Kari L. Olson, BSc (Pharm), PharmD

To evaluate the health system cost of a home blood pressure monitoring (HBPM) program versus usual care in an integrated healthcare system.

This cost-effectiveness analysis was based upon a previously completed randomized controlled trial of 348 hypertensive patients, in which mean systolic blood pressure (BP) was lowered 21 versus 8 mm Hg in the HBPM and usual care groups, respectively, and BP control was achieved in 54% versus 35% of patients (

This analysis compared direct costs from the health plan perspective, including clinic visits, e-mail and telephone encounters, laboratory tests, medications, hospitalizations, and emergency department visits between the 2 groups. Primary outcomes were the incremental hypertension care-related cost of HBPM per mm Hg lowering of systolic BP per patient, per additional BP controlled, and per life-year gained.

Median hypertension-related cost per patient over 6 months was $455 in the HBPM group and $179 for usual care (P <.001). This increase was attributable to additional e-mail and telephone encounters, greater antihypertensive medication use, additional laboratory monitoring, and the BP monitor. Median total cost per patient was $1530 and $1283 for the HBPM and usual care groups, respectively (

 = .034). The HBPM program increased hypertension-related expenditures by $20.50 per mm Hg lowering of systolic BP, $1331 per additional patient achieving BP control at 6 months, and $3330 per life-year gained.

The HBPM program requires investment in outpatient encounters, medications, and laboratory monitoring, but produces significantly improved BP control.

This study highlights the cost-effective manner in which home-monitoring technology plus clinical pharmacy specialist involvement improves blood pressure (BP) control.

		Patients in the Home Blood Pressure Monitoring (HBPM) program had more overall telephone and email encounters with a pharmacist, but the same number of office visits with a pharmacist, and utilized more antihypertensive medications and laboratory monitoring compared with patients managed through usual care.

		The incremental 6-month cost of this intervention was $20.50 per mm Hg of systolic BP lowered, $1331 per additional BP controlled, and $3330 per life-year gained compared with usual care.

		The incremental costs of this intervention compare favorably with other interventions, largely because the HBPM program was more effective than usual care.

Nearly $51 billion in direct and indirect costs related to hypertension were spent in the United States in 2009, with much of it attributable to the healthrelated consequences of hypertension.

 One in 3 adults in the United States has hypertension, and about half of those have uncontrolled blood pressure (BP), putting them at increased risk for acute myocardial infarction, stroke, renal disease, and congestive heart failure.

 Lowering BP has been shown to reduce the occurrence of these events.

Despite effective therapeutic interventions to control BP, at least a quarter of patients with uncontrolled hypertension receive no pharmacologic treatment. Novel care delivery models using home BP monitoring have demonstrated improved BP control.

 Demonstrating the benefits, costs, and cost effectiveness of such programs will help clinicians and policy makers to decide whether to invest in these programs.

Investigators at Kaiser Permanente Colorado (KPCO) conducted a randomized, controlled trial to evaluate the effectiveness of a home BP monitoring (HBPM) intervention that used the American Heart Association Heart360 Web interface (

) to send home BP readings to a clinical pharmacy specialist who managed the patient’s medication therapy via phone or e-mail communication. The purpose of this study was to determine the cost-effectiveness of the HBPM program compared with usual care.

The study was conducted at KPCO, a group-model, closed-panel, nonprofit managed care organization that cares for more than 500,000 members in the Denver-Boulder metropolitan area. Outpatient medical services are provided at 18 primary care clinics spread geographically across the metropolitan area, 10 of which participated in the present study. Each clinic is staffed with 1 or more clinical pharmacy specialists who assist primary care providers with drug therapy management. With regard to hypertension management, clinical pharmacy specialists work under preapproved collaborative drug therapy management protocols that permit them to initiate or change antihypertensive medications, adjust medication doses, and order laboratory tests related to medication monitoring. KPCO clinicians use a commercially available EpicCare electronic health record (EHR) as part of routine care delivery. The KPCO EHR has a feature called My Chart which allows patients and their providers to communicate electronically through a password-protected website.

The study was approved by the KPCO Institutional Review Board.

