Heart Disease and Stroke Prevention: Self-Measured Blood Pressure Monitoring Interventions for Improved Blood Pressure Control When Used Alone

The systematic review included 26 studies with 28 study arms.

• Blood Pressure Outcomes
  • Proportion of patients with blood pressure at goal: median increase of 6.9 percentage points (median duration: 6 months; 13 study arms)
  • Change in mean systolic blood pressure: median reduction of 3.2 mmHg (median duration: 9 months; 18 study arms)
  • Change in diastolic blood pressure: median reduction of 1.3 mmHg (median duration: 6 months; 21 study arms)
  • Results were statistically significant at 6 months and continued to be favorable at 12 months, although they were smaller in magnitude and not statistically significant.
• Other Outcomes
  • No studies reported sickness or death outcomes.
  • Findings were inconsistent for medication adherence, health-related quality-of-life, and patient satisfaction outcomes.

The economic review included 8 studies (search period through March 2015). Monetary values are reported in 2014 U.S. dollars.

• There was not enough evidence to determine cost-effectiveness of the interventions when used alone. However, the averted cost of medication and outpatient visits exceeded the intervention cost.
• No studies reported the effect of the intervention on worksite productivity or provided a full assessment for cost-benefit analysis.
• Intervention Cost
  • Intervention cost included the cost of blood pressure monitoring devices, the cost of communicating blood pressure readings to healthcare providers, and the labor cost associated with training patients and reviewing records.
  • The median intervention cost was $60 per person (7 studies).
• Intervention Cost and Healthcare Cost
  • The intervention cost plus the change in healthcare cost equals the total cost of the intervention.
    • Healthcare cost is defined as the cost for medication, outpatient visits, hospital inpatient stays, and emergency room visits.
    • When the estimated total cost is positive, the intervention is cost-increasing; when it is negative, the intervention is cost-saving.
  • Five of six total cost estimates were negative (median: -$72 per person) over a median follow-up period of 12 months, indicating the intervention is cost-saving.
• Cost-Effectiveness
  • Two methods from the literature (Mason et al., 2005; McEwan et al., 2006) were used to translate reductions in systolic blood pressure to quality adjusted life year (QALY) saved. An intervention is considered cost-effective if cost per QALY saved is less than $50,000.
  • Cost per QALY estimates were inconsistent across five studies.
    • Two studies indicated cost savings and QALY saved.
    • Two studies reported cost savings, but systolic blood pressure increased.
    • One study indicated the intervention was not cost-effective ($100,000 and $144,000 per QALY saved, based on two methods).

• Adults with high blood pressure
• Women and men
• Outpatient, general practice, and primary care settings

• The effectiveness of blood pressure monitoring interventions that require patients to provide their own blood pressure monitoring devices. In all of the included studies, blood pressure monitoring devices were provided to patients.
• How often patients should measure their blood pressure, and how often clinicians should monitor patients’ self-measured blood pressure readings.
• The role of telemedicine in self-measured blood pressure monitoring interventions, and how it affects patient-provider interaction and medication management.
• The effectiveness of self-measured blood pressure monitoring interventions among various subgroups including racial/ethnic minorities, low-income populations, patients with comorbidities, and children.
• Long-term benefits of self-measured blood pressure monitoring interventions that last longer than 12 months, including effects on rates of sickness and death.
• The effectiveness of self-measured blood pressure monitoring interventions in community and worksite settings, and whether they strengthen community-clinical linkages.
• The intervention cost when the cost of devices and software used in self-measured blood pressure monitoring interventions are distributed over the duration of their use.
• Returns on investment in self-measured blood pressure monitoring interventions, based on the monetized value of benefits including reduced mortality and averted productivity losses.

• Studies were done in the United States (10 studies), Western Europe (9 studies), Canada (3 studies), Australia (2 studies), and Brazil (2 studies).
• In 23 studies, interventions were delivered in outpatient, general practice, or primary care settings.
• Included studies represented both men (median: 44.0%; 24 studies) and women (median: 55.0%; 24 studies).
• Study populations included adults ages 18 years and older (median: 56.6 years; 23 studies).
• Six studies reported race/ethnicity with study populations mainly identifying as white. One study included a study population with more than 75% identifying as African American.
• All 26 evaluated interventions provided patients with blood pressure monitors and training, with patients measuring their blood pressure at home.
• Twenty interventions provided patients with fully automated blood pressure monitor devices.
• Patients’ blood pressure readings were delivered to healthcare providers during medical visits as self-recorded readings (16 studies), through electronic transmissions sent directly from blood pressure devices to central databases that providers could access (2 studies), or by mail (3 studies).

