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Cardiovascular Disease: Self-Measured Blood Pressure Monitoring Interventions for Improved Blood Pressure Control – When Combined with Additional Support

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review published in 2013 (Uhlig et al., 52 studies, search period through February 2013). Twenty-five (29 study arms) of the included studies evaluated the effectiveness of self-measured blood pressure monitoring interventions when combined with additional support to manage high blood pressure.

Context

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Summary of Results

More details about study results are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 631 kB].

The systematic review included 25 studies with 29 study arms.

  • Blood Pressure Outcomes
    • Proportion of patients with blood pressure at goal: median increase of 5.3 percentage points (median duration: 9 months; 18 study arms)
    • Change in mean systolic blood pressure: median reduction of 4.6 mmHg (median duration: 12 months; 26 study arms)
    • Change in diastolic blood pressure: median reduction of 2.3 mmHg (median duration: 9 months; 28 study arms)
    • Results demonstrated consistent and meaningful improvements in blood pressure that were sustained at 12 months when compared with usual care.
  • Other Outcomes
    • One study conducted over a five year period reported lower death rates among patients receiving self-measured blood pressure monitoring combined with educational sessions compared with patients receiving usual care.
    • Findings were inconsistent for outcomes measuring medication adherence, health-related quality-of-life, or patient satisfaction.

Summary of Economic Evidence

More details about study results are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 631 kB].

The economic review included 16 studies (search period through March 2015): 8 studies of self-measured blood pressure monitoring with additional support, and 8 studies of self-measured blood pressure monitoring with team-based care. All monetary values are reported in 2014 U.S. dollars.

  • Economic evidence indicates self-measured blood pressure monitoring interventions are cost-effective when they are used with either additional support or within team-based care.
  • No studies reported the effect of the intervention on worksite productivity.
  • No studies provided a full assessment for cost-benefit analysis.
  • Intervention Cost
    • The cost of interventions that added patient support included the cost of self-measured blood pressure monitoring alone plus the cost of web- or phone-based support.
      • The median intervention cost per person was $174 (7 studies)
    • The cost of interventions used within team-based care included the cost of self-measured blood pressure monitoring alone plus the labor cost of staff engaged in team care.
      • The median intervention cost per person was $732 per year (6 studies)
  • Intervention Cost and Healthcare Cost
    • The intervention cost plus the change in healthcare cost equals the total cost of the intervention.
      • Healthcare cost is defined as the cost for medication, outpatient visits, hospital inpatient stays, and emergency room visits.
      • When the estimated total cost is positive, the intervention is cost-increasing; when it is negative, the intervention is cost-saving.
    • Self-measured blood pressure monitoring with additional support:
      • Five of six total cost estimates were positive (median: $44 per person) over a median follow-up period of 9 months, indicating the intervention was cost-increasing.
    • Self-measured blood pressure monitoring interventions within team-based care:
      • All seven estimates of total cost were positive (median: $430 per person per year) over a median follow-up period of 18 months, indicating the intervention was cost-increasing.
  • Cost-Effectiveness
    • Two methods from the literature (Mason et al., 2005; McEwan et al., 2006) were used to translate reductions in systolic blood pressure to quality-adjusted life year (QALY) saved. An intervention is considered cost-effective if cost per QALY saved is less than $50,000.
    • Four studies of self-measured blood pressure monitoring with additional support indicated cost-effectiveness (medians of $2800 and $4000 per QALY saved).
    • Four studies of self-measured blood pressure monitoring used within team-based care indicated cost-effectiveness (medians of $7500 and $10,800 per QALY saved)

Applicability

Based on results for interventions in different settings and populations, findings are applicable to the following:

  • Adults with high blood pressure
  • Adults with both high blood pressure and diabetes
  • Women and men
  • Outpatient, general practice, and primary care settings

Evidence Gaps

Additional research and evaluation are needed in these areas, to fill existing gaps in the evidence base. (What are evidence gaps?)

  • The effectiveness of blood pressure monitoring interventions that require patients to provide their own blood pressure monitoring devices. In all of the included studies, blood pressure monitoring devices were provided to patients.
  • How often patients should measure their blood pressure, and how often clinicians should monitor patients' self-measured blood pressure readings.
  • The effectiveness and costs of different types of additional support provided to determine whether one form of additional support is more effective than another.
  • The role of telemedicine in self-measured blood pressure monitoring interventions, and how it affects patient-provider interaction and medication management.
  • The effectiveness of self-measured blood pressure monitoring interventions among various subgroups including racial/ethnic minorities, low-income populations, patients with comorbidities, and children.
  • Long-term benefits of self-measured blood pressure monitoring interventions lasting longer than 12 months, including effects on rates of sickness and death.
  • The effectiveness self-measured blood pressure monitoring interventions in community and worksite settings and whether they strengthen community-clinical linkages.
  • The intervention cost when the costs of devices and software used in self-measured blood pressure monitoring interventions are distributed over the duration of their use.
  • Returns on investment in self-measured blood pressure monitoring interventions, based on the monetized value of benefits including reduced deaths and avoided productivity losses.

Study Characteristics

  • Studies were done in the United States (13 studies), Western Europe (7 studies), Canada (3 studies), Australia (1 study), and South Korea (1 study). Interventions were delivered mainly in outpatient, general practice, or primary care settings (23 studies).
  • In 19 of the studies, interventions were delivered in outpatient, general practice, or primary care settings.
  • Included studies reported an even distribution of men (median: 47.5%; 24 studies) and women (median: 52.5%; 24 studies).
  • Study populations included adults ages 18-64 years old (median: 57.2 years; 20 studies) and adults 65 years and older (median: 70.8 years; 3 studies).
  • Thirteen studies reported race/ethnicity with study populations mainly identifying as white/Caucasian. Three studies included populations with more than 75% identifying as African American.
  • Four studies that targeted populations with both high blood pressure and diabetes observed greater improvements in blood pressure outcomes compared to overall findings.
  • All 25 of the included studies provided patients with blood pressure monitors and training, and patients measured their blood pressure at home.
  • Fifteen studies provided patients with fully automated blood pressure monitor devices.
  • Patients' blood pressure readings were delivered to healthcare providers during medical visits as self-recorded readings (10 studies), through electronic transmissions sent directly from blood pressure devices to central databases that providers could access (9 studies), or by mail (2 studies).
  • More than half of included studies used a team-based care arrangement where primary care providers worked alongside other healthcare professionals such as nurses and pharmacists to improve coordination of care and support for patients (14 studies).

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