The HBPM study has been described in detail elsewhere. 8 This was a randomized, controlled study of 348 patients with uncontrolled hypertension randomly assigned to the HBPM program or usual care. Patients in the HBPM group were provided with and trained to use a home BP monitor (Omron HEM-790IT monitor), and they were guided in establishing a Heart360 account and in how to automatically upload BP measurements from their monitor to their Heart360 account. Patients in the HBPM group also met with a clinical pharmacy specialist, who reviewed their current BP medication regimen, provided counseling on lifestyle changes, and adjusted or changed antihypertensive medications, as needed. Patients in the usual care group were instructed to follow up with their primary care physician for BP care. Patients in both groups returned at 6 months for an in-clinic BP measurement. Blood pressure goal was <140/90 mm Hg for all patients, except for those with diabetes mellitus or chronic kidney disease for whom the goal was <130/80 mm Hg. At 6 months, 54% of patients in the HBPM group attained their BP goal, compared with 35% in the usual-care group (

 <.001). The HBPM group lowered their systolic blood pressure (SBP) by an average of 21 mm Hg compared with 8 mm Hg in the usual care group (

The economic analysis was conducted from the health plan perspective over the 6-month study period. Cost inputs included costs of the blood pressure cuff, clinic visits, e-mail and telephone encounters, laboratory tests, medications, hospitalizations, and emergency department (ED) visits. Indirect costs (eg, the administrative costs necessary for day-to-day operations) were not included as they were not expected to differ between the groups.

Healthcare utilization data were collected for 6 months prior to and after study enrollment using administrative databases maintained by KPCO. Data included all outpatient encounters (office visits, telephone contacts, e-mails), laboratory and radiology tests, prescriptions, ambulatory surgery, ED visits, and hospital admissions both within the KPCO system as well as claims for care that occurred outside KPCO. Costs were classified as hypertension-related if the primary 

International Classification of Diseases, Ninth Revision, Clinical Modification

 code associated with each expenditure was hypertension (401.9); hospitalizations, clinic encounters, and ED visits were reviewed manually to verify accurate categorization. Current procedural terminology codes were used to assign costs according to a fee schedule derived from the 2009 national Medicare fee schedule.

Costs for professional claims were based on billed amounts. Prescriptions billed through insurance were collected during the same time frame, and costs were determined using discounted average wholesale price to approximate Medicare pricing, with the addition of an $8 dispensing fee.

Costs for the initial clinic visit, telephone encounters with a clinical pharmacy specialist, and all e-mail encounters were estimated by multiplying the time spent by each provider type by the hourly wage. Provider compensation rates were taken from the United States Census Bureau wages and compensation 2009 data plus 29.2% to account for benefits.

The following hourly rates were used: pharmacist, $74.14; medical assistant, $19.39; registered nurse, $44.09; and physician, $99.72. The initial clinic visits differed in that the HBPM group required an additional 20 minutes of medical assistant time for training on the home BP monitor, setting up a Heart360 account, and downloading BP readings to the website, plus 20 minutes with a clinical pharmacy specialist to review antihypertensive medications and make any necessary dose adjustments. Based on a survey of the clinical pharmacy specialists participating in the study, pharmacist time was estimated at 10 minutes for each telephone follow-up encounter. E-mails from any provider were estimated at 6 minutes per e-mail encounter. All costs have been adjusted to reflect 2013 dollars using the Consumer Price Index rates for medical costs.16 The selected home BP monitor or a similar model can be purchased for approximately $60.

Direct costs were grouped into the following categories: outpatient encounters (including in-person clinic visits, telephone calls, and e-mail exchanges); outpatient laboratory; pharmacy outpatient; and all other costs (ambulatory surgery, ED, hospitalizations, and outpatient radiology). Total healthcare costs for 6 months prior to enrollment were compared between groups to assess for baseline differences in costs and to adjust for such differences (if present) during the study period. Total and hypertension-related costs during the 6-month study period were calculated to demonstrate the relationship between hypertension-related and total healthcare costs and to capture any unintended increases in healthcare utilization (eg, due to adverse events) related to the study. Three incremental cost-effectiveness ratios (ICERs) were calculated: cost per mm Hg lowering of SBP per patient, cost per controlled BP achieved, and cost per life-year gained. To determine the cost of an additional 1 mm Hg lowering of SBP in a patient, the mean difference in 6-month costs for hypertension care was divided by the mean SBP change in each group. To determine the cost of 1 patient achieving BP control, the mean difference in 6-month hypertension-related costs was divided by the difference in the number of patients achieving control in each group.

