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Home blood pressure monitoring: take it to the bank.

Forty years ago, to deposit a check, transfer funds, or get cash, a person had to visit a local bank—during weekday business hours—and meet face-to-face with a teller. Today, with Internet banking and automated teller machines, transactions can be made anywhere and anytime. Unlike banking, the approach to hypertension care has changed little in the last 40 years. Patients are expected to make regular visits to a medical office for blood pressure (BP) measurements and inperson meetings with a clinician. In this issue of JAMA, the well-designed and well-executed Home Blood Pressure Telemonitoring and Case Management to Control Hypertension (HyperLink) study by Margolis and colleagues1 demonstrates how to improve BP control by making hypertension management more like modern banking: accessible, easy, and convenient. In the United States, hypertension is the most common diagnosis made at primary care office visits and accounts for more than half of diagnoses made in adults with chronic conditions.2 Hypertension is a greater risk factor for cardiovascular disease than tobacco use or obesity, and approximately half of the cases of ischemic heart disease and stroke are attributable to high BP.3 Despite effective medication and behavioral therapies to treat high BP, the current clinic-based approach to hypertension care produces suboptimal results in which more than half of the 76 million US adults with hypertension have uncontrolled BP.4 The current practice of clinic-based hypertension management leads to undertreatment for some patients and overtreatment for others. Even with proper techniques, BP control is misclassified for more than 25% of patients when a single office visit measurement is used.5 Some patients exhibit “white-coat hypertension” with elevated BP levels in the medical office but not in other settings, whereas others have “masked hypertension” with elevated BP outside the clinical setting but not in a medical office. Using 24-hour ambulatory BP monitoring as a criterion standard, an average of 6 BP readings taken at different clinic visits are needed to classify BP control with 80% accuracy.6 This many in-person visits are impractical for most patients. Home BP monitoring, in which patients regularly measure their BP in nonclinical settings, addresses several limitations of traditional office-based BP management. Home monitoring enables more frequent measurements in settings familiar to the patient, reducing misclassification due to white-coat or masked hypertension and prompting more timely action to address elevated BP. The HyperLink study1 tested the effectiveness of home BP monitoring combined with team care, in which home BP data are communicated regularly to health care practitioners who use these data to make treatment recommendations. The HyperLink study was a cluster randomized trial of 450 patients who received care at 16 HealthPartners Medical Group clinics. Eight clinics were randomly assigned to usual care and 8 to the intervention. Intervention clinic patients received home BP telemonitors that transmitted patient BP measurements to clinic-based pharmacists, who adjusted antihypertensive therapy based on the data. The main outcome was BP control (<140 mm Hg systolic and 90 mm Hg diastolic or <130 mm Hg systolic and 80 mm Hg diastolic in patients with diabetes or kidney disease). The intervention lasted 12 months. A unique aspect of the study was assessing maintenance of the intervention effect at 18 months, which was 6 months after the intervention ended. The HyperLink intervention led to significantly higher rates of BP control and greater BP reductions than usual care. At 12 months, 71% of patients in the intervention group achieved BP control vs 53% of patients in the usual care group. The HyperLink study also demonstrated significant improvements in BP control 6 months after the intervention ended. Intervention patients had greater antihypertensive medication intensification and better self-reported medication adherence. The intervention was safe and also improved some aspects of patient satisfaction. The HyperLink study findings are consistent with 2 recent randomized trials of home BP monitoring with team care.7,8 In all 3 studies, patients with uncontrolled hypertension were provided with automated BP monitors that stored home BP measurements and electronically transmitted the BP data to pharmacists. The pharmacists recommended changes to antihypertensive medications via telephone or electronic communications with patients. Notably, none of the interventions required regular office visits; patients received care without missing work, traveling to a medical office, or waiting at a clinic. Compared with usual care, interventions in all 3 studies resulted in a larger decrease in systolic BP of 10 mm Hg or higher, a level of BP reduction associated with decreases in coronary heart disease events by 22% and stroke by 41%.9 Based on the consistent and substantial evidence from these and other studies,10,11 it is clear that bringing hypertension care out of the office and into patients’ homes works. Nonetheless, widespread adoption of home BP monitoring supported by team care has not occurred in the United Related article page 46 Opinion