Jacob V, Chattopadhyay SK, Proia KK, et al. Economics of Self-Measured Blood Pressure Monitoring: A Community Guide Systematic Review. American Journal of Preventive Medicine. 2017;53(3):e105–13.

Community Preventive Services Task Force. Self-Measured Blood Pressure Monitoring Improves Outcomes: Recommendation of the Community Preventive Services Task Force. American Journal of Preventive Medicine. 2017;53(3):e115–8.

Chattopadhyay SK, Jacob V, Mercer SL, Hopkins DP, Elder RW, Jones CD, Community Preventive Services Task Force. Community Guide Cardiovascular Disease Economic Reviews: Tailoring Methods to Ensure Utility of Findings. American Journal of Preventive Medicine. 2017;53(6S2):S155–63. Available at: http://www.sciencedirect.com/science/article/pii/S0749379717303227?via%3Dihub.

Shantharam SS, Mahalingam M, Rasool A, et al. Systematic Review of Self-Measured Blood Pressure Monitoring With Support: Intervention Effectiveness and Cost. American Journal of Preventive Medicine. 2022;62(2):285−98.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension. Annals of Internal Medicine 2013, 159(3): 185-194.

Economic Review

Summary Evidence Table – Economic Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Bailey B, Carney SL, Gillies AA, Smith AJ. Antihypertensive drug treatment: a comparison of usual care with self blood pressure measurement. J Hum Hypertens 1999;13(2):147-50.

Binstock ML, Franklin KL. A comparison of compliance techniques on the control of high blood pressure. Am J Hypertens 1988;1(3 Pt 3):192S-4S.

Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med 2009;151(10):687-95.

Broege PA, James GD, Pickering TG. Management of hypertension in the elderly using home blood pressures. Blood Press Monit 2001;6(3):139-44.

Carnahan JE, Nugent CA. The effects of self-monitoring by patients on the control of hypertension. Am J Med Sci 1975;269(1):69-73.

Dalfo i Baque A, Capillas Perez R, Guarch Rocarias M, et al. [Effectiveness of self-measurement of blood pressure in patients with hypertension: the Dioampa study]. Aten Primaria 2005;35(5):233-7.

Dejesus RS, Chaudhry R, Leutink DJ, Hinton MA, Cha SS, Stroebel RJ. Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: a pilot study. Vasc Health Risk Manag 2009;5:705-11.

Fitzgerald DJ, O’Callaghan WG, O’Brien E, Johnson H, Mulcahy R, Hickey N. Home recording of blood pressure in the management of hypertension. Ir Med J 1985;78(8):216-8.

Fuchs SC, Ferreira-da-Silva AL, Moreira LB, et al. Efficacy of isolated home blood pressure monitoring for blood pressure control: randomized controlled trial with ambulatory blood pressure monitoring – MONITOR study. J Hypertens 2012;30(1):75-80.

Godwin M, Lam M, Birtwhistle R, et al. A primary care pragmatic cluster randomized trial of the use of home blood pressure monitoring on blood pressure levels in hypertensive patients with above target blood pressure. Fam Pract 2010;27(2):135-42.

Halme L, Vesalainen R, Kaaja M, Kantola I. Self-monitoring of blood pressure promotes achievement of blood pressure target in primary health care. Am J Hypertens 2005;18(11):1415-20.

Johnson AL, Taylor DW, Sackett DL, Dunnett CW, Shimizu AG. Self-recording of blood pressure in the management of hypertension. Can Med Assoc J 1978;119(9):1034-9.

Madsen LB, Kirkegaard P, Pedersen EB. Blood pressure control during telemonitoring of home blood pressure. A randomized controlled trial during 6 months. Blood Press 2008;17(2):78-86.

