Improving Hypertension Management: Home Blood Pressure Monitoring and Medication Adherence

Hypertension is one of the most common health conditions worldwide. It increases the risk of heart attack, heart disease, and stroke, with heart disease and stroke being 2 of the leading causes of death in the United States. Based on the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for hypertension management in adults, hypertension is defined as having a systolic blood pressure (SBP) greater than 130 mmHg or a diastolic blood pressure (DBP) greater than 80 mmHg.¹ According to the CDC, 119.9 million adults have hypertension, which translates to 48.1% of the population.² With this fact being known, only about 25% of adults with hypertension have their blood pressure under control.²

Previously, the decision to initiate, or step up or down, antihypertensive therapy has commonly been based on blood pressure readings collected in a health care provider’s office. There are factors that can lead to an inaccurate office blood pressure reading, including improper technique and patient anxiety, also referred to as white coat syndrome.³ The 2017 ACC/AHA guidelines for high blood pressure recommend the use of out of office blood pressure monitoring to confirm a person’s hypertension diagnosis before initiating treatment.¹

One of the most important drivers of a patients’ uncontrolled hypertension is medication nonadherence. Studies that assess home blood pressure monitoring show that there is a positive correlation between medication adherence and the frequency of home blood pressure monitoring.^3,4

Studies that assess home blood pressure monitoring show that there is a positive correlation between medication adherence and the frequency of home blood pressure monitoring. Image Credit: © kaznadey - stock.adobe.com

Community Care Plan (CCP) is a managed medical assistance (MMA) insurance provider based in South Florida. A study was conducted which included CCP’s MMA Medicaid members who were at least 18 years old and had a diagnosis of hypertension, were taking at least 1 antihypertensive medication for a minimum of 3 consecutive months, and had CCP coverage for at least 3 months prior to study initiation. Members were excluded if they had another primary insurance provider other than CCP, required the assistance of a caretaker, or lived in a skilled nursing facility. Members were also excluded if they were pregnant, had a history of cancer, or had a diagnosis of heart disease, heart failure, benign prostatic hyperplasia, thyroid dysfunction, renal or liver failure.

Outreach attempts to members were via phone call, text messaging, and email. Members who were reached completed an initial questionnaire and were provided with a free blood pressure monitor if they did not have one. Members were also provided instructions for proper use of the blood pressure monitor, counseling on the importance of medication adherence, and lifestyle changes to help manage their blood pressure. Participants were instructed to take their blood pressure every morning and evening for 4 weeks and to report results daily. Baseline blood pressure levels were calculated by averaging the 6 most recent blood pressure readings available at provider’s offices or found in the EMR.

Weekly averages were calculated and compared to each participant’s calculated baseline blood pressure. Participants were monitored for recent hospitalizations, emergency room and urgent care visits, related to uncontrolled blood pressure by reviewing insurance claims. Medication adherence was determined based on proportion of days covered (PDC) and the participants’ self-reporting. The demographics of the participants can be found in Figure 1.

There were 6 participants in this study, initially. One participant was lost to follow up during the first week of the study. Results include data from the 5 participants who completed the study. By the end of the study, participants experienced, on average, a drop in systolic blood pressure of 5.13 mmHg and diastolic blood pressure of 3.78 mmHg from their baseline. Weekly averages of the morning and evening blood pressure readings were used in the calculations, with a weekly breakdown available in Figure 2. There were no changes made to the participants’ antihypertensive medication regimen. All participants reported adherence to their antihypertensives for the study duration and this was verified using the PDC based on pharmacy claim information. No participants had an emergency room, urgent care, or hospitalization, due to uncontrolled blood pressure.

To conclude, study limitations include the length of the study, the number of participants involved, and the self-reporting of home blood pressure readings. The accuracy in participants’ technique for checking their blood pressure was not able to be verified, which potentially allowed for inaccurate blood pressure readings being reported. This study supports that there may be a positive effect of home blood pressure monitoring on blood pressure control.

REFERENCES

1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065
2. Centers for Disease Control and Prevention. Facts about Hypertension. Centers for Disease Control and Prevention. September 27, 2021. Accessed July 23, 2024. https://www.cdc.gov/bloodpressure/facts.htm
3. Andraos J, Munjy L, Kelly MS. Home blood pressure monitoring to improve hypertension control: a narrative review of international guideline recommendations. Blood Press. 2021;30(4):220-229. doi:10.1080/08037051.2021.1911622
4. Bryant KB, Green MB, Shimbo D, et al. Home Blood Pressure Monitoring for Hypertension Diagnosis by Current Recommendations: A Long Way to Go. Hypertension. 2022;79(2):e15-e17. doi:10.1161/HYPERTENSIONAHA.121.18463