Published Online: September 16, 2013
Paul A. Fishman, PhD; Andrea J. Cook, PhD; Melissa L. Anderson, MS; James D. Ralston, PhD, MPH; Sheryl L. Catz, PhD; David Carrell, PhD; James Carlson, PharmD; and Beverly B. Green, MD, MPH
Background: Web-based collaborative approaches to managing chronic illness show promise for both improving health outcomes and increasing the efficiency of the healthcare system.
Objective: Analyze the cost-effectiveness of the Electronic Communications and Home Blood Pressure Monitoring to Improve Blood Pressure Control (e-BP) study, a randomized controlled trial that used a patient-shared electronic medical record, home blood pressure (BP) monitoring, and web-based pharmacist care to improve BP control (<140/90 mm Hg).
Study Design: Incremental cost-effectiveness analysis conducted from a health plan perspective.
Methods: Cost-effectiveness of home BP monitoring and web-based pharmacist care estimated for percent change in patients with controlled BP and cost per mm Hg in diastolic and systolic BP relative to usual care and home BP monitoring alone.
Results: A 1% improvement in number of patients with controlled BP using home BP monitoring and web-based pharmacist care—the e-BP program—costs $16.65 (95% confidence interval: 15.37- 17.94) relative to home BP monitoring and web training alone. Each mm HG reduction in systolic and diastolic BP achieved through the e-BP program costs $65.29 (59.91-70.67) relativeto home BP monitoring and web tools only. Life expectancy was increased at an incremental cost of $1850 (1635-2064) and $2220 (1745-2694) per year of life saved for men and women, respectively.
Conclusions: Web-based collaborative care can be used to achieve BP control at a relatively low cost. Future research should examine the cost impact of potential long-term clinical improvements.
Am J Manag Care. 2013;19(9):709-716
Hypertension care that includes patients monitoring their blood pressure at home and using secure web-based tools to collaboratively manage their care with clinical pharmacistsis both a clinically effective and cost-effective way to improve blood pressure control.
Providing patients with the skills and tools to identify and manage their own medical needs with support from pharmacists while using the latest advances in health information technology demonstrates the potential for increasing access to care through costeffective means.
The Institute of Medicine reports1 that approximately 73 million Americans have hypertension, defined as sustained blood pressure (BP) of >140/90 mm Hg,1,2 and hypertension care increases national healthcare costs by $73 billion a year. Randomized trials have provided clear evidence that lowering BP with antihypertensive medications decreases mortality and major disability; however, hypertension remains inadequately treated in those most affected.2
Medical care's focus on one-on-one doctor/patient interactions in clinics misses opportunities to influence patient outcomes. Electronic communications offer patients new opportunities to be involved in their own care, and patient websites support these efforts to connect care between home and the clinic. We previously demonstrated that a new model of care that leverages patient home BP monitoring, electronic medical records (EMRs), and patient access to a secure patient website with collaborative pharmacist care can be successfully used to improve BP control.3,4 We now report the cost-effectiveness from a health plan perspective of the Electronic Communications and Home Blood Pressure Monitoring to Improve Blood Pressure Control (e-BP) Trial, a randomized controlled trial to improve hypertension control.
Setting and Context
e-BP was a 3-arm randomized controlled trial conducted within Group Health Cooperative, which provides comprehensive health services to over 600,000 residents of Washington State and Idaho. Most enrollees receive care through a closed group practice, which has a commercially available EMR integrated with a patient website. The patient website allows patients to refill medications, make appointments, view portions of the EMR, and use secure messaging to communicate with healthcare team members.5 The trial was conducted at 10 primary care medical centers within Group Health’s Western Washington group practice. All study protocols were reviewed and approved by the Group Health Institutional Review Board and all participants provided written, informed consent before randomization.
Adults aged 25 to 75 years diagnosed with hypertension and taking antihypertensive medications, with no diagnoses of diabetes, cardiovascular, or other serious conditions, were eligible for the study, and invited to 2 screening visits at their primary care clinic, where a research assistant measured BP using the validated Omron Hem-705-CP automated monitor. 6 Individuals with mean diastolic BP between 90 and 109 mm Hg or mean systolic BP between 140 and 199 mm Hg at both visits were invited to join the study. A single-blind block independent randomization design ensured balance within medical centers and baseline systolic BP measurements. The primary outcomes of the e-BP study were change in systolic and diastolic BP and the percentage of patients with controlled BP (<140 mm Hg systolic and <90 mm Hg diastolic) at 12 months following randomization. Complete descriptions of the trial design3 and results4 have been published elsewhere.
