Disclosure of Relationships

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1 American Society of Hypertension, Inc. (ASH) Disclosure of Relationships Over the past 12 months Consultant: Novartis, Pfizer Advisory Board: Abbott Vascular, Gilead

2 Partnership with the Patient to Improve Blood Pressure Control American Society of Hypertension 26 th Annual Scientific Meeting Saturday, May 21, 2011 New York, New York Nancy Houston Miller, RN, BSN, FAHA, FPCNA

3 American Society of Hypertension, Inc. (ASH) Objectives 1.To discuss the role of home blood pressure monitoring in increasing blood pressure control 2.To highlight patient/provider needs to improve HBPM 3.To provide other key quality improvement strategies that enhance BP control

4 Blood Pressure: A Public Health Approach 76.4 million Americans ( 1 in 3 adults) suffer from high blood pressure million have pre-hypertension NHANES data indicate that 78.7% are aware of their hypertension, 69.1% are under treatment and 45.4% have adequate control Home blood pressure monitoring (HBPM) increases our ability to improve upon hypertension detection, treatment and control Roger VL et al. Heart disease and stroke statistics-2011 update. Circulation 123: e18-e209.

5 Blood Pressure: A Public Health Approach A meta-analysis of 18 RCT's indicates that OBP was lower by 4.2/2.4 (systolic/diastolic) mmhg in those undertaking HBPM compared to standard BP measurement Home blood pressure monitoring has been recommended by several national and international organizations e.g. AHA, PCNA, BHS, ESC, JHS, WHO HBPM should be undertaken by 100 million individuals at risk (pre-hypertension) and those with hypertension.

6 Thirty Years of Research on Diagnostic and Therapeutic Thresholds for the Self-Measured Blood Pressure at Home "Any reduction in the systolic blood pressure by 3 mmhg will reduce the incidence of stroke, MI, CVD events by approximately 20, 15, and 15%. Any reduction in conventional blood pressure will also be accompanied by a decrease in the self-measured blood pressure at home."... EACH MILLIMETER COUNTS IN THE PREVENTION OF CVD COMPLICATIONS BY BLOOD PRESSURE LOWERING TREATMENTS--- THIS IS A PUBLIC HEALTH APPROACH Staessen JA, et al. Blood Pressure Monitoring 2008; 13:

7 Clinical Indications for HBPM Diagnosis Masked hypertension White coat hypertension Pre-hypertension Resistant hypertension Special populations ( e.g. elderly, diabetics, pregnancy, CKD, children) Treatment and Control Improve medication adherence/control Predict CVD risk Pickering TG, et al. Hypertension. 2008; 52:

8 Prospective Studies of Home and Office BP s to CVD Events and Mortality Trial # subjects Tot Meas. Outcome Ohsama (am) Strokes/mort better pred. HBPM Sheaf (am/pm) CV morb/mort better pred. HBPM PAMELA (am/pm) CV morb/mort better pred. HBPM Belgian (am) Combined CV events better pred. HBPM Didima (am/pm) CV events pred by both HBPM/office Pickering TG, et al. Hypertension. 2008; 52:

9 Masked Hypertension: A systemic review Bobrie G. et al. J Hypertension 2008; 26: HR 1.92 ( ) Treated Hypertensives Pierdomenico, 63 events Untreated Hypertensives Mixed Bobrie, 324 events Bjorklund, 72 events Fagard, 86 events Okhubo, 152 events Hansen, 156 events Total

10 Self-Measurement of Blood Pressure at Home Reduces Need for Antihypertensive Drugs RCT of 430 mild-mod hypertensive adults allocated to SMBP (n=216) or OP ( n=214)--1 yr. Methods: OP--10 visits, Amb Monit (start/end) SMBP--8 times, Amb Monit ( start/end) MD's blinded to study group Results: SMBP used less med (1.47 vs 2.48 drugs) Lower costs ($3222 vs per 100 pts/mo) No sig. change in LVM or urine microalbumin Verbeck WJ, et al. Hypertension 2007; 50:

11 Systematic Review of Effects of HBPM on Medication Adherence Study Dur of Int/Pts Adh. Measure Improv Bailey (1999) 8wks/62pts Pill Count No Binstock (1988) 1 yr/111pts Self-report No Friedman (1996) 6 mo/ 267pts Pill Count Yes Haynes (1976) 6 mo/38 pts Pill Count Yes Girvin (2004) 6 mo/136 pts Pill Count No McKenney (1992) 24 wks/67pts Elec Med Mont. Yes Mehos (2000) 6 mo/36 pts Pharm. Records No Ogbuokiri (1980) 5 mo/24 pts Pill Count Yes Rudd (2004) 6 mo/150 pts Elec Med Mont. Yes Vrijens (1997) 6 wk/628 pts Elec Med Mont. Yes Zarnke (1997) 8 wk/31 pts Self-report No Ogedegbe G. J Clin Hypertens 2006; 8:

12 Superiority of HBPM over Clinic Measures Over 70 years ago observations indicated that office BP can vary by 25 mmhg between visits HBPM may more closely reflect true level of intra-arterial pressure versus OBPM which may reflect white coat/masked HTN HBPM allows for greater number of measures and smoothing of variation in BP Measurement may be particularly important in smokers smoking-induced BP is masked Sheikh S. et al. Curr Hypertens Rep 2011; 13:

13 Patient Use of Home Blood Pressure Monitors Cross-sectional survey of 530 adults with HTN in 24 primary care clinics in North Carolina (n=223, 46%) who perform HBPM Results: 19% monitor daily, 26% few times per week, 29% few times a month 70.4% did not provide a report to their MD 29% had their monitor checked by an MD or nurse Viera AJ, et al. Blood Pressure Monitoring 2008, 13:

14 Attitudes of PCP s and Pts. On Home Blood Pressure Monitoring Mailed 28-item survey of PCP s in Ontario, Canada ( n=478) and patients ( n=149) PCP Results: 63% encouraged HBPM by pts. Only 13% preferred HBPM compared to amb./office measures for diagnosis and 19% to guide therapy 70% of PCPs were worried about pt s preoccupation with HBPM 65% were concerned about accuracy of devices Only 13% of MD s averaged readings Logan AG et al. J. Hypertension 2008; 26:

15 Attitudes of PCP s and Pts. On Home Blood Pressure Monitoring Results of Patient Survey 68% of pts. measured BP s at home 80% received no advice from their MD s on appropriate use Only 8% had specific training on appropriate measurement 68% did not take readings to MD 39% did nothing about alarm readings Logan AG et al. J. Hypertension 2008; 26:

16 Implications of PCP Survey on Home Blood Pressure Monitoring Patient Education must include: Appropriate measurement technique Specific instructions on appropriate method of handling results Meaning of readings Steps for unusual readings Logan AG et al. J. Hypertension 2008; 26:

17 Effectiveness of Home Blood Pressure Monitoring, Web Communication and Pharmacist Care on HTN Control RCT of 778 uncontrolled HTN pts. Group 1 Usual Care Group 2---HBPM/ Website Training Group 3---HBPM/ Website Training and Pharmacist Care Management Outcomes: Control ( % of pts.) with BP < 140/90 and changes in systolic/diastolic BP Green BB, et al. JAMA 2008; 299:

18 Effectiveness of Home Blood Pressure Monitoring, Web Communication and Pharmacist Care on HTN Control U.C. BP Monitoring/Web Only Pharm Care Systolic BP * Adjust Mean Diastolic BP Adjust Mean BP (% cont.) 29% 34% 51%* (<140/90) RR 1 (ref) p<.001 UC vs pharmacist care and only vs. pharmacist care Green BB, et al. JAMA 2008; 299:

19 Telemonitoring and Self-management in the Control of Hypertension (TASMINH2) RCT of 527 HTN pts (BP> 140/90 mmhg despite HTN trt.) from 22 general practices in the UK. Intervention: Self-monitoring of BP and selftitration of anti-hypertensive meds combined with tele-monitoring of HBP measures Primary Outcome: Mean in SBP baseline to 6 and 12 months (91% follow-up) McManus RJ, et al. The Lancet 2010; 376:

20 Telemonitoring and Self-management in the Control of Hypertension (TASMINH2) Intervention 2 training sessions by RN HBPM for first week of each month using OMRON device 2 readings each morn. If readings were above target 4 or more days over 2 months med titration was indicated NICE guidelines Usual Care Attend a review with family physician McManus RJ, et al. The Lancet 2010; 376:

21 Telemonitoring and Self-management in the Control of Hypertension (TASMINH2) Results: Int. Pts. took a median of 152 BP readings and 74% took more than 90% of expected readings Reduction in systolic BP was 3.7 and 5.4 mmhg lower at 6 and 12 months compared to usual care ( p<0.013, p<0.0004). No differences in diastolic BP Of 80% of pts. who self-managed BP for 12 months, 70% made at least one med change and were prescribed 0.32 additional HTN medications compared to control subjects McManus RJ, et al. The Lancet 2010; 376:

22 Health Coaching, HBPM, and Home-titration Among Low-Literacy Patients RCT of 300 low-literacy pts. assigned to a PCP with a diagnosis of HTN and BP > 145/90 on 2 or more visits Control Grp: Weekly coaching on HBPM, medication understanding and adherence Int. Grp.: Weekly coaching by medical assistants and assistance with home titration of HTN meds following home algorithm Primary Outcome: in clinic systolic 6 and 12 months Bennett H. et al. BMC Public Health 2009, 9: 456

23 Key Issues About HBPM Methodology Medical supervision and training Appropriate choice of validated HBPM devices and specific validation in special populations Adequate BP measurement schedule and data reporting by patient Ability of HCP s to interpret results correctly Parati G, et al. Journal of human Hypertension 2010; 24:

