People enrolled in a pharmacist-led telemonitoring programme to control high blood pressure were about half as likely to have a heart attack or stroke compared to those who received routine primary care, according to research.
Researchers, led by study author Dr Karen L Margolis, executive director of research at HealthPartners Institute in Minneapolis, found that a heart attack, stroke, stent placement or heart failure hospitalisation occurred in 5.3% of the telemonitoring group vs 10.4% of the routine primary care group.
“Home blood pressure monitoring linked with treatment actions from the health care team delivered remotely (telehealth support) in between office visits has been shown to lower blood pressure more than routine care, and patients really like it,” said Margolis. “In addition, by avoiding serious cardiovascular events over 5 years, our results indicate significant cost savings.” Patients reported that they liked having support from a trusted professional, rapid feedback and adjustments to their treatment, and having someone to be accountable to.
Margolis reports that over 5 years, the savings from reduced cardiovascular disease events exceeded the telemonitoring intervention costs by $1,900 per patient. “The findings were just short of statistical significance,” said Margolis, “meaning they could have been due to chance. However, we were surprised that the figures on serious cardiovascular events pointed so strongly to a benefit of the telemonitoring intervention,” she said.
Uncontrolled high blood pressure is the largest modifiable risk factor contributing to death from all causes. Nearly half of US adults have high blood pressure, defined as equal to or greater than 130 mm Hg systolic (top number), or 80 mm Hg diastolic (bottom number). However, most adults with high blood pressure don’t have their numbers under control.
450 participants with uncontrolled high blood pressure were enrolled in the study, conducted at 16 primary care clinics within the HealthPartners system in Minnesota. Participants were blinded and randomised to two groups: 222 patients were in the routine primary care group, and 228 in the telemonitoring group that also received one year of remote care managed by a pharmacist. In the telemonitoring group, patients were able to measure their blood pressure at home and send it electronically to the pharmacist, who then worked with them to make medication and lifestyle changes in their treatment.
In clinic visits for all participants, researchers monitored blood pressure at enrolment, 6 months, 12 months, 18 months and 5 years; kept track of any heart attacks, strokes, coronary stents, heart failure hospitalisations and heart-related deaths that occurred; and counted all the costs of their blood pressure-related care and cardiovascular event care.
They found: In the telemonitoring group, there were 15 serious cardiovascular events (5 non-fatal heart attacks, 4 non-fatal strokes, 5 heart failure hospitalisations, 1 CV death) among 10 patients. This group also had 2 stent placements, making the total event rate 5.3%.
In the routine primary care group, there were 26 serious cardiovascular events (11 non-fatal heart attacks, 12 non-fatal strokes, 3 heart failure hospitalisations) among 19 patients. They also had 10 stent placements, making the total event rate 10.4%.
Based on these findings, “widespread adoption of the telemonitoring model might help US adults with uncontrolled high blood pressure avoid serious cardiovascular events and reduce health care costs,” according to Margolis and colleagues. They recommend future studies to figure out how to increase the number of patients engaged in home blood pressure monitoring over many years, and to measure cardiovascular risk factors and cardiovascular events over that extended period.
The study’s limitations are its relatively small size, and it was at a single medical group’s urban and suburban primary care clinics, which may not represent the diversity of patients who receive care in other settings across the country.
Uncontrolled hypertension is a leading contributor to cardiovascular disease. A cluster-randomized trial in 16 primary care clinics showed that 12 months of home blood pressure telemonitoring and pharmacist management lowered blood pressure more than usual care (UC) for 24 months. We report cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, hospitalized heart failure, coronary revascularization, and cardiovascular death) and costs over 5 years of follow-up. In the telemonitoring intervention (TI group, n=228), there were 15 cardiovascular events (5 myocardial infarction, 4 stroke, 5 heart failure, 1 cardiovascular death) among 10 patients. In UC group (n=222), there were 26 events (11 myocardial infarction, 12 stroke, 3 heart failure) among 19 patients. The cardiovascular composite end point incidence was 4.4% in the TI group versus 8.6% in the UC group (odds ratio, 0.49 [95% CI, 0.21–1.13], P=0.09). Including 2 coronary revascularizations in the TI group and 10 in the UC group, the secondary cardiovascular composite end point incidence was 5.3% in the TI group versus 10.4% in the UC group (odds ratio, 0.48 [95% CI, 0.22–1.08], P=0.08). Microsimulation modeling showed the difference in events far exceeded predictions based on observed blood pressure. Intervention costs (in 2017 US dollars) were $1511 per patient. Over 5 years, estimated event costs were $758 000 in the TI group and $1 538 000 in the UC group for a return on investment of 126% and a net cost savings of about $1900 per patient. Telemonitoring with pharmacist management lowered blood pressure and may have reduced costs by avoiding cardiovascular events over 5 years.
Karen L Margolis, Steven P Dehmer, JoAnn Sperl-Hillen, Patrick J O’Connor, Stephen E Asche, Anna R Bergdall, Beverly B Green, Rachel A Nyboer, Pamala A Pawloski, Nicole K Trower, Michael V Maciosek