Eligible individuals that met study inclusion criteria and provided informed written consent were randomized into 1 of 3 arms:
The Usual Care (UC), care provided to Group Health patients with hypertension, which includes patient information materials including a wallet card with their BP numbers; a pamphlet on hypertension control, including information on medications, adherence, and lifestyle behaviors to lower BP; and “The No-Waiting Room” pamphlet, which describes the MyGroupHealth website and utilities available to registered users. The MyGroupHealth website allows members to communicate with their providers through secured messaging, schedule appointments, refill prescriptions that are then mailed, and view most of the medical record including lab results. A detailed review of the services available through the website may be found at http://www.ghc.org/mygrouphealthpromos/onlinesvcs.jhtml. Patients were told their BP was not in control and were encouraged to work with their physician to improve it.
Home BP Monitoring (BPM) patients received UC as well as a home BP monitor and training in its proper use. They were instructed to use this monitor to check their BP at least twice a week with a goal for home BP of less than 135 mm Hg systolic and 85 mm Hg diastolic.7 Patients received training on use of the MyGroupHealth website, were told their hypertension was not controlled, and were encouraged to work with their physician and use their BP monitor and MyGroupHealth tools to manage their BP.
BPM Plus Pharmacist Care (e-BP) patients received all BPM features and direct care supervision from a clinical pharmacist trained in hypertension evidencebased care, stepped medication protocols based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,8 and patient-centered techniques for addressing behavioral issues related to medication adherence and lifestyle change. Pharmacists sent an introductory secure message to e-BP patients and made 1 telephone call to obtain a detailed medication history and review allergies, intolerances, and cardiovascular risk factors. The pharmacist detailed the patient’s action plan for improving BP control, including instructions for home BP monitoring, a list of current medications, and at least 1 patient-selected lifestyle goal; any recommended medication changes based on the stepped medication protocols; and the follow-up plan. This plan was sent to the patient and their physician and planned communications then occurred over the web every 2 weeks until BP was controlled, and less often thereafter. Patients were asked to provide BP measurements, concerns about medications, and progress related to their lifestyle goals. Pharmacists made specific recommendations (including medication changes) and patients were encouraged to provide feedback and collaboratively change the action plan. All clinical concerns were referred back to the patient’s physician.
The extant literature includes multiple studies documenting the valuable role clinical pharmacists play in treating hypertension. 9-15 Pharmacists may be more aware of the benefits of alternative medication regimens and have greater time and opportunities to evaluate a patient’s experience with particular drugs and provide patients specific tailored regimens. The additional time patients may spend with pharmacists allows for the development of a relationship that can lead to greater trust and greater adherence to recommendations.
Table 1 provides descriptive information on the 778 patients that participated in the trial. One year following randomization, BP control had improved among e-BP patients to 56% compared with 31% in UC and 36% in BPM. e-BP patients had a greater decrease in systolic BP (net change –6.0 mm Hg; P <.001) and diastolic BP (net change –2.6 mm Hg; P <.001) compared with BPM and an even greater decrease in systolic BP (net change –8.9 mm Hg; P <.001) and diastolic BP (net change –3.6 mm Hg; P <.001) compared with UC. Patients receiving BPM only had a modest, but significantly greater, decrease in systolic BP (net change –2.6 mm Hg; P = .02)12 compared with UC. However, BP control and change in mean diastolic BP among BPM patients was not significantly different from UC.
The mean (standard deviation [SD]) number of message threads (secure message and subsequent responses) was 22.3(10.2) in the e-BP group compared with 2.4 (4.6) in the UC and 3.3 (7.4) in the BPM group. Excluding the 1 planned call,telephone encounters at 12 months were higher in the e-BP group with a mean of 7.5 (9.3) compared with 3.8 (5.0) in the BPM group (P <.001) and 4.0 (4.8) in the UC group (P <.001). There were no significant differences in primary care visits,inpatient visits, or urgent care or emergency use at 12 months among patients across arms. There was a modest but significant decrease in the percentage of patients with office visits to a specialist in the e-BP group (P = .04) relative to baseline and to patients in the other groups.
We calculate incremental cost-effectiveness ratios (ICERs) for the e-BP program for 4 specific outcomes: improved BP control, reduced mm HG systolic and diastolic BP, and change in life expectancy achieved through greater control of hypertension. ICER measures the change in costs relative to the improvement in outcomes for 2 programs or interventions and is estimated through the formula given by equation 1:
ICER = [ . Dostsi /DOutcomesi]
where . D Costs is the difference in costs and DOutcomes is the difference in outcomes for the more intensive intervention relative to the less intensive intervention.The base, or reference case,16,17 for our estimates of ICER is UC, which reflects the standard of care provided to all Group Health patients with uncontrolled hypertension. We then estimate the ICER for each outcome for the BPM arm relative to UC and e-BP relative to the BPM to provide estimates of the additional costs incurred in these stepped interventions to improve BP control, reduce systolic and diastolic BP, and increase life expectancy. For outcomes between groups that are not statistically significant we report that the intervention is dominated and do not calculate an ICER since additional costs associated with the intervention do not yield an improved outcome.
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