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Research Article
Originally Published 31 August 2020
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Cardiovascular Events and Costs With Home Blood Pressure Telemonitoring and Pharmacist Management for Uncontrolled Hypertension

Karen L. Margolis https://orcid.org/0000-0003-1862-7402 [email protected], Steven P. Dehmer https://orcid.org/0000-0003-3508-9239, 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, and Michael V. Maciosek https://orcid.org/0000-0002-8164-8858Author Info & Affiliations
Hypertension
Volume 76, Number 4
https://doi.org/10.1161/HYPERTENSIONAHA.120.15492
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Graphical Abstract

Abstract

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.

Registration—

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781365.

Introduction

Uncontrolled high blood pressure (BP) is the largest modifiable risk factor for all-cause mortality (contributing 30%) and cardiovascular mortality (contributing 41%) in the US population.1 Between 2007 and 2016, about half of people with hypertension in the United States did not have BP controlled to <140/90 mm Hg.2,3 The prevalence of uncontrolled hypertension is even higher with the lower target level of <130/80 mm Hg specified in the 2017 ACC/AHA guideline (2017 Hypertension Clinical Practice Guidelines).4,5
Self-monitoring of BP without additional patient support offers at best modest BP lowering for up to 6 months,6,7 but when combined with moderate or high levels of patient support, there are 4 to 6 mm Hg greater mean reductions in systolic BP (SBP) and ≈2 mm Hg greater mean reductions in diastolic BP, as well as about 50% improvement in BP control compared with usual care (UC) for 12 months.8 Individual patient counseling and educational care management support can be provided by nurses or pharmacists as part of team-based care, which has also been shown to lower BP and improve BP control with or without self-monitoring.9 Home telemonitoring allows BP data to be transmitted electronically to care managers and has also been shown to substantially improve BP compared with UC.10,11
In the Hyperlink trial, our research team compared an intervention combining home BP telemonitoring and pharmacist care management (telemonitoring intervention, TI) to UC in primary care patients with uncontrolled hypertension. After the 12 month intervention, SBP was 10 mm Hg lower and diastolic BP was 5 mm Hg lower in the TI group than in the UC group, with BP differences persisting for up to 24 months.12,13 Despite ample data on the BP-lowering effects of telemonitoring, self-monitoring, and team-based care for hypertension, few studies report long-term follow-up with clinical outcomes. To address this important evidence gap, we report cardiovascular events and costs over 5 years of follow-up of Hyperlink.

Methods

Data available on request from the authors.

Study Design, Setting, and Patients

The Hyperlink study was a cluster-randomized trial in 16 primary care clinics at HealthPartners Medical Group clinics that had a Medication Therapy Management pharmacist on site at least once weekly at the start of the study in 2009. The study protocol was approved by the HealthPartners institutional review board, and all enrolled patients provided written informed consent. Detailed study methods have been published.14
Recruitment, enrollment, and follow-up of the study cohort are shown in Figure 1. Briefly, 14 492 adults with uncontrolled hypertension as identified through electronic systems were invited by mail to participate. A total of 2020 patients were screened for eligibility, including having uncontrolled BP (≥140/90 mm Hg or ≥130/80 mm Hg if diabetes mellitus or kidney disease was present) based on the mean of 3 automated measurements taken using a standardized protocol in the research clinic. Of these, 450 were eligible and agreed to participate, and all are included in this analysis of health and economic outcomes. Clinics were randomized to either TI (8 clinics with 228 patients) or UC (8 clinics with 222 patients). Patients were blinded to their clinic’s treatment assignment before randomization.
Figure 1. Participant recruitment, enrollment, randomization, and follow-up.

Interventions

TI patients received an automated oscillometric home BP monitor (A&D Medical 767PC, San Jose, CA) that stored and transmitted BP data to a secure website (AMC Health, New York, NY). In an initial face-to-face visit with the pharmacist, they were instructed to transmit at least 6 BP measurements weekly, including both morning and evening measurements. During the first 6 months, patients and pharmacists met every 2 weeks via telephone until BP control was sustained for 6 weeks, then frequency was reduced to monthly. During the second 6 months of the intervention period, phone visits were reduced to every 2 months, after which patients returned the telemonitors and resumed hypertension care managed by their primary care physician.
Telephone visits included review of home BP data, discussion of adherence to medication and lifestyle changes, and treatment issues. A collaborative practice agreement between pharmacists and primary care physicians at all 16 study clinics allowed pharmacists to prescribe and change antihypertensive therapy according to a specified protocol. In the TI group, pharmacists were asked to adjust antihypertensive drug therapy if <75% of readings since the last visit met the BP goal (<135/85 mm Hg or <125/75 mm Hg for patients with diabetes mellitus or kidney disease) and the patient could tolerate additional treatment. The UC group had hypertension care managed by their primary care physicians as usual. This could include referral to a Medication Therapy Management pharmacist for consultation and conventional home BP measurement.

