Long-Term Outcomes of Home BP Monitoring and Pharmacist Management

Study Questions:

Does an intensive intervention (with telemonitoring and pharmacist management) to improve blood pressure (BP) have sustained effects in routine clinical care?

Methods:

This was a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension who were enrolled in a large health system between March 2009 and November 2015. The intervention included a home BP telemonitoring intervention with pharmacist management, which was compared to usual care. The primary outcomes of interest were change from baseline to 54 months in systolic BP (SBP) and diastolic BP (DBP) measured as the mean of three measurements obtained at each research clinic visit.

Results:

Of the 450 patients, 228 were randomized to the intervention group (mean age 62 years, 54.8% male) and 222 (mean age 60.2 years, 55.9% male) were randomized to usual care. From the original cohort, 326 participants (72.4%) attended the 54-month follow-up visits, including 162 randomized to the intervention and 164 to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6,248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was −2.5 mm Hg (95% confidence interval [CI], −6.3 to 1.2 mm Hg; p = 0.18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of −1.0 mm Hg (95% CI, −3.2 to 1.2 mm Hg; = 0.37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months.

Conclusions:

The authors concluded that this intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases.

Perspective:

It should be noted that sustained reductions of >10 mm Hg in SPB from baseline were noted in both groups at 54 months. One wonders if enrollment and follow-up in a trial was a component of continued monitoring, which led to the BP improvement in both groups. Although the intervention group did have greater improvements at 6-, 12-, and 18-month follow-up, there was not a significant difference at 54 months. Although not significant after so much time, is this a reasonable expectation for any intervention? In other words, should we expect such interventions to have permanent changes, when we do not expect antihypertensive medications once stopped to have sustained benefits in BP?

Clinical Topics: Prevention, Hypertension

Keywords: Ambulatory Care, Ambulatory Care Facilities, Antihypertensive Agents, Blood Pressure, Hypertension, Outcome Assessment (Health Care), Pharmacists, Primary Health Care, Primary Prevention


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