Cost per life-year gained was determined by first calculating the discounted life expectancy (DLE) for each patient at baseline and after the intervention using the formula:

=1.5% is the discount rate for life years,

is the current age of the patient in years, and 

 denotes the probability of surviving until age 

 denotes the 1-year risk of death for a patient of age s with the same gender and BP control level as the patient. (The symbol Π denotes the product operator; for example 

 ). The mortality rates were estimated from life expectancy data based on age, gender, and BP control level.18 The mortality rate for a patient of age s years was calculated by the formula:

 is the life expectancy of a patient of age s of the same gender and BP control level; this was determined by linear interpolation or extrapolation from Tables 3, 

 The mortality rate formula was derived by assuming that deaths occur at the end of each year so that:

We calculated the incremental hypertension care costs of the intervention for year 1 of the program plus subsequent years of follow-up. Total hypertension care cost in each group for year 1 was calculated by first estimating the increased cost of antihypertensive medications for the entire year for each patient. To account for expected follow-up needs in the second 6-month period, the costs for non—study-related outpatient encounters in the first 6 months was doubled and an additional e-mail encounter was added for intervention patients. Additional laboratory costs were not added for the second 6-month period because most antihypertensive medications require annual monitoring. To determine the incremental hypertension care cost for each intervention patient in year 1, the mean cost of a usual-care patient was subtracted from the actual cost for each intervention patient. Incremental cost for subsequent years was calculated as the average difference in costs for antihypertensive medication plus laboratory monitoring between groups plus the cost of 3 e-mail encounters in the intervention group.

The discounted cost of intervention for each patient in the intervention group was calculated by the formula:

where rc = 3% is the discount rate for costs,

 is the incremental hypertension care cost for intervention patients in year 1 as described above, and 

 is the incremental cost for each subsequent year. Subset analyses were performed on the group of patients with diabetes mellitus to calculate the incremental cost-effectiveness ratios for this high-risk group.

Cost comparisons between each group were reported as median and interquartile range values as cost data were not normally distributed. Wilcoxon rank sum was used to determine the significance of the between-group differences in cost. Level of significance was set at an α of 0.05. All statistical analyses were performed using SAS version 9.2 (SAS Institute, Carey, North Carolina).

The average age of the 348 study participants was 60 years; about 60% were male (

). Almost half of the participants had either diabetes mellitus or chronic kidney disease (Table 1).

Compared with patients in the usual care group, patients in the HBPM group had significantly more e-mail (median 5 vs 1, 

 <.001) encounters during the 6-month study period. There were no statistically significant differences between the 2 groups in the number of office visits, ED visits, or hospitalizations over the 6-month study period (

There were no statistically significant differences in total costs for the intervention and usual care groups in the 6-month pre-enrollment period (

 = .828 for total costs). Median total healthcare costs per patient during the 6-month study period were higher in the HBPM group ($1590) than in the usual care group ($1283; 

). This difference was largely driven by higher outpatient encounter costs ($481 vs $381, 

 = .006) and higher medication costs ($622 vs $475, 

 = .034) for HBPM and usual care groups, respectively.

When only considering hypertension-related costs, all major cost categories were higher in the HBPM group (median hypertension-related care cost of $455 per patient) compared with usual care (median cost $179; 

 <.001, Table 3). The incremental hypertension-related cost per additional mm Hg reduction in SBP was $20.50. The incremental hypertension-related cost per patient who achieved BP control was $1331 (

Articles

A technology-based, pharmacist-run home blood pressure monitoring program improves health outcomes by investing $20.50 per mm Hg systolic blood pressure lowered and $3300 per life-year gained.