Measurements and Outcomes

BP and Cardiovascular Events

Methods for measuring BP and other outcomes during follow-up have been described in detail and reported previously.13 BP was measured at research clinic visits at baseline and 6, 12, 18, and 54 months using a standardized technique. In a separate analysis, we also extracted routine clinical BP measurements for each participant from the electronic health record. Participants were asked at each follow-up visit at 6, 12, 18, and 54 months to report any hospitalization for ≥12 hours. All hospital stays and deaths were reviewed by a physician adjudicator blinded to study treatment group for evidence of the following cardiovascular events: myocardial infarction (MI), stroke, heart failure, or coronary revascularization. All deaths were classified as due to cardiovascular disease, cancer, or other causes. Available documents used to adjudicate events included death certificate, discharge summary, admission history and physical examination, emergency room notes, cardiology and neurology consultations, other physician and nurse notes, laboratory reports, ECG tracings, and cardiac, vascular, and neurological imaging reports. To search for events that were not self-reported or occurred in participants who did not attend a follow-up visit, we searched electronic health records and insurance claims data for all participants through 60 months of follow-up. The search included International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision diagnosis or procedure codes indicative of MI, stroke, heart failure, or coronary revascularization. After removing duplicate events that had already been reported and adjudicated, inpatient and outpatients records were reviewed and events adjudicated in a similar manner as for self-reported events.
Cardiovascular deaths were deaths due to MI, stroke, heart failure, cardiac arrhythmia, or sudden deaths judged likely to be related to underlying cardiovascular disease. MI was based on the presence of at least 2 of 3 criteria: chest pain, cardiac enzymes at least 2× the upper limit of normal, and ischemic EKG changes. Stroke was based on rapidly developing neurological signs lasting at least 24 hours (unless interrupted by surgery or death) of probable cerebrovascular origin, corroborated by abnormalities on neuroimaging studies. Heart failure hospitalization was based on physician diagnosis and treatment and findings on physical examination, chest x-ray, cardiac ultrasound, and laboratory tests. Coronary revascularization was based on operative or cardiac catheterization laboratory reports.

Costs

We previously reported that direct program costs, which were comprised of and split almost equally between Medication Therapy Management pharmacist care management services and telemonitoring services, were about $1350 per patient at market prices at the time of the study intervention.12 TI patients had a mean (SD) of 11.4 (3.9) pharmacist visits lasting 34.2 minutes per visit, and 217 TI patients used telemonitoring services for an average (SD) of 9.8 (2.5) months.12 We adjusted direct costs for inflation to 2017 US dollars ($1511). Prior analysis revealed that the change in costs from the 12 month intervention period compared with previous 12 months for clinic visits, total pharmacy, laboratory, and radiology did not differ significantly between TI and UC patients.15 Therefore, these costs are not included in intervention costs. The increase in costs for hyperlipidemia and BP medications alone was $100 (2017 US dollars) higher for TI patients. We assessed the inclusion of these costs in a sensitivity analysis.
The costs of events are taken from the literature for observed events and simulated events. Ambulatory, inpatient, and pharmacy costs associated with MI, stroke, and heart failure hospitalization events were estimated from Medical Expenditure Panel Survey data16 and inflation-adjusted to 2017 dollars. For each of these events, one cost was assigned during the year of the event and another cost was assigned for subsequent years as follows: MI $45 259 in first year and $3038 subsequent years; stroke $22 196 and $6575; heart failure $36 686 and $14 132. Revascularizations that were not preceded by an MI were assigned costs of $33 339 in 2017 dollars based upon a literature review17 and assuming a 75%/25% mix of percutaneous coronary intervention and coronary artery bypass grafting. The costs of revascularizations that were preceded by an MI (n=0 in TI group; n=4 in UC) are reflected in the cost of MIs and were not costed separately to avoid double counting. We did not assign a cost to premature cardiovascular death.

