The economic impact of the introduction of home blood pressure measurement for the diagnosis and treatment of hypertension

OBJECTIVES: To investigate the economic consequences resulting from introduction of home blood pressure measurement in diagnosis of hypertension instead of casual clinic blood pressure measurement. METHODS: We constructed a decision tree model using data from the Ohasama study and a Japanese national database. The Ohasama study provided the prognostic value of home blood pressure as compared with clinic blood pressure measurement. RESULTS: It is predicted that the use of home blood pressure for hypertension diagnosis results in a saving of 9.30 billion US dollars (1013.6 billion yen) in hypertension-related medical costs in Japan. Most of this was attributable to medical costs saved by avoiding the start of treatment for untreated individuals who were diagnosed as hypertensive by clinic blood pressure but whose blood pressures were in the normal range when based on home blood pressure; that is, the so called white-coat hypertension. Furthermore, it could be expected that adequate blood pressure control mediated by the change in the diagnostic method from clinic to home blood pressure measurement would improve the prognosis for hypertension. We estimated that the prevention of hypertensive complications resulted in a reduction of annual medical costs by 28 million US dollars (3.0 billion yen). In addition, stroke prevention due to adequate blood pressure control based on home blood pressure measurement reduced annual long-term care costs by 39 million US dollars (4.2 billion yen). A per-person break-even cost for introducing home blood pressure monitoring was calculated as 409 US dollars (44,580 yen). CONCLUSIONS: The introduction of home blood pressure measurement for the diagnosis and treatment of hypertension would be very effective to save costs.     

Accuracy of telemedical home blood pressure measurement in the diagnosis of hypertension

This study was conducted to compare the accuracy of clinic blood pressure (CBP) and telemedical home blood pressure (HBP) measurement in the diagnosis of hypertension in primary care. The study subjects were 411 patients with average CBP > or =140 mmHg systolic or > or =90 mmHg diastolic, who performed telemedical HBP measurement (5 days, four times daily) and ambulatory blood pressure (ABP) monitoring in random order. Main outcome measure was the agreement of CBP and HBP with daytime ABP. CBP was much higher than daytime ABP and average HBP (P<0.001) with no difference between the latter two. The correlation between CBP and ABP was weak (systolic: r=0.499, diastolic: r=0.543), whereas strong correlations existed between HBP and ABP (systolic: r=0.847, diastolic: r=0.812). A progressive improvement in the strength of the linear regression between average HBP of single days and ABP was obtained from day 1 to day 4, with no further benefit obtained on the fifth day. The HBP readings taken at noon and in the afternoon showed significantly stronger correlations with ABP than the blood pressures measured in the morning and in the evening. In conclusion, the accuracy of telemedical HBP measurement was substantially better than that of CBP in the diagnosis of hypertension in primary care. HBP most accurately reflected ABP on the fourth day of monitoring, and the readings at noon and in the afternoon seemed to be most accurate.     

Central blood pressure measurement may improve risk stratification

Central systolic blood pressure (SBP) may differ between individuals with similar brachial SBP, which may have implications for risk assessment. This study aimed to determine the variation and potential clinical value of central SBP between patients with similar brachial SBP. Brachial SBP was measured by sphygmomanometer and central SBP by radial tonometry in 675 people (430 men), comprising healthy individuals (n = 222), patients with known or suspected coronary artery disease (n = 229) and diabetes (n = 224). Individuals were stratified by brachial SBP in accordance with European Society of Hypertension guidelines (optimal, normal, high-normal, grades 1, 2 and 3 hypertension). The potential clinical value of central SBP was determined from the percentage of patients re-classified into different brachial SBP groups due to the difference between brachial and aortic SBP (defined as brachial SBP-central SBP). Central SBP increased with each brachial SBP level (optimal to grade 3 hypertension; P < 0.001 for all). However, large variation in brachial-aortic SBP difference occurred within each brachial SBP group (range 2-33 mm Hg), resulting in sizeable overlap of central SBP between brachial SBP groups. For patients with normal brachial SBP, 96% had central SBP within the range of patients with high-normal brachial SBP, as well as 64% within the range of patients with grade 1 hypertension. We conclude that wide variation in brachial-aortic SBP difference occurs between patients with similar brachial SBP. This results in a significant overlap of central SBP scores between brachial SBP risk groups. This is likely to have treatment implications but remains to be tested.     

Automated blood pressure measurement for diagnosing hypertension

Guidelines for the management of hypertension have started to include home blood pressure (BP) and 24-h ambulatory BP monitoring as preferred methods for diagnosing hypertension. The next step will be to incorporate automated office BP measurement into the algorithm for diagnosing hypertension. Recent studies support this approach with automated office BP readings being closely correlated with the ambulatory BP.     