Cost-effectiveness Evaluation of a Home Blood Pressure Monitoring Program

To determine if a multimodal intervention composed of patient education, home blood pressure (BP) monitoring, BP measurement reporting to an interactive voice response (IVR) phone system, and clinical pharmacist follow-up improves BP control compared with usual care.

Prospective study with patient enrollment, medication consultation and adjustment, remote BP monitoring, and follow-up at 6 months.

This randomized controlled trial was conducted at 3 healthcare systems in Denver, Colorado, including a large health maintenance organization, a Veterans Affairs medical center, and a county hospital. At each site, patients with uncontrolled BP were randomized to the multimodal intervention vs usual care for 6 months, with the  primary end point of BP reduction.

 Of 338 patients randomized, 283 (84%) completed the study, including 138 intervention patients and 145 usual care patients. Baseline BP was higher in the intervention group vs the usual care group (150.5/89.4 vs 143.8/85.3 mm Hg). At 6 months, BPs were similar in the intervention group vs the usual care group (137.4 vs 136.7 mm Hg, P = .85 for systolic; 82.9 vs 81.1 mm Hg, P = .14 for diastolic). However, BP reductions were greater in the intervention group vs the usual care group (−13.1 vs −7.1 mm Hg, P = .006 for systolic; −6.5 vs −4.2 mm Hg, P = .07 for diastolic). Adherence to medications was similar between the 2 groups, but intervention patients had a greater increase in medication regimen intensity.

A multimodal intervention of patient education, home BP monitoring, BP measurement reporting to an IVR system, and clinical pharmacist follow-up achieved greater reductions in BP compared with usual care.

	This practical clinical trial implemented across 3 healthcare systems showed that a multimodal intervention composed of patient education, home blood pressure (BP) monitoring, BP measurement reporting to an interactive voice response system, and clinical pharmacist management of hypertension led to greater BP reductions compared with usual care.

		This difference was likely due to greater therapy intensification (number and intensity of hypertension medications) in the intervention group, as adherence was comparable between the 2 study groups.

		These findings suggest that encouraging self-care through home BP monitoring and using clinical pharmacists to initiate and titrate antihypertensive medications with    physician oversight can improve BP levels.

	Uncontrolled hypertension is associated with increased risk of myocardial infarction, stroke, kidney failure, and heart failure.

 Randomized controlled clinical trials have  shown the benefit of blood pressure (BP) lowering for reducing these adverse events.

 Yet, hypertension remains uncontrolled in a large proportion of treated patients.

 Some interventions to improve hypertension control have demonstrated reductions in BP, but the interventions are often complex and difficult to implement in routine clinical  practice.

 Furthermore, it cannot be assumed that interventions shown to work in one healthcare setting will be transportable and effective in a different healthcare setting.

	The objective of the Improving Blood Pressure in Colorado study was to evaluate a multimodal intervention across 3 distinct healthcare settings. The intervention was composed of patient education, home BP monitoring, and BP measurement reporting to an interactive voice response (IVR) phone system, and clinical pharmacist  management of hypertension with physician oversight. This was a practical clinical trial comparing the intervention plus usual care vs usual care alone for patients having diagnosed hypertension and uncontrolled BP. Our hypothesis was that patients randomized to the intervention plus usual care would have greater reductions in BP at 6 months compared with patients randomized to usual care alone (clinicaltrials.gov identifier: NCT00520988).

	This study was conducted at 3 healthcare systems located in metropolitan Denver, Colorado, including Denver Health and Hospitals, Veterans Affairs Eastern Colorado Healthcare System, and Kaiser Permanente Colorado. Denver Health and Hospitals is a safety-net health system that provides services to a large proportion of indigent, vulnerable, and minority populations in the city and county of Denver.

 Veterans Affairs Eastern Colorado Healthcare System serves more than 60,000 Colorado veterans through its medical center in Denver and 8 outpatient clinics located throughout eastern Colorado. Many veterans live in rural Colorado communities with limited access to healthcare. Kaiser Permanente Colorado is a nonprofit managed care organization that cares for more than 500,000 patients in the Denver-Boulder—Colorado Springs metropolitan areas through 2 contract hospitals and 20 outpatient clinics. Kaiser Permanente Colorado provides care to more than 60,000 Medicare, Medicaid, or dually eligible Medicare-Medicaid patients.