Statistical Analysis

We conducted 2 analyses for this report: a comparison of cardiovascular events observed in the 5-year follow-up period and a microsimulation analysis. The analysis of cardiovascular events was not prespecified in the analysis plan and should thus be considered exploratory. The microsimulation analysis was prespecified. Counts of cardiovascular events are reported along with the count and proportion of patients having one or more cardiovascular events by treatment group. The primary cardiovascular composite end point included MI, stroke, heart failure, and cardiovascular death; the secondary cardiovascular end point also included coronary revascularization. Logit analysis accommodating clinic clustering utilized generalized estimating equations with robust standard errors to test differences in cardiovascular event incidence by group. Marginal Cox models estimated the hazard ratio for time to first cardiovascular event by treatment group.18 The observation period for patients without cardiovascular events was censored by noncardiovascular death date and for those without death dates by the latest of (1) the date on which the last research visit occurred, (2) date of health plan disenrollment, (3) date on which the last patient encounter occurred.
We calculated 5-year return on investment (ROI) on a per capita basis as ROI=net return/intervention costs×100%, where net return=(UC event costs–TI event costs)–intervention costs. ROI tabulated in this manner is directly comparable to how return on financial investments are reported (eg, the interest rate on a bond). To facilitate comparisons in the health literature, we also report benefit-cost ratios measured as (UC event costs–TI event costs)/intervention costs. Future costs were discounted to present value at a rate of 3% per year when calculating ROI and benefit-cost ratios.

Simulation Model

We used the HealthPartners Institute ModelHealth: Cardiovascular Disease microsimulation model to determine whether the observed cardiovascular events were similar to model-predicted results, based on the observed SBP differences through 54 months. Details on the simulation model itself are published elsewhere.16,19–21 To conduct the comparison, the model was initialized with virtual counterparts of the patients in each study group using characteristics at baseline, which maintained all applicable differences between groups described in Table 1, including the 1.8-year difference in mean age (Table 1). The model simulated the incidence of cardiovascular events (MI, stroke, heart failure, and cardiovascular death) for subjects in each group over 5 years while maintaining the mean difference in SBP observed between the TI and UC groups in the research clinic at 12 and 54 months (with the difference linearly interpolated between these time points). Simulations were repeated 1000×, from which mean incidence of events, median odds ratios of event incidence between arms, and the percentage of simulations in which the model predicted a ratio at or better than the incidence of the primary cardiovascular composite end point observed between the TI and UC group (ie, ≤0.49) were calculated with adjustment for the age difference between groups. CIs were calculated using the percentile method. Sensitivity analyses included a simulation with the TI group receiving no differential effect in SBP compared with the UC group (ie, assuming no effect of the TI intervention) and calculating results without the age adjustment.
Table 1. Patient Characteristics at Enrollment
Patient CharacteristicMean (SD) or N (%)Mean (SD) or N (%)
Telemonitoring Intervention (n=228)Usual Care (n=222)
Age, mean (SD)62.0 (11.7)60.2 (12.2)
Women, n (%)103 (45.2)98 (44.1)
Non-Hispanic White, n (%)191 (83.8)177 (79.7)
Education below 4-year college degree, n (%)108 (48.9)119 (55.3)
Household income <$50 000/y, n (%)61 (32.6)67 (34.4)
Current smoker, n (%)24 (10.7)25 (11.4)
Diabetes mellitus, n (%)46 (20.2)40 (18.0)
Chronic kidney disease, n (%)47 (20.6)37 (16.7)
Cardiovascular disease, n (%)23 (10.1)20 (9.0)
Antihypertensive medication classes, mean (SD)1.6 (1.2)1.4 (1.2)
Systolic BP, mm Hg, mean (SD)148.2 (12.9)147.7 (13.2)
Diastolic BP, mm Hg, mean (SD)84.5 (11.7)84.9 (11.5)
BP indicates blood pressure.

Results

The study population (Table 1) has been described in detail.12 Briefly, the 450 study participants had a mean age of 61, 45% were women, 82% were non-Hispanic White, and 10% to 20% had additional individual co-morbidities (smoking, diabetes mellitus, chronic kidney disease, cardiovascular disease). They reported taking a mean of 1.5 antihypertensive drug classes, and mean BP was 145/85 mm Hg at enrollment. The TI and UC group did not differ significantly on these and other key characteristics, although the mean age in the TI group was 1.8 years greater than in the UC group. Compared with the UC group, SBP decreased more from baseline among patients in the TI group at 6 months (−10.7 mm Hg, P<0.001), at 12 months (−9.7 mm Hg, P<0.001), and at 18 months (−6.6 mm Hg, P=0.004) but did not differ from the UC group at 54 months (−2.5 mm Hg, P=0.18).13 Routine clinical measurements taken from the electronic health record suggested significantly lower SBP and diastolic BP in the TI group for up to 24 months.

