Reuters (7/3, Pittman) reports that a study that appeared Tuesday in the Journal of the American Medical Association found that patients with hypertension who were involved in a telemonitoring program were able to keep their systolic and diastolic blood pressure readings down compared to others who received “usual treatment.” Dr. Karen Margolis from HealthPartners Institute for Education and Research in Minneapolis and her colleagues followed a group of people with uncontrolled blood pressure and had them utilize home pressure monitors to measure readings at home and then call in the readings to the pharmacist.
At the end of the program, researchers found 71% of participants involved in the telemonitoring program had their blood pressure in the recommended range, compared to only 53% of participants in the control group.
BLOGFINGER MEDICAL COMMENTARY: By Paul Goldfinger, MD, FACC
In this small study of 450 adult patients with poorly controlled high blood pressure reported on July 3 in the Journal of the American Medical Association, it is suggested that home blood pressure readings coupled with pharmacists’ monitoring the results and adjusting medications could produce better blood pressure control in hypertensive patients whose target readings were not achieved under the care of primary doctors (i.e. “usual treatment.”)
Large trials have shown that there are millions of patients with poorly controlled hypertension in the US, but only half have achieved the goal of BP under 140/90. The reason for the unacceptable stats is not that we need pharmacists to take over care; it’s because the usual and customary care in the hands of primary physicians has not worked well.
This particular study gave no long term results and no evidence that pharmacists are better for the job than real doctors doing the job correctly. The main lesson of this trial has been known for some time: Home BP measurements are an excellent tool to achieve better control. Home readings are superior to office readings in managing hypertension.
Doctors can produce excellent results in their office practices if they organize their procedures better. The idea that hypertension care should be “pharmed out” to pharmacists is nonsense and potentially risky to patients. There are too many potential problems in these cases to allow the care to slide downhill to the corner Rite-Aid. It is not enough to simply focus on the BP reading. The care of such patients is complicated, and fragmenting that care is not conducive to therapeutic success.
The hazards inherent in caring for hypertensives include failure to identify complications such as drug reactions/interactions and side effects that affect other body systems. For example, drug therapy for hypertension can promote kidney malfunction, worrisome low blood pressure, and metabolic disturbances. Hypertension is a major risk factor for stroke and heart attacks, so turning over the job to pharmacists is just a political gimmick to further disrupt the doctor-patient relationship. Physicians are not doing the job well now, but that can be fixed by a new healthcare system.
In my own practice, I achieved nearly perfect BP control for my patients by using home BP devices, education and careful/detailed record keeping by patients, and supervision by our cardiac trained RN’s who helped me with the process. We encouraged necessary life style changes including weight control, diet, salt advice, exercise, and paying attention to emotional factors such as stress. Controlling high blood pressure is usually not difficult, but it can be expensive (as with all good medical care) and it requires commitment on the part of the doctors and their office management personnel. It does not require yet another category of pseudo-doctors.
I say that physicians are the best choice to do the job and they can do it with a team approach in their practices, better technology (especially, tele-transmission of results and accurate and easy to use home monitors), practice guidelines created by doctors, success- based reimbursements for physicians, and insurance coverage of qualified office staff and necessary equipment including the home BP machines and transmission devices.
Guidance is key, i have encountered many patients who request an ambulance or present to the ER with “high BP”. Once you gather a decent history, you realize the patient was sitting at home taking their blood pressure over and over with an automatic cuff and started getting concerned because it would get slightly higher each time.
I’ve also found store-bought cuffs to be wildly inaccurate as they are never calibrated or compared against a manual cuff.
In response to an inquiry about home BP devices, here is the discussion:
Each case is individual re: how to do the monitoring. I like them to do at least two readings a few minutes apart, and then choose the last and write it down with the time, date and if there is anything special going on. There are lots of variables such as when medicines are dosed. So I instruct each patient individually. I do like to have them do different times of day and vary the times, but not more than twice a day so as to not make them crazy. Then they bring their reading to the office at the next visit, or, if there is some issue, they can call or fax the results to the nurse. In the study, the devices would transmit the readings to the pharmacists by telephone.
The home device cuffs show you where to position the marker over the brachial artery, about one inch above the elbow crease. I ask them to sit down and place their arm outstretched, about level with the device. If you use the old fashioned way with a stethoscope, you put it over the brachial artery. (the pinky side of the arm). It’s hard to do that yourself.
I don’t trust any device but the arm ones. I always had my patients bring their machines to the office so we could check them against our mercury sphygmomanometers. Omron suggests calibration every 5 years at their lab, but the way I did it, they were advised to send it back only if it were off.
For many patients who are alone, they do it themselves, but I do like the idea of someone doing it for you to reduce the anxiety factor.
I never make a diagnosis of hypertension from just a few readings unless the number is very high. Quite a few should be done, and then the doctor should try to see the patterns. It might influence the choice of therapy or the choice of some lifestyle decisions, e.g. high readings at work; low readings at home. Also, any confusion of interpretation might require a 24 hr. BP monitor which is a great idea, but insurances often won’t pay for it.
Thanks very much for clarification Doctor Blogfinger. In so many ways you are very helpful. Not only do you keep us in touch with what is going on in OG but you also help us stay healthy.
Frank S: In the study which we are discussing, successful therapy is defined as a reading of under 140/90. Most doctors still use that number to define successful drug treatment for high blood pressure.
However, the National Institutes of Health and the American Heart Association have approved new diagnostic categories. To be considered “hypertensive” is to have a blood pressure of over 140/90. That is subdivided into “Stage one hypertension” which is 140-159/90-99 and “Stage two hypertension” which is 160 or over systolic, OR 100 diastolic or over.
A new category of “pre-hypertension” is 120-130 systolic OR 80-90 diastolic. ” This is NOT hypertension and is not a reason to start pharmaceuticals, but it is a wakeup call to engage in non-drug life style changes such as weight loss, exercise, etc.
So these diagnostic categories shouldn’t be confused with the goals of drug therapy. The NIH has yet to come out with new treatment goals, so their current recommendation cut-off is:
“Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease."
The Mayo Clinic says, "Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level."
Doctors must individualize each patient, and a physician might be more aggressive with lowering BP in, let’s say, someone who has heart disease, especially the kinds that are directly related to high blood pressure. In medicine good judgement tempered by science is often the way to achieve the best results.
You say BP goal is under 140/90 . I thought goal was 120/80 . My tough young Doctor says 110/75 . So which is it ?