	We performed population screening of potentially eligible patients using electronic BP data available within each healthcare system. Eligible for study participation were  patients with hypertension who were taking 4 or fewer antihypertensive medications and who had elevations in 2 of the 3 most recent electronic BP measurements (>140 mm Hg for systolic or >90 mm Hg for diastolic; for patients with diabetes mellitus or chronic kidney disease, >130 mm Hg for systolic or >80 mm Hg for diastolic). Potentially eligible patients were contacted by phone and were invited for an initial (baseline) study enrollment clinic visit.

	At the enrollment clinic visit, the patient’s BP was measured using techniques recommended in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.6 Three BP measurements were obtained 1 minute apart using an electronic BP cuff (BPM-100 professional BP monitor   [A/A grade from the British Hypertension Society]; VSM MedTech Ltd, Coquitlam, British Columbia, Canada), and the average of the latter 2 BPs was calculated. Patients whose averaged BP exceeded 140 mm Hg for systolic or 90 mm Hg for diastolic (or >130/80 mm Hg for patients with diabetes or chronic kidney disease) and who consented to participate in the study were randomized to the intervention or to usual care. Patients whose averaged BP levels were below the cutoffs were ineligible for the study.

	A block randomization design was used to ensure balance within healthcare systems. A random allocation sequence was computer generated using stratified  randomization with an allocation ratio of 1:1 (intervention to usual care). We used commercially available statistical software (SAS RANUNI function; SAS Institute Inc, Cary, North Carolina) to generate the assignment list for each stratum according to site (Denver Health and Hospitals, Veterans Affairs Eastern Colorado Healthcare System, and Kaiser Permanente Colorado). The sequence was concealed until the intervention and usual care groups were assigned at the baseline visit. Patients randomized to usual care were educated about hypertension using a National Institutes of Health booklet on hypertension entitled Your Guide to Lowering Blood Pressure (http://www.nhlbi.nih.gov/health/public/heart/hbp/hbp_low/hbp_low.pdf) and were instructed to follow up with their primary care provider to get their BP under control.

	Four main components of the multimodal intervention were the following: (1) patient education, (2) home BP monitoring, (3) home BP measurement reporting to an IVR  phone system, and (4) clinical pharmacist management of hypertension with physician oversight. After randomization to the intervention, patients were educated about hypertension using a National Institutes of Health booklet on hypertension (

), instructed about use of the IVR phone system, and trained on using an electronic BP cuff (UA-767; LifeSource, Milpitas, California) to monitor home BP.

	Patients were instructed to measure their BP 3 to 4 times per week and were encouraged to measure their BP on different days of the week and at various times of the day. Patients were asked to report their BP measurements to the IVR phone system on a weekly basis. During the IVR call, patients were prompted to input their systolic and diastolic BP readings for the week using the touch-tone keypad of their phone. The average of the inputted measurements was calculated, and patients were given feedback on whether their BP measurements were at goal at the end of the call. In addition, patients were offered an opportunity to listen to educational messages or to request a call from the clinical pharmacist to answer questions.

	Next, the clinical pharmacist reviewed the reported home BP measurements. For patients whose home BP measurements were above guideline-recommended treatment  goals, clinical pharmacists reviewed medication adherence, made adjustments to antihypertensive medication regimens as appropriate, and provided counseling on healthy therapeutic lifestyle changes. For patients with essential hypertension, average home readings with systolic BP exceeding 135 mm Hg or diastolic BP exceeding 85 mm Hg triggered a clinical pharmacist intervention. For patients with diabetes or chronic kidney disease, average home readings with systolic BP exceeding 125 mm Hg or diastolic BP exceeding 75 mm Hg triggered a clinical pharmacist intervention.