Marquez Contreras E, Martin de Pablos JL, Espinosa Garcia J, Casado Martinez JJ, Sanchez Lopez E, Escribano J. [Prevention of therapeutic inertia in the treatment of arterial hypertension by using a program of home blood pressure monitoring]. Aten Primaria 2012;44(2):89-96.

Marquez-Contreras E, Martell-Claros N, Gil-Guillen V, et al. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens 2006;24(1):169-75.

Mehos BM, Saseen JJ, MacLaughlin EJ. Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension. Pharmacotherapy 2000;20(11):1384-9.

Midanik LT, Resnick B, Hurley LB, Smith EJ, McCarthy M. Home blood pressure monitoring for mild hypertensives. Public Health Rep 1991;106(1):85-9.

Pierce JP, Watson DS, Knights S, Gliddon T, Williams S, Watson R. A controlled trial of health education in the physician’s office. Prev Med 1984;13(2):185-94.

Rogers MA, Small D, Buchan DA, et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial. Ann Intern Med 2001;134(11):1024-32.

Soghikian K, Casper SM, Fireman BH, et al. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Med Care 1992;30(9):855-65.

Souza WK, Jardim PC, Brito LP, Araujo FA, Sousa AL. Self measurement of blood pressure for control of blood pressure levels and adherence to treatment. Arq Bras Cardiol 2012;98(2):167-74.

Stahl SM, Kelley CR, Neill PJ, Grim CE, Mamlin J. Effects of home blood pressure measurement on long-term BP control. Am J Public Health 1984;74(7):704-9.

van Onzenoort HA, Verberk WJ, Kroon AA, et al. Effect of self-measurement of blood pressure on adherence to treatment in patients with mild-to-moderate hypertension. J Hypertens 2010;28(3):622-7.

Varis J, Kantola I. The choice of home blood pressure result reporting method is essential: Results mailed to physicians did not improve hypertension control compared with ordinary office-based blood pressure treatment. Blood Press 2010;19(5):319-24.

Verberk WJ, Kroon AA, Lenders JW, et al. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial. Hypertension 2007;50(6):1019-25.

Zarnke KB, Feagan BG, Mahon JL, Feldman RD. A randomized study comparing a patient-directed hypertension management strategy with usual office-based care. Am J Hypertens 1997;10(1):58-67.

Additional Studies Linked to Included Studies

Madsen LB, Kirkegaard P, Pedersen EB. Health-related quality of life (SF-36) during telemonitoring of home blood pressure in hypertensive patients: a randomized, controlled study. Blood Press 2008;17(4):227-32.

Economic Review

Arrieta A, Woods JR, Qiao N, Jay SJ. Cost benefit analysis of home blood pressure monitoring in hypertension diagnosis and treatment: an insurer perspective. Hypertension 2014;64(4):891-6.

Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Annals of Internal Medicine 2009;151(10):687-95.

Boubouchairopoulou N, Karpettas N, Athanasakis K, Kollias A, Protogerou AD, et al. Cost estimation of hypertension management based on home blood pressure monitoring alone or combined office and ambulatory blood pressure measurements. Journal of the American Society of Hypertension 2014;8(10):732-8.

Den Hond E, Staessen JA, Celis H, Fagard R, Keary L, et al. Antihypertensive treatment based on home or office blood pressure the THOP trial. Blood Pressure Monitoring 2004;9(6):311-4.

Fukunaga H, Ohkubo T, Kobayashi M, Tamaki Y, Kikuya M, et al. Cost-effectiveness of the introduction of home blood pressure measurement in patients with office hypertension. Journal of Hypertension 2008;26(4):685-90.

Funahashi J, Ohkubo T, Fukunaga H, Kikuya M, Takada N, et al. The economic impact of the introduction of home blood pressure measurement for the diagnosis and treatment of hypertension. Blood Pressure Monitoring 2006;11(5):257-67.

Rogers MA, Small D, Buchan DA, Butch CA, Stewart CM, et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial. Annals of Internal Medicine 2001;134(11):1024-32.

Reed SD, Li Y, Oddone EZ, Neary AM, Orr MM, et al. Economic evaluation of home blood pressure monitoring with or without telephonic behavioral self-management in patients with hypertension. American Journal of Hypertension 2010;23(2):142-8.

