific training.17 Data from his home device are automatically uploaded and integrated into his electronic medical record (EMR), avoiding the additional patient burden of manually logging or transcribing the measurement values, which could introduce potential error and additional logistical barriers. Therefore, his primary care provider has both an office-based BP measurement and home-measured values at the time the patient is seen in the clinic. In the event that the patient fails to enter numbers in the specified time period prior to the appointment, an automatic reminder would be sent via e-mail or phone. Because home BP data are already in the EMR, the provider is easily able to see both the real-time, in-clinic BP measurement and measurements obtained at home, which present automatically as a range and average of his home BP numbers to minimize the noise of expected short-term fluctuations. Moreover, the provider can see the time of day that BPs are obtained and give weight to nighttime BP recordings given evidence suggesting that they are better predictors of cardiovascular events.10 Incorporating BP measurements both in clinic and at home into the clinical record allows for clarity in communication of data considered in clinical decision-making. In addition, the provider's quality metrics would be tied to appropriate clinical action in the context of integrated clinic and home hypertension control. Barriers to meaningful integration of home BP values include: (1) difficulty in integrating home-based BP measurements into the EMR, (2) inability to obtain reimbursement for clinical services provided remotely, (3) concern about the reliability of home devices, and (4) the need for long-term patient engagement with, and adherence to, the home BP measurement process. While these are valid barriers in today's health care climate, we anticipate that the utility of EMRs will evolve under meaningful use criteria to better incorporate non-clinic-based assessments, along with the increased development of mhealth technology.18 For example, a patient might have a wireless BP monitor at home and check her values twice daily (eg, morning and evening). The ability for a patient to generate and use this information exists, but this information is seldom incorporated into the electronic health record in a meaningful way, such as a regular report to the provider or dashboard in the electronic health record. Better practices are needed at multiple levels. Current hypertension guidelines offer some support for the incorporation of home-based BP measurements into treatment decisions, but are lacking in details about implementation and evidence-based standards.3, 19-23 At the clinic level, we need to establish policies for validating home BP monitoring devices and clarify which clinical team members should assume that role. High-quality data are needed to inform how and when BP treatment changes should be followed up and what the optimal frequency and intervals of home BP measurement should be. At the team level, mechanisms are needed to allow patients to translate their home BP measurements into a format that is easily and seamlessly incorporated into the chart. Care must also be taken to avoid perverse incentives that select for patients who are more easily able to engage in self-monitoring and avoid the marginalization of those who have limited access to Web-based health platforms24 for management of BP. Health systems need to identify the cost of incorporating this BP-reported data and balance it against the burden of uncontrolled chronic disease. For example, noncapitated systems currently have a disincentive to spend time and energy on care not provided in the context of an in-person visit. Ultimately, we need to shift our focus back to the patient outside of the clinic. If we fail to integrate what is happening to our patients in between office visits, then we are missing 99% of the story and making clinical decisions based on what happens during the 1% of the time when patients are in the office. In order to provide truly patient-centered care, we need to shift our focus to that 99% and incorporate what is supposed to be at the center––the patient. The authors report no specific funding in relation to this research and no conflicts of interest to disclose. Dr Goldstein was supported by VA's Health Services Research and Development (VA HSR&D) CDA 13-263, Dr Zullig was supported by VA HSR&D CDA 13-025, and Dr Bosworth was supported by VA HSR&D 08-027. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US government.