Heart Disease and Stroke Prevention: Self-Measured Blood Pressure Monitoring Interventions for Improved Blood Pressure Control When Combined with Additional Support

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends self-measured blood pressure monitoring interventions combined with additional support to improve blood pressure outcomes in patients with high blood pressure. Additional support may include patient counseling, education, or web-based support.

Economic evidence indicates that self-measured blood pressure monitoring interventions are cost-effective when they are used with additional support or within team-based care.

The CPSTF has related findings for self-measured blood pressure monitoring interventions when used alone (recommended).

The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Self-Measured Blood Pressure Monitoring Interventions for Improved Blood Pressure Control are available in The Community Guide Collection on CDC Stacks.

Intervention

Self-measured blood pressure monitoring interventions support and promote the use of personal blood pressure measurement devices in the management and treatment of high blood pressure. Patients are trained to use validated, and usually automated, blood pressure measurement devices on a regular basis in familiar settings, typically their homes. Patients share blood pressure readings with their healthcare providers during clinic visits, by telephone, or electronically. These measurements are monitored and used in treatment decisions to improve blood pressure control.

Self-measured blood pressure monitoring interventions combined with additional support include one or more of the following:

  • One-on-one patient counseling on medications and health behavior changes (e.g., diet and exercise)
  • Educational sessions on high blood pressure and blood pressure self-management
  • Access to electronic or web-based tools (e.g., electronic requests for medication refills, text or email reminders to measure blood pressure or attend appointments, direct communications with healthcare providers via secure messaging)

Self-measured blood pressure monitoring interventions are often used with team-based care.

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.

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).

Summary of Results

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

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.
  • Self-measured blood pressure monitoring with additional support:
    • The median intervention cost per person was $174 (7 studies)
    • 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.
    • Four studies indicated cost-effectiveness (medians of $2800 and $4000 per QALY saved).
  • Self-measured blood pressure monitoring interventions within team-based care:
    • The median intervention cost per person was $732 per year (6 studies)
    • 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.
    • Four studies 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

  • 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.

Implementation Considerations and Resources

Million Hearts released two action guides on self-measured blood pressure monitoring interventions based on findings from Uhlig et al. (2013):

The following considerations for implementation are drawn from information provided in these actions guides.

  • Implementers need to consider the type of blood pressure monitor patients use. The action guides suggest monitors with an automated upper arm cuff.
  • Programs that require patients to provide their own blood pressure monitors should have patients bring them into their doctors’ offices now and then to ensure proper use and function.
  • Some patients may not be able to afford their own blood pressure monitor. In 2015, the cost of an automated blood pressure device ranged from $50 to $100. Insurance benefits for blood pressure monitors vary by payer.
  • The type and cost of additional support with self-measured blood pressure monitoring varied among included studies, making it difficult to determine whether one form of support was more effective than another. The action guides note the following elements of successfully monitoring support for self-measured blood pressure provided across the evaluated interventions:
    • Delivery by trained healthcare providers (e.g., pharmacists, nurse practitioners, physician assistants, health educators)
    • Regular patient communication of blood pressure readings to providers
    • Establishing a patient/provider “feedback loop” in which provider support and advice are personalized based on patients’ reported information
  • Although face-to-face office visits remain an important form of interaction between patients and clinicians, healthcare providers may incorporate other forms of care such as electronic and phone communication that could make care more effective, timely, and efficient. Reimbursement mechanisms for telemedicine, which could be a large component of some blood pressure monitoring interventions, should be considered.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.