Soghikian K, Casper SM, Fireman BH, Hunkeler EM, Hurley LB, et al. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Medical Care 1992;30(9):855-65.

Staessen JA, Den Hond E, Celis H, Fagard R, Keary L, et al. Antihypertensive treatment based on blood pressure measurement at home or in the physician’s office: a randomized controlled trial. JAMA 2004;291(8):955-64.

Verberk WJ, Kroon AA, Lenders JWM, Kessels AGH, van Montifrans GA, et al. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial. Hypertension 2007;50(6):1019-25.

The following papers were linked:

• Den Hond et al., 2004 and Staessen et al., 2004
• Bosworth et al., 2009 and Reed et al., 2010
• Funahashi et al., 2006 and Fukunaga et al., 2008

McGrath D, Meador M, Wall HK, et al. Self-measured blood pressure telemonitoring programs: a pragmatic how-to guide. American Journal of Hypertension 2023;36(8):417-27.

Wall HK, Wright JS, Jackson SL, Daussat L, Ramkissoon N, et al. How do we jump-start self-measured blood pressure monitoring in the United States? Addressing barriers beyond the published literature. American Journal of Hypertension 2022;35(3): 244-55.

The CPSTF findings are based on evidence from a systematic review published in 2013 (Uhlig et al., 52 studies). Uhlig and colleagues searched MEDLINE (inception to 8 February 2013) and the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (fourth quarter 2012) without language restriction.

The full search strategy reported below is included in the publication:

Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension: A systematic review and meta-analysis. Ann Intern Med. 2013; 159:185-194.

Effectiveness Review

Economic Review

This literature search was performed to provide studies on the economics of self-measured blood pressure monitoring interventions for the treatment and control of high blood pressure.

Six bibliographic databases were searched during March 2015, using the terms listed below. The following databases were searched: Medline, Cochrane (trials, systematic reviews, and economic evaluations), EconLit, and the Centre for Reviews and Dissemination. Years of publication from 1970 March, 2015 were covered, and the types of documents retrieved by the searched included journal articles, books, book chapters, reports, and conference papers.

Search terms and search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Once the literature search was completed, Community Guide staff reviewed the citations using inclusion and exclusion criteria to narrow down the publications to be included.

Database: Medline (OVID) (Includes Medline In-Process)

Date Searched: 3/25/2015
Results: 855/841 after duplicates removed
Search Strategy:

1. exp blood pressure monitoring, ambulatory/
2. exp blood pressure monitors/
3. exp blood pressure/
4. exp hypertension/
5. exp self care/
6. ((blood pressure or hypertens$) and self and (measure$ or monitor$ or care or manage$)).mp.
7. randomized controlled trial.pt.
8. controlled clinical trial.pt.
9. randomized controlled trials/
10. random allocation/
11. double-blind method/
12. single-blind method/
13. clinical trial.pt.
14. clinical trials.mp. or exp clinical trial/
15. (clinic$ adj25 trial$).tw.
16. ((singl$ or doubl$ or trebl$ or tripl$) adj (mask$ or blind$)).tw.
17. placebo$.tw.
18. Placebos/
19. random$.tw.
20. trial$.tw.
21. (randomized contro$l trial$l or clinical control$ trial$).mp.
22. (latin adj square).tw.
23. comparative study.tw. or comparative study.pt.
24. exp evaluation studies/
25. follow-up studies/
26. prospective studies/
27. (control$ or prospectiv$ or volunteer$).tw.
28. Cross-Over Studies/
29. exp cohort studies/ or exp prospective studies/ or exp retrospective studies/ or exp epidemiologic studies/ or exp case-control studies/
30. (cohort or retrospective or prospective or longitudinal or observational or follow-up or followup or registry).af.
31. case-control.af. or (case adj10 control).tw.
32. ep.fs.
33. (home adj20 blood pressure).mp.
34. exp telemedicine/
35. exp self-examination/
36. exp blood pressure/
37. exp hypertension/
38. (cost or costs or economic or economics).mp.
39. exp Economics/
40. exp “Costs and Cost Analysis”/
41. 3 or 4
42. 5 and 41
43. 1 or 2 or 6 or 42
44. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28
45. 29 or 30 or 31 or 32
46. 44 or 45
47. 43 and 46
48. 44 or 45 or 47
49. 33 and 48
50. 34 or 35
51. 36 or 37
52. 50 and 51
53. 48 and 52
54. 47 or 49 or 53
55. 38 or 39 or 40
56. 54 and 55