Cardiovascular Events During 5-Year Follow-Up

During the follow-up period, there were 15 cardiovascular events (5 MI, 4 stroke, 5 heart failure, 1 cardiovascular death) among 10 patients in the TI group and 26 events (11 MI, 12 stroke, 3 heart failure) among 19 patients in the UC group (Table 2). The primary cardiovascular composite end point incidence was 4.4% in the TI group versus 8.6% in the UC group (odds ratio [OR], 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 (OR, 0.48 [95% CI, 0.22–1.08], P=0.08). Time-to-first-event analyses showed similar results for the primary end point (hazard ratio, 0.50 [95% CI, 0.22–1.11], P=0.09) and the secondary end point including coronary revascularization (hazard ratio, 0.49 [95% CI, 0.23–1.04], P=0.06).
Table 2. Cardiovascular Events During 5 y of Follow-Up
Type of EventIntervention (n=228)Usual Care (n=222)
Events, NPatients, N (%)Events, NPatients, N (%)
MI5 11 
Stroke4 12 
Heart failure5 3 
CV death1 0 
 Total Events1510 (4.4%)2619 (8.6%)
Revascularization2 10 
 Total Events1712 (5.3%)3623 (10.4%)
CV indicates cardiovascular.

Five-Year Follow-Up ROI

Over 5 years, event costs were estimated to total $2772 per person in the TI group and $5721 in the UC group for a difference of $2949 favoring the TI group (Table 3). Based on $1511 in intervention costs, there was a net cost savings of about $1438 per patient ($1241 when discounted to present value). Return on investment was 82% (for every dollar spent, that dollar was recouped plus $0.82). Using the secondary composite measure (including revascularization costs), the difference in event costs increases to $3517 per patient, net savings increase to $2006 ($1792 when discounted), and the ROI becomes 119%.
Table 3. Five-Year ROI and Benefit-Cost Ratios
 InterventionUsual CareDifference
Event costs per participant
 MI$1166$2598−$1433
 Stroke$678$2118−$1440
 Heart failure$928$1005−$77
 Revascularization$273$841−$568
Composite event costs per participant
  Primary end point$2772$5721−$2949
  Primary end point, discounted$2595$5347−$2752
  Secondary end point$3045$6562−$3517
  Secondary end point, discounted$2841$6144−$3303
Intervention costs*$1511$0$1511
5-year return on investment*
  Primary end point  −82%
  Secondary end point  −119%
5-year benefit-cost ratio*
  Primary end point  −1.82
  Secondary end point  −2.19
*
Return on investment (ROI) and benefit-cost ratios reflect discounting of future benefits to their present value in the enrollment year at a rate of 3% per year; all interventions costs occurred in the enrollment year and therefore are not discounted. MI indicates myocardial infarction.
In sensitivity analyses, adding the costs of hypertension and lipids medications that were previously found to be statistically different between the TI and UC group,15 reduces ROI slightly to 71% and 105% using the primary and secondary composite end points, respectively. Reducing and increasing the costs of all event rates by one-third produces a range of ROIs of 21% to 143% using costs of primary composite events, and 46% to 191% using costs of secondary composite events. Reducing intervention costs by one-third, assuming lower costs of new technology and increased scale, increases net savings to $1942 and $2510 per patient using the primary and secondary composite event definitions, respectively, and the increases corresponding ROI measures to 178% and 228%.

