9. What are the recommended techniques for HBPM?
Patients should use a device that is validated, fully automated, and has an upper arm cuff (not a wrist monitor), according to a joint statement from the AHA, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association.17 (SOR C). (See validated BP monitor list at http://www.dableducational.org/sphygmomanometers/devices_2_sbpm.html.)
Patients should measure their BP in their nondominant arm after 5 minutes of rest with the arm at heart level, back supported, and feet flat on the ground. Patient technique and the accuracy of the home BP monitor should be checked annually. It is also recommended that patients check their BP 2 to 3 times every morning and evening. An average of 12 morning and evening measurements should be used for monitoring and treatment changes. An AHA informational sheet that shows how to measure BP properly can be found on their Web site (https://www.heart.org/-/media/files/health-topics/high-blood-pressure/how-to-measure-blood-pressure-letter-size-ucm_445846.pdf).
Several studies examining the accuracy of measuring BP over clothing did not find significant differences in BP measurements performed on a bare arm vs over a sleeve.30-33
10. What are the predictors of differences between home and office BP measurements?
Gender is one of the biggest predictors (SOR B).
A 2016 meta-analysis reported a total of 60 different hypothesized predictors of differences between home and clinic BP measurements (eg, gender, age, body mass index, systolic BP, diastolic BP). Masked hypertension was defined as a normal clinic BP reading and an elevated home BP reading. White coat hypertension was defined as an elevated clinic BP measurement with an acceptable home BP measurement. The researchers extracted odds ratios (ORs) for each study describing the association between patient characteristics and white coat or masked hypertension.34 Studies of masked hypertension diagnosed from HBPM showed male gender as the most significant predictor of home-clinic BP differences (OR=1.47, 95% CI, 1.18-1.75). In contrast, female gender was the only significant predictor of white coat hypertension (OR=3.38; 95% CI, 1.64-6.96) when comparing home BP with clinic BP measurements.
Literature limitations and barriers to greater implementation
Most studies looking at HBPM outcomes have measured outcomes using ABPM or office BP measurements. The authors of studies using office BP as the outcome measure usually performed multiple BP measurements at often multiple office or clinic visits to calculate the true BP—a procedure that primary care practices rarely follow.35 Additionally, there are significant methodologic differences in HBPM and ABPM; home BP is measured at rest, while ambulatory BP is measured while the patient is mobile and functioning. There are insufficient prospective studies looking at HBPM effects on clinical and patient-oriented outcomes.
The evidence clearly supports using HBPM in the diagnosis of hypertension and suggests its benefit in hypertension management. However, there are significant barriers to incorporating HBPM into practice—barriers that are largely unaddressed in the literature.
For HBPM to be successful, patients need affordable validated home BP monitors covered by insurance that can translate home BP readings into usable information. Additional administrative and/or nursing assistance is required for patient education and support. Uploaded data need to be summarized in a way that is actionable and linked to the electronic health record.
Continue to: As the volume of patient-generated home date increases...