Self-Monitoring Blood Pressure – The Patient and Pharmacist Team

Slice of Pie

By: Ann Nagle and Chrystian Pereira

The COVID-19 pandemic has significantly impacted the ability to provide in-person CMM services and therefore made it more difficult for pharmacists to collect the clinical data needed from their patients. For example, gathering blood pressure data generally could not be completed in the pharmacy for most sites during CMM visits. In the midst of a global pandemic where patients may be apprehensive to come to a clinic for their care, at-home care delivery must be prioritized. How can pharmacists support patients in the delivery of these important interventions and help patients reach their health care goals? How will these interventions shape the future of care delivery after the pandemic? In order to support pharmacists to develop and implement home blood pressure monitoring at home, the Slice of PIE initiative collaborated with faculty at the University of Minnesota and the MN Department of Health to outline key points and resources in the attachment below

It is widely understood that blood pressure control to prevent cardiac, cerebrovascular, and renal events is critical. Identifying and managing hypertension however, is difficult. Patients may go undiagnosed because they are asymptomatic and, as a result, elevations in blood pressure may be more pronounced and require escalated therapy. Additionally, it may be difficult for patients and providers to establish accurate and representative readings when clinic visits are infrequent and do not accurately reflect blood pressures in daily life.  The 2018 ACC/AHA Hypertension Guidelines recommend out of office blood pressure monitoring for diagnosis of hypertension in conjunction with clinical interventions, titration of medications, and counseling.1 At home blood pressure monitoring accurately portrays the risk of a cardiovascular event, is more accessible, and may be a more affordable option than clinic visits.2 A survey was developed for the Slice of PIE pharmacies that aimed to gather additional information surrounding home blood pressure monitoring prior to and after the start of the COVID-19 pandemic. Approximately 63% of sites had 51% or more of their patients monitoring their blood pressure from home prior to March 2020. However, this increased to 92% of sites in just October of the same year due to the disruptions to patient care caused by the pandemic. With this increase in the number of patients monitoring their blood pressure from home, it allows pharmacists to gather much needed clinical information surrounding a patient’s blood pressure control in a safe environment for the patient.

While current hypertension guidelines recommend self-monitored blood pressure measurements, the evidence for at-home monitoring without co-intervention such as telehealth counseling or clinical direction is inconclusive.1 Clinically, self-monitored blood pressure alone has been shown to increase the number of patients reaching their goal readings.3,4  When coupled with pharmacist intervention, however, not only do more patients reach their blood pressure goals, but they have lower blood pressure readings and sustained control leading to a reduction in mortality in patients who monitor their blood pressures at home.5  With an increasing number of patients monitoring their blood pressures at home and working closely with pharmacists, there is the potential to increase the number of patient’s meeting their blood pressure goals and ensuring they continue to stay at goal, despite global disruptions to care models. 

Pharmacist intervention and home blood pressure monitoring has been shown to further extend the benefits of self-monitoring blood pressure. One study found as high as 71.8% of their patients continued to meet their blood pressure goals for 6 months following pharmacist intervention.6 Others have reported significant reductions of absolute systolic blood pressures (SBP) of up to 17 mmHg7,8 with pharmacist involvement pointing to optimization of medications as a significant contribution to these outcomes. This reduction is especially pronounced in those patients with SBPs >160 mmHg and comorbidities leading to reduced complications and even reduced mortality.5,9 Additional patient-reported outcome measures such as patient engagement, medication adherence, cost effectiveness, positive lifestyle changes, and establishing trends in blood pressure have been reported and should not be overlooked, especially when considering the consequences of undiagnosed or untreated hypertension.2  As a result of these works, it is understood that greater success is achieved with clinical intervention in addition to home blood pressure monitoring. 

Pharmacists have the potential through these outpatient services to help patients meet their blood pressure goals, especially in times where healthcare may be less accessible. As the healthcare landscape continues to change, pharmacists have the opportunity to deliver interventions with significant impact on patient morbidity and mortality by supporting patients in achieving their optimal blood pressure goals.10 View the PDF below and the video series, to learn more about how pharmacists can develop and implement home blood pressure monitoring.  

Home Blood Pressure Monitoring- Resource for Pharmacists 

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1Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., ... & MacLaughlin, E. J. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.

2Liyanage-Don, N., Fung, D., Phillips, E., & Kronish, I. M. (2019). Implementing home blood pressure monitoring into clinical practice. Current hypertension reports, 21(2), 1-14.

3Green, B. B., Cook, A. J., Ralston, J. D., Fishman, P. A., Catz, S. L., Carlson, J., ... & Thompson, R. S. (2008). Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. Jama, 299(24), 2857-2867.

4Magid, D. J., Olson, K. L., Billups, S. J., Wagner, N. M., Lyons, E. E., & Kroner, B. A. (2013). A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program. Circulation: Cardiovascular Quality and Outcomes, 6(2), 157-163.

5Ohkubo, T., Imai, Y., Tsuji, I., Nagai, K., Kato, J., Kikuchi, N., ... & Ito, S. (1998). Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan. Journal of hypertension, 16(7), 971-975.

6Margolis, K. L., Asche, S. E., Bergdall, A. R., Dehmer, S. P., Groen, S. E., Kadrmas, H. M., ... & O’Connor, P. J. (2013). Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. Jama, 310(1), 46-56.

7Mehos, B. M., Saseen, J. J., & MacLaughlin, E. J. (2000). Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 20(11), 1384-1389.

8Zillich, A. J., Sutherland, J. M., Kumbera, P. A., & Carter, B. L. (2005). Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study). Journal of general internal medicine, 20(12), 1091-1096.

9Bobrie, G., Chatellier, G., Genes, N., Clerson, P., Vaur, L., Vaisse, B., ... & Mallion, J. M. (2004). Cardiovascular prognosis of masked hypertension detected by blood pressure self-measurement in elderly treated hypertensive patients. Jama, 291(11), 1342-1349.

10 Currently within Slice of PIE, pharmacists are eligible for quality-based payment for members achieving appropriate blood pressure control.