	The clinical pharmacists practiced under preapproved drug therapy management protocols. The clinical pharmacist intervention varied based on the level of BP elevation, and clinical judgment was used to determine the intervention implemented (eg, patient counseling or education, dose adjustment, and addition of new medication). The  clinical pharmacist discussed these changes with the patient during phone visits. The patient’s primary care provider was notified of any medication changes through progress notes entered into the electronic medical record available within each of the healthcare systems, via a phone call, or both. Patients who did not enter any BP measurements into the IVR system after 10 days received an automated reminder call, followed by a call from the pharmacist 4 days later if necessary. Overall, 94% of intervention patients uploaded BP measures at least 1 time during the study period.

Primary Outcomes of BP Control and Change in BP

	Primary study outcomes were (1) the proportion of patients who achieved guideline-recommended BP goals (ie, <140/90 mm Hg [or <130/80 mm Hg for those with diabetes or chronic kidney disease]) and (2) the change in systolic and diastolic BPs between the enrollment visit and the 6-month follow-up visit.

	Intervention and usual care patients returned after 6 months for an end-of-study clinic visit to obtain 3 in-person BP measurements using the same standardized research methods used at the baseline enrollment visit. The research assistant who obtained the BP measurements was blinded to patient study group assignment.

Secondary Outcomes of Therapy Intensification and Medication Adherence

	The secondary outcome of intensity of hypertension medication regimen was based on patient report of medication regimen (specific medication and dosage) at the enrollment visit and at the 6-month follow-up visit, with confirmation by reviewing the pharmacy list available through the site’s electronic medical record or the pill bottles that patients brought to the visits. Each antihypertensive medication was categorized as low, moderate, or high intensity corresponding to a score of 1, 2, or 3 points based on the dosage prescribed (

). For example, lisinopril at less than 20 mg was classified as low intensity (1 point), lisinopril at 20 to 40 mg as moderate intensity (2  points), and lisinopril at greater than 40 mg as high intensity (3 points). This algorithm was reviewed by a panel of internists and cardiologists not involved with the study and was believed to have face validity. For each patient, an average intensity score was derived based on the sum of the medication intensity score divided by the number of antihypertensive medications prescribed.

	To assess the secondary outcome of medication adherence during the study, only Veterans Affairs Eastern Colorado Healthcare System and Kaiser Permanente Colorado patients were included because those sites had comparable automated pharmacy data that included all medications dispensed and sold within each of the respective  healthcare systems. A medication possession ratio (MPR) was calculated based on the total number of days supplied for each filled antihypertensive medication divided by the period for which the medication was prescribed. For patients using multiple antihypertensive medications during this time, adherence to each medication was averaged to derive a summary adherence measure. Classes of antihypertensive medications considered included β-blockers, dihydropyridine calcium channel blockers, nondihydropyridine calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, α-blockers, and diuretics. Patients were categorized as adherent vs nonadherent using MPR cutoffs of at least 0.80 vs less than 0.80, consistent with the literature.

	Our primary analyses applied intent-to-treat principles to patients who completed the end-of-study visit. Follow-up was attempted for all patients, and all patients who completed follow-up in their randomized intervention assignment were included, regardless of whether they used the IVR phone system or interacted with the study pharmacist. Baseline characteristics and BP, MPR, and therapy intensification outcomes were compared using t test for continuous variables and χ2 test for categorical variables.

	In secondary analyses, we assessed the association between medication intensity, medication adherence, and BP control. Because there was an interaction between  medication intensity and medication adherence, we constructed separate models for the association between BP control and medication intensity among patients who were adherent vs nonadherent. In addition, a stratified analysis of change in BPs was conducted for patients with baseline systolic BP of at least 150 mm Hg vs less than 150 mm Hg. Finally, regression analyses that included site as a covariate were conducted. In this analysis, the outcomes of the intervention group vs the usual care group were similar to those noted in the primary analysis and are not presented in detail. All analyses were performed using commercially

	available statistical software (SAS version 9).

shows the flow of patients through the initial screening, baseline visit, randomization, and 6-month followup phases of the study. Of 338 patients enrolled in the study, 283 (84%) completed the 6-month visit. Reasons for not completing the 6-month visit included failed contact attempt, moved from the area, and declined further participation in the study. There were no significant differences in the baseline demographic and clinical characteristics of patients who did vs did not complete the 6-month visit, although patients who did not complete the study had higher baseline systolic and diastolic BPs.