清晨血压在高血压诊治中的价值

目的分析清晨血压监测在高血压诊治中的临床价值。方法选取2014年9月~2014年10月我院接收的高血压患者308例,通过动态血压监测,选取全天收缩压、舒张压均增高的高血压患者100例,将清晨血压、下午血压与全天血压进行比较。结果清晨收缩压、舒张压与全天收缩压、舒张压无统计学差异。下午收缩压、舒张压与全天收缩压、舒张压有统计学差异。进一步行相关性分析,得出清晨血压与全天血压存在较好的相关性,其中清晨收缩压与全天收缩压相关性最高,(R=0.6339,p0.001)。结论清晨血压可真实地反映全天血压,有利于高血压的筛查及临床诊治效果的评估。     

Home blood pressure measurement may lead to less strict control of office blood pressure

Home blood pressure (HBP) measurement is useful for detecting morning hypertension, white coat as well as masked hypertension. However, target BP levels based on HBP remain unknown. The purpose of the present study was to evaluate the relationship between HBP measurement and office BP control status in hypertensive patients. Subjects were a total of 720 hypertensive outpatients (mean age: 64 +/- 11 years; females: 57%). Two-time averaged office BP in 2005 were categorized as excellent (<130/85 mmHg), good (> or =130/85 and <140/90 mmHg), or poor (>140/90 mmHg) control. In all patients, 37% were classified as excellent, 37% as good, and 26% as poor control. A total of 393 (55%) patients regularly measured HBP (HBP group). More women belonged to the HBP group (62 vs. 52%, p < 0.05). The HBP group also showed lower body mass index (23.8 +/- 3.3 vs. 24.7 +/- 3.4 kg/m(2), p < 0.01), lower triglyceride (136 +/- 78 vs. 158 +/- 89 mg/dl, p < 0.01), and lower blood glucose (104 +/- 20 vs. 118 +/- 42 mg/dl, p < 0.01). HBP group showed a significantly higher prevalence of poor BP control (33 vs. 23%, p <0.01) and higher office SBP (134.5 +/- 14.5 vs. 131.3 +/- 11.7 mmHg, p < 0.01) than those who did not measure HBP (non-HBP). In a multivariate analysis for office SBP, age (partial r = 0.21, p < 0.05) and HBP measurement (partial r = 0.12, p < 0.05) were detected as significant independent variables. These results suggest that HBP measurement may lead to less strict office BP control unless the target HBP levels are clearly indicated. Until the recommendations or target HBP levels are available, we should make an effort to obtain goal office BP.     

动态血压监测在高血压诊治中的价值

目的分析动态血压监测应用于高血压诊治中的临床价值。方法选取2011年9月-2013年9月接收的高血压患者(研究组)以及血压正常的体检者(对照组)各70例,均分别进行动态血压和常规方式血压监测,对两组采用不同监测方式的24h血压和脉压监测值,以及白天和夜间的血压和脉压监测值分别比较分析。结果研究组在不同监测方式下,24h血压监测值以及白天和夜间血压平均监测值均存在明显性差别(P0.05),对照组则均无明显性的差别(P0.05)。结论动态血压监测应用于高血压诊治中,可对血压进行更准确的监测,利于临床诊治效果的改善和心脑血管疾病等发生率的降低,有重要的应用价值。     

Self-measured versus ambulatory blood pressure in the diagnosis of hypertension

OBJECTIVE: We examined to what extent self-measurement of blood pressure at home (HBP) can be an alternative to ambulatory monitoring (ABP) to diagnose white-coat hypertension. METHODS: In 247 untreated patients, we compared the white-coat effects obtained by HBP and ABP. The thresholds to diagnose hypertension were > or = 140/> or = 90 mmHg for conventional blood pressure (CBP) and > or = 135/> or = 85 mmHg for daytime ABP and HBP. RESULTS: Mean systolic/diastolic CBP, HBP and ABP were 155.4/100.0, 143.1/91.5 and 148.1/95.0 mmHg, respectively. The white-coat effect was 5.0/3.5 mmHg larger on HBP compared with ABP (12.3/8.6 versus 7.2/5.0 mmHg; P < 0.001). The correlation coefficients between the white-coat effects based on HBP and ABP were 0.74 systolic and 0.60 diastolic (P < 0.001). With ABP as a reference, the specificity of HBP to detect white-coat hypertension was 88.6%, and the sensitivity was 68.4%. CONCLUSION: Our findings are in line with the recommendations of the ASH Ad Hoc Panel that recommends HBP for screening while ABP has a better prognostic accuracy.     

Independent predictors of effective blood pressure control in patients with hypertension on drug treatment in Brazil

Population assessment of effective blood pressure (BP) control is fundamental for reducing the global burden of hypertension, especially in low‐ and middle‐income countries. The authors evaluated the effectiveness of BP control and determined independent predictors associated with effective control among patients with hypertension on drug treatment in a large cross‐sectional study performed in two metropolitan areas in Brazil's southeast region. A total of 43 647 patients taking antihypertensive treatment were identified. Less than half of the patients (40.9%) had controlled BP (systolic BP <140 mm Hg and diastolic BP <90 mm Hg). Independent predictors of BP control were age, eating fruit daily, physical activity, previous cardiovascular disease, male sex, diabetes mellitus, ethnicity, and obesity. Simple variables associated with BP control may be utilized for knowledge translation strategies aiming to reduce the burden of hypertension.     

The measurement of blood pressure: sitting or supine, once or twice?

In 166 patients attending a hypertension review clinic, we compared supine and sitting blood pressure measurements and first and second measurements (1 min apart) in each position to determine whether any differences seen might have implications for the routine measurement of blood pressure in these patients, as a group or as individuals. Measurements were made with the Copal UA-251 semi-automated sphygmomanometer. In the group there was no significant difference between the first and the second diastolic measurements. The first systolic measurement was on average 3-4 mmHg higher than the second in both positions. Mean supine systolic pressures were 2-3 mmHg higher and diastolic pressures 2-3 mmHg lower than the corresponding sitting pressures. In individual subjects there were substantial disagreements between successive measurements in both positions and between positions. However, these differences would not have influenced blood pressure management in more than a few instances. We suggest that two measurements should routinely be taken, and the average recorded, particularly when the average exceeds 155/90 mmHg.