Sonal J Patil, Nuha K Wareg, Kelvin L Hodges, Jamie B Smith, Mark S Kaiser, Michael L LeFevre 

Abstract

Purpose: Conventional clinic blood pressure (BP) measurements are routinely used for hypertension management and physician performance measures. We aimed to check home BP measurements after elevated conventional clinic BP measurements for which physicians did not intensify treatment, to differentiate therapeutic inertia from appropriate inaction.

Methods: We conducted a pre and post study of home BP monitoring for patients with uncontrolled hypertension as determined by conventional clinic BP measurements for which physicians did not intensify hypertension management. Physicians were notified of average home BP 2-4 weeks after the initial clinic visit. Outcome measures were the proportion of patients with controlled hypertension using average home BP measurements, changes in hypertension management by physicians, changes in physicians' hypertension metrics, and factors associated with home-clinic BP differences.

Results: Of 90 recruited patients who had elevated conventional clinic BP recordings, 65.6% had average home BP measurements that were <140/90 mm Hg. Physicians changed treatment plans for 61% of patients with average home BP readings of ≥140/90 mm Hg, whereas decisions to not change treatment for the remaining patients were based on contextual factors. Substituting average home BP for conventional clinic BP for 4% of patients from 2 physicians' hypertension registries improved the physicians' hypertension control rates by 3% to 5%. Greater body mass index and increased number of BP medications were associated with home BP measurement ≥140/90 mm Hg. Clinic BP levels did not estimate normal home BP levels.

Conclusions: Documented home BP in cases of clinical uncertainty helped differentiate therapeutic inertia from appropriate inaction and improved physicians' hypertension metrics.

This Article was Featured on the January, 27, 2022 Lunch and Learn Discussion

Home blood pressure monitoring in cases of clinical uncertainty to differentiate appropriate inaction from therapeutic inertia

• Physicians and patients are reluctant to intensify treatment when they are uncertain if that single elevated platelet blood pressure truly reflects the patient's hypertension control state. Clinic blood pressures are known to be least accurate and repeated outside-the-office blood pressure measurements accurately reflect hypertension control state.
• When physicians and patients are uncertain about identifying treatments in the presence of an elevated clinic blood pressure reading, documenting average home blood pressures improves hypertension control rates and clinical decision-making.
• Findings: Two-thirds of patients with clinic blood pressure in an uncontrolled hypertension range had controlled hypertension with average home blood pressure measurements. Overall, average home blood pressure documentation improved hypertension control rates.
• Policy Recommendations:
  • Average home blood pressures should be used for estimating hypertension control rates and for clinical decision-making.
  • Loaning or prescribing valid home BP monitors is crucial. Non-validated home blood pressure monitors are common. Only about 20% of the 3,000 commercially available blood pressure monitors are validated.
  • The American Medical Association (AMA) has a list of validated blood pressure monitors.
  • Insurance coverage of valid home blood pressure machines may reduce disparities because 83% of patients who did not own blood pressure monitors said they would buy one if insurance covered it.