The rapid expansion of telemedicine due to COVID-19 presents an opportunity for home blood pressure (BP) monitoring to stake a place as a component of routine clinical practice — provided that policymakers recognize the changes needed to facilitate greater access to healthcare, according to a discussion by hypertension experts.
There is increasing recognition of the importance of out-of-office confirmation of BP elevation even when white coat hypertension isn’t strongly suspected, said J. Brian Byrd, MD, of University of Michigan Medical School in Ann Arbor.
It may be the right time to push for home BP measurement — a more practical alternative to ambulatory monitoring — as a standard part of patient care, several suggested during a session of the virtual Hypertension conference, hosted by the American Heart Association (AHA).
In-office screening for hypertension in adults with confirmation outside of the clinical setting was tentatively given a grade A recommendation by the U.S. Preventive Services Task Force in June. Around the same time, a joint policy statement from the AHA and American Medical Association affirmed that self-measured blood pressure at home is a validated, cost-effective addition to office monitoring.
“The pre-COVID status quo of the cost of care for hypertension is not sustainable. Increased utilization of telehealth has the potential to reduce the economic burden from costly hospital care attributed to poor hypertension control,” said Gbenga Ogedegbe, MD, MPH, of NYU Grossman School of Medicine in New York City.
With people avoiding doctor’s offices due to SARS-CoV-2 exposure risk, non-urgent care virtual visits exploded with an increase of 4,345% from March to April this year at NYU, he said.
Patients Can Do a Better Job Themselves
Switching from office to home BP reading could be an improvement given the unreliability of the former, some suggested.
“Patients can do as good a job or an even better job than what happens in the office setting” provided that they use a validated, calibrated device and are properly educated on how to use it, Byrd said.
Both home and 24-hour ambulatory BP monitoring are more reproducible than office BP, according to Steven Yarows, MD, of IHA Chelsea Primary Care in Michigan.
Yarows detailed the workflow of starting home BP monitoring with a patient:
- Provider recommends a validated automatic upper arm monitor and suggests the correct sized cuff (usually a size large in the U.S.). The medical assistant teaches patient how to use the monitor or arranges for an educational nurse visit at another time (billable for $11 once).
- Patient is then told the frequency and times of measurement. “I personally ask for breakfast and dinner readings for 1 month when starting or changing medication,” Yarows said.
- After a month of data has been recorded on a spreadsheet, the patient is given an action plan (billable at $16 per month until BP is under control).
Home BP readings should be accompanied by regular clinician contact, Ogedegbe emphasized. His group found that tailored feedback on home BP was shown to push systolic BP lower at 12 months among low-income stroke survivors in New York City in a randomized study.
Hurdles to Wider Adoption
Yet there are “still many rivers to cross” when it comes to making home BP telemonitoring part of routine practice, Ogedegbe said.
Reimbursement is one of the most prominent and lamented barriers.
On the upside, new CPT codes for self-measured BP were introduced January 2020.
However, coverage of home monitoring variable among payers, Ogedegbe noted. He added that CMS still has no national coverage determination addressing this practice despite recently finalizing one for the use of ambulatory BP monitoring.
“We should advocate for coverage for home BP devices from Medicare too — affordability should not be a barrier,” commented Ian Kronish, MD, MPH, of New York-Presbyterian/Columbia University Irving Medical Center in New York City, during the virtual chat.
“Completely agree! Devices should be covered period,” wrote Stephen Juraschek, MD, PhD, of Beth Israel Deaconess Medical Center in Boston.
“It seems so obvious that it would be cost-effective to pay for these device [sic],” Byrd added.
Another obstacle for home monitoring is the assurance of patient confidentiality without making data transfer cumbersome.
“Currently, privacy and security concerns prohibit automatic input of data from home BP monitors directly into most EMRs via web-based interfaces. This is a major barrier preventing the full realization of the potential for [home BP telemonitoring] as an effective tool for the management of hypertension,” according to Ogedegbe.
“In a busy practice, it is prohibitive to have to log into a separate cloud-based vault to extract home BP data,” he continued.
The preponderance of non-validated automated oscillometric devices on the market is all the more reason for caution, suggested James Sharman, PhD, of the University of Tasmania, Australia.
FDA and other regulators allow BP devices to be cleared for sale without validation according to rigorous scientific standards, so validated and non-validated BP devices can be sold next to one another, indistinguishable by appearance alone.
“Non-validated BP devices are less accurate and may lead to suboptimal care,” Sharman emphasized.
His group recently reported that among BP devices available for online purchase in Australia, 18% of upper arm cuff devices met international validation standards (versus 8% of wrist cuff devices and zero of the wristband wearables that dominate the marketplace). E-commerce retailers such as Amazon and eBay supplied 92% of BP devices available online but only 5.5% turned out to be validated.
Sharman and several discussants recommended that consumers check the validity of BP devices on www.validatebp.org. Other resources include the general registries STRIDE BP and Medaval.
Finally, existing socioeconomic disparities in healthcare may be exacerbated by the increased use of telemedicine during and after COVID-19, Ogedegbe warned.
At least one in every four people in the U.S. may not have digital literacy skills or access to Internet to engage in video chat, he said.