Simulated Cardiovascular Events During 5-Year Follow-Up

The mean age–adjusted cardiovascular event incidence over 5 years predicted by the model was 18.0 events for the TI group and 20.5 events for the UC group (median OR, 0.88 [95% CI, 0.49–1.65]; Figure 2). Only 5.3% of simulations yielded an OR ≤0.49 (the observed OR for the primary composite end point). Without adjustment for the baseline age differences between groups, the predicted median OR narrowed to 0.97 (95% CI, 0.54–1.78), and only 2.2% of simulations yielded an OR ≤0.49. Additionally, when the model assumed no beneficial BP effect for the TI group, the model predicted the TI group would have experienced cardiovascular events at a greater rate compared with the UC group (median OR, 1.06 [95% CI, 0.61–1.87]).
Figure 2. Microsimulation model-predicted 5-year event rates for study population. Events shown are based on predictions from a microsimulation model, over 1000 replicated simulations, using synthetic counterparts of the study participants. Results for the usual care (UC) population are based on the model-predicted events using the observed pattern in blood pressure (BP) over 5 years for this group. Results for the telemonitoring intervention (TI [a]) scenario are based on the model-predicted events for the TI group assuming that the TI group had the same pattern in the BP as the UC group (ie, the events expected with no intervention effect). Results for the TI (b) scenario are based on the model-predicted events for the TI group using the observed pattern in BP over 5 years for this group. Results for the TI (c) scenario are based on the model-predicted events for the TI group using the observed pattern in BP over 5 years for this group, after accounting for the age differences between study groups. Results for the TI (d) scenario are based on the model-predicted events for the TI group using odds ratio (OR) in observed events between the TI and UC groups (ie, OR, 0.49). CV indicates cardiovascular; and MI, myocardial infarction.

Discussion

In this 5-year follow-up of a randomized trial, in which 6 months of intensive home BP telemonitoring and pharmacist care management lowered BP for about 2 years compared with usual primary care,13 we observed reduced cardiovascular events in the TI group by about 50% over 5 years. Although the reduction in cardiovascular events was substantial, the study was not powered for this outcome and the reduction was not statistically significant. However, if the reduction in cardiovascular events is not due to chance, the intervention is cost-saving over 5 years.
The observed effect on cardiovascular events in the current study is greater than predicted based on meta-analyses of large-scale BP-lowering trials. In a meta-analysis of 123 trials with 613 815 participants, every 10 mm Hg reduction in SBP reduced the relative risk of major cardiovascular events by 20% (95% CI, 7%–13%).22 In another meta-analysis of 19 trials and 44 989 participants comparing more and less intensive BP-lowering strategies, the mean difference in SBP was 7 mm Hg, and the relative risk for major cardiovascular events was reduced by 14% (95% CI, 4%–22%).23 These observations led us to use microsimulation to replicate the trial using the observed SBP results, and this was consistent with the clinical trial data: a 12% predicted reduction in cardiovascular events when accounting for the baseline age difference of 2 years between the TI and UC groups.
Few studies have reported on long-term effects of the types of interventions used in the present study (self-monitoring of BP, BP telemonitoring, and team-based care for hypertension) on cardiovascular events, as noted in meta-analyses of these topics.6,9,10 One longitudinal prepost study in North Carolina of pharmacist education with hypertension and lipid therapy management found about a 50% decrease in cardiovascular events compared with historical rates.24 A trial in the United Kingdom of nurse-led clinics for hypertension and lipid management in patients with diabetes mellitus found a 45% reduction in all-cause mortality compared with UC (OR, 0.55 [95% CI, 0.32–0.92]).25 A cluster-randomized trial in South Asia of home visits by community health workers for BP monitoring and counseling linked with existing public health care led to improved BP and reduced cardiovascular mortality compared with UC over 24 months (0.6% versus 1.7%, P=0.006).26 It is worth noting that these were all studies of forms of team-based care that likely influenced cardiovascular risk more broadly than in hypertension treatment efficacy trials, which could explain the larger treatment effects. An alternative explanation is that most trials did not collect data on cardiovascular events or did not report null results.
The economic evidence on self-monitoring of BP has been thoroughly reviewed for the Guide to Community Preventive Services, categorized as self-monitoring of BP alone, with some support, and with team-based care.27 Using standardized estimates of quality-adjusted life years saved per one mm Hg reduction in SBP, self-monitored BP alone was cost-saving in 2 studies and not cost-effective in 3 studies. Self-measured BP with some support and with team-based care was cost-effective but not cost-saving. Follow-up was 24 or fewer months in studies in which downstream cost-offsets were observed.
Simulation models of home BP monitoring in US health care systems have a longer time horizon but also produced varied results. One study estimated that home BP monitoring to adjust treatment would have no cost savings at 5 years for privately insured 20- to 44-year-olds, an ROI of 1.87 for privately insured 45- to 64-year-olds, and an ROI of 13.96 for Medicare recipients age ≥65 years.28 The mean change in SBP used in their analysis (2.6 mm Hg) was similar to the difference between our TI and UC groups at 54 months (2.5 mm Hg), but predicted event rates were not reported. Another study compared the experience of participants in a home BP monitoring study to assumptions (bounded by data) on what participants’ experience would have been without intervention.29 With program costs of $2142 per person, they found the program to be cost-saving only with optimistic assumptions and 10-year follow-up. Although they did not report absolute event rates, the difference in events rates at 10 years (0.47%–1.32%) is substantially smaller than the observed difference at 5 years between our TI and UC groups (5.1%). A third study found that telemonitoring combined with pharmacist care management was cost-effective in the long-term without factoring in any reduction in event costs.30
Reports of both observed and simulated economic analysis of home BP monitoring vary on several dimensions that may substantially influence results and costs. The most notable differences include the study population, the protocol for home BP monitoring, the extent and nature of additional support, the length of follow-up observed or time horizon simulated, the costs that result from differing intervention designs, and the types of health care utilization included in potential cost-offsets.
Several caveats are important to consider when interpreting our trial results. The trial was relatively small, was conducted in a single medical group in urban and suburban clinics, and included relatively few minority and low socioeconomic status participants; hence, our results might not be representative of those that would be seen in other settings or with different populations. The reduction in cardiovascular events was not statistically significant and could have been due to chance. Another potential explanation for our findings is that the pharmacist intervention may have had effects on important cardiovascular risk factors besides BP that we did not measure precisely, including effects on tobacco use, lipid management, and other medications. Intervention costs were among the highest of those reported in the literature.27 However, advances in technology, including the ability to use patient-provided smartphones, and more targeted follow-up may reduce costs without reducing effectiveness of the intervention. Finally, in our study, home BP monitoring was not used to diagnose or confirm hypertension, which may be more cost-effective than using it for treatment monitoring alone.28,31