24 Comparison of Web Sites to Manage and Present HBP Readings Review of 20 web sites evaluated for 33 desirable features for HBPM Results--- 70% offered option to print in tabular form 70% offered graphical form 47% could be downloaded from Microsoft HealthVault None were directly linked to an EMR Patel BS, et al. J Clin Hypertens 2010; 12:

25 Comparison of Web Sites to Manage and Present HBP Readings Seven PHR s offered 75% of universal features: *AHA Bloodindex *Health Circles LLC Zume Life Life Clinic * Mayo Clinic Cerner Patel B. J Clin Hypertens 2009; 12: * Top 3 sites

26 Comparative Effectiveness Review of Self- Measured Blood Pressure Monitoring Key Questions: Does SMBP monitoring compared to usual care or other interventions without SMBP have an effect on clinically important outcomes? (e.g. clinical outcomes, BP control, health outcomes, adherence) Key Findings: SMBP compared to UC resulted in modest but statistically significant reduction in clinic SBP and DBP (-3.1/-2.0mmHg) at 6 months, as well as SBP at 12 mo. (-2.0mmHg) the large heterogeneity in trials limits conclusions. Agency for Healthcare Research and Quality. Comparative Effectiveness Review of Self-Measured Blood Pressure Monitoring

27 Future Research to Improve HBPM Individualize study goals: lower BP in those with uncontrolled HTN versus avoiding overtreatment in white coat HTN Effects of SMHP on drug titration when BP is not controlled Better standardization: retesting of alreadyinvestigated promising protocols, different monitoring schedules, accuracy and adherence with SMBP, improving transmission of SMBP information for decision-making, comparison of automated devices Agency for Healthcare Research and Quality. Comparative Effectiveness Review of Self-Measured Blood Pressure Monitoring

28 Future Research to Improve HBPM Extend length of follow-up to examine the effects of SMBP on clinical events RCTs should compare treatment to different home BP targets and their effect on clinical outcomes Establish a central database to serve as a reference on accreditation information that support clinician, investigator, and consumer selection of devices Agency for Healthcare Research and Quality. Comparative Effectiveness Review of Self-Measured Blood Pressure Monitoring

29 The Case for Home Monitoring in Hypertension Whether one is to convert to the use of self-blood pressure monitoring or not, it is difficult to argue against the fact that such machines are being used extensively by patients themselves in primary care. We can choose to ignore the results that they obtain or we can work with them to improve the information about blood pressure levels and thus perhaps produce more effective drug treatment for the condition of hypertension that is the cause of so much morbidity and mortality. Paul Padfield

30 Effect of Quality Improvement Strategies on Blood Pressure Control (44 trials) Provider Focus Med in SBP Med in DBP Reminders (6) 1.2 mmhg 0.3 mm Hg Relay of Clin.Data (16) 8.0 mmhg 1.8 mmhg Audit/Feedback (3) 1.5 mmhg 0.6 mmhg Provider Ed. (11) 3.3 mmhg 0.6 mmhg Patient Focus Patient Education (18) 8.1 mmhg 3.8 mmhg Prom. Of Self Manage (9) 3.3 mmhg 2.8 mmhg Pt Reminders (5) 3.3 mmhg 0.4 mmhg Walsh, JM et al. J Clin Hypertens 2008; 10:

31 Effect of Quality Improvement Strategies on Blood Pressure Control (44 trials) System Focus Med in SBP Med in DBP Team Change (20) 9.7 mmhg * 4.2 mmhg * Financial Inc. (1) mmhg 0.0 mmhg All comparisons 4.5 mmhg 2.1 mmhg p< 0.5 Walsh, JM et al. J Clin Hypertens 2008; 10:

32 Effect of Quality Improvement Strategies on BP Outcomes (n= 37 trials) Type of Quality Imp. Med SBP Med DBP (mmhg) (mmhg) Free Medications Pharmacist rec. to MD Education re: BP meds Pharmacist intervention Drug profile/med hist Medication compliance Nurse intervention Treatment algorithm used Carter BL, et al. Arch Intern Med 2009; 169:

33 Effect of Quality Improvement Strategies on BP Outcomes (n= 37 trials) Better Control of Blood Pressure Intervention O.R. (C.I.) Nurses 1.69 ( ) Pharmacists/PC Clinics 2.17 ( ) Community pharmacists 2.89 ( ) Carter BL, et al. Arch Intern Med 2009; 169:

34 Summary Home blood pressure monitoring is a key strategy to help improve blood pressure control Opportunities exist to improve both patient and provider success with the use of home BP monitoring Quality improvement initiatives also include improved education, audit and feedback and the careful design/use of healthcare teams

35 American Society of Hypertension, Inc. (ASH) Disclosure of Relationships Over the past 12 months Consultant: Novartis, Pfizer Advisory Board: Abbott Vascular, Gilead