Database: Cochrane Central Register of Controlled Trials

Date Searched: 3/25/2015
Results: 220/69 after duplicates removed
Search Strategy:

#1
(hypertension or “blood pressure”) and (self or telemedicine):ti,ab,kw or (hypertension or “blood pressure”) near/20 home:ti,ab,kw or “ambulatory blood pressure monitoring”:ti,ab,kw in Trials (Word variations have been searched)
#2
cost or costs or economic*
#3
#1 and #2

Database: Cochrane Database of Systematic Reviews

Date Searched: 3/25/2015
Results: 24/17 after duplicates removed
Search Strategy:

#1
(hypertension or “blood pressure”) and (self or telemedicine):ti,ab,kw or (hypertension or “blood pressure”) near/20 home:ti,ab,kw or “ambulatory blood pressure monitoring”:ti,ab,kw
#2
cost or costs or economic*
#3
#1 and #2

Database: Cochrane Economic Evaluations

Date Searched: 3/25/2015
Results: 27/26 after duplicates removed
Search Strategy:

#1
(hypertension or “blood pressure”) and (self or telemedicine):ti,ab,kw or (hypertension or “blood pressure”) near/20 home:ti,ab,kw or “ambulatory blood pressure monitoring”:ti,ab,kw

Database: EconLit (EBSCOhost)

Date Searched: 3/25/2015
Results: 53/45 after duplicates removed
Search Strategy:

Search modes – Boolean/Phrase
S6
S4 OR S5
S5
(S1 AND S2)
S4
(S1 AND S3)
S3
TX ambulatory
S2
TX self OR TX home OR TX telemedicine
S1
TX “blood pressure” OR TX hypertension

Database: Centre for Reviews & Dissemination University of York

Date Searched: 3/15/205
Results: 293/241 after duplicates removed
Search Strategy:

Any Field: “blood pressure” or hypertension
AND
Any Field: self or home or ambulatory
AND
Any Field: cost or costs or economic*

CDC. Self-measured blood pressure monitoring: action steps for public health practitioners. Atlanta (GA): Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2013.

Mason JM, Freemantle N, Gibson JM, New JP. Specialist nurse-led clinics to improve control of hypertension and hyperlipidemia in diabetes: economic analysis of the SPLINT trial. Diabetes Care 2005;28(1):40-6.

McEwan P, Peters JR, Bergenheim K, Currie CJ. Evaluation of the costs and outcomes from changes in risk factors in type 2 diabetes using the Cardiff stochastic simulation cost-utility model (DiabForecaster). Curr Med Res Opin 2006;22(1):121-9.

Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension. Annals of Internal Medicine 2013, 159(3): 185-194.

Million Hearts released two action guides on self-measured blood pressure monitoring interventions based on findings from Uhlig et al. (2013):

• Self-Measured Blood Pressure Monitoring: Action Steps for Public Health Practitioners
• Self-Measured Blood Pressure Monitoring: Action Steps for Clinicians

The following considerations for implementation are drawn from information provided in these actions guides.

• Implementers need to consider the type of blood pressure monitor patients use. The action guides suggest monitors with an automated upper arm cuff.
• Programs that require patients to provide their own blood pressure monitors should have patients bring them into their doctors’ offices now and then to ensure proper use and function.
• Some patients may not be able to afford their own blood pressure monitor. In 2015, the cost of an automated blood pressure device ranged from $50 to $100. Insurance benefits for blood pressure monitors vary by payer.
• Although face-to-face office visits remain an important form of interaction between patients and clinicians, healthcare providers may incorporate other forms of care such as electronic and phone communication that could make care more effective, timely, and efficient.
• Reimbursement mechanisms for telemedicine, which could be a large component of some blood pressure monitoring interventions, should be considered.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Improve cardiovascular health in adults — HDS-01
• Increase control of high blood pressure in adults — HDS-05
• Increase the proportion of adults who use IT to track health care data or communicate with providers — HC/HIT-07