Perspectives

Telemonitoring with pharmacist management lowered BP and may have reduced costs by avoiding cardiovascular events over 5 years. Future studies of telemonitoring and pharmacist care should plan for long-term follow-up and be powered to detect differences in clinical cardiovascular events. They should also carefully measure changes in other cardiovascular risk factors, like lipids and smoking, that could be influenced by pharmacists or other care team members.

Novelty and Significance

What Is New?

•
Reporting of cardiovascular events and costs during 5 years of follow-up of a randomized trial of home blood pressure telemonitoring with pharmacist management for uncontrolled hypertension.

What Is Relevant?

•
Self-monitoring of blood pressure (including telemonitoring) with additional support as part of team-based care has been shown to lower blood pressure compared with routine care.
•
Few studies of similar interventions have reported long-term follow-up, costs, or cardiovascular outcomes.

Summary

Telemonitoring with pharmacist management may have reduced cardiovascular events by about 50% over 5 years. Savings from the reduction in cardiovascular events more than offset the intervention costs.

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Published In

Go to Hypertension
Go to Hypertension
Hypertension
Volume 76 • Number 4 • October 2020
Pages: 1097 - 1103
PubMed: 32862713

Copyright

© 2020 American Heart Association, Inc.

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History

Received: 8 May 2019
Revision received: 15 May 2020
Accepted: 14 July 2020
Published online: 31 August 2020
Published in print: October 2020

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Keywords

  1. blood pressure
  2. heart failure
  3. hypertension
  4. myocardial infarction
  5. pharmacist
  6. stroke, and medical economics

Subjects

  1. Hypertension

Authors

Affiliations

Karen L. Margolis https://orcid.org/0000-0003-1862-7402 [email protected]
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
View all articles by this author
Steven P. Dehmer https://orcid.org/0000-0003-3508-9239
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
View all articles by this author
JoAnn Sperl-Hillen
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
View all articles by this author
Patrick J. O’Connor
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
View all articles by this author
Stephen E. Asche
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Anna R. Bergdall
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Beverly B. Green
Kaiser Permanente Washington Health Research Institute, Seattle, WA (B.B.G.).
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Rachel A. Nyboer
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Pamala A. Pawloski
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Nicole K. Trower
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Michael V. Maciosek https://orcid.org/0000-0002-8164-8858
From the HealthPartners Institute, Minneapolis, MN (K.L.M., S.P.D., J.S.-H., P.J.O., S.E.A., A.R.B., R.A.N., P.A.P., N.K.T., M.V.M.)
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Notes

This paper was sent to Daniel Jones, Guest Editor, for review by expert referees, editorial decision, and final disposition.
Correspondence to Karen L. Margolis, 8170 33rd Ave S, Mail stop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524. Email [email protected]

Disclosures

None.

Sources of Funding

Funded by National Heart, Lung, and Blood Institute (R01 HL090965).

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