	Baseline demographic and medical history characteristics of patients completing the 6-month visit in the intervention and usual care groups were comparable (

). The mean age was 62 years; one-third of patients were female, and two-thirds were of white race/ethnicity. Slightly more than 50% of patients had diabetes or chronic kidney disease. At baseline, the mean (SD) BPs were significantly higher for 138 intervention patients vs 145 usual care patients (150.5 [19.5] vs 143.8 [16.8] mm Hg, P <.01 for systolic; 89.4 [13.6] vs 85.3 [11.1] mm Hg, P = .02 for diastolic).

	At 6 months, the mean (SD) BPs were similar in the intervention group vs the usual care group (137.4 [19.4] vs 136.7 [17.0] mm Hg, P = .85 for systolic; 82.9 [12.9] vs 81.1 [11.7] mm Hg, P = .14 for diastolic). There was no difference between the intervention group vs the usual care group in the proportions achieving BP goal (36.0% vs 35.2%, P = .89).

	Evaluating the changes in BP, greater reductions were experienced by intervention patients vs usual care patients in systolic BP (−13.1; 95% confidence interval [CI], −16.5 to −9.7 mm Hg vs −7.1; 95% CI, −9.8 to −4.4 mm Hg; P = .006) and in diastolic BP (−6.5; 95% CI, −8.5 to −4.6 mm Hg vs −4.2; 95% CI, −5.9 to −2.5 mm Hg; P = .07; 

). The differences in BPs for intervention patients compared with usual care patients were −6.0 (95% CI, −10.4 to −1.7) mm Hg for systolic and −2.3 (95% CI, −4.9 to −0.2) mm Hg for diastolic. When the analysis was stratified by baseline systolic and diastolic BPs, among patients with a baseline systolic BP of 150 mm Hg or higher, there was a statistically significant difference in the change in systolic BP between baseline and 6 months for intervention patients vs usual care patients (−23.3 vs −15.1 mm Hg, P = .047). There was no statistically significant difference among patients with a baseline systolic BP of less than 150 mm Hg.

	At baseline, the mean (SD) number of antihypertensive medications (2.1 [1.0] vs 2.1 [1.1], P = .99) and the mean (SD) intensity of the hypertension regimen (3.2 [1.9] vs 3.3 [1.9], P = .39) were comparable between the intervention group and the usual care group. At 6 months, the intervention group vs the usual care group had a greater increase in the number of hypertension medications (change of 0.3 vs 0.1, P = .05) and a higher intensity of hypertension medication regimens (change of 0.6 vs 0.2, P = .008). For Veterans Affairs Eastern Colorado Healthcare System and Kaiser Permanente Colorado patients (n = 224), there was no significant difference between intervention patients  vs usual care patients in the mean (SD) MPR (0.85 [0.19] vs 0.84 [0.19], P = .88) or in the proportion of patients categorized as being adherent (69.9% vs 69.4%, P = .93).

	Finally, we assessed the association between medication intensity, medication adherence, and BP control. Among patients who were nonadherent (MPR, <0.80), medication intensity was not associated with BP control (P = .32). However, among patients who were adherent (MPR, ≥0.80), increasing medication intensity was  associated with BP control (parameter estimate, −2.2; P = .04), suggesting that uptitration of medications does not affect BP control when patientsare nonadherent to their BP medications.

	This practical clinical trial implemented across 3 healthcare systems showed that a multimodal intervention composed of patient education, home BP monitoring, home BP measurement reporting to an IVR phone system, and clinical pharmacist management of hypertension led to greater BP reductions compared with usual care. This  difference was likely due to greater therapy intensification (number and intensity of hypertension medications) in the intervention group, as adherence to hypertension medications was comparable between the 2 study groups. These findings suggest that encouraging self-care through home BP monitoring and using clinical pharmacists to initiate and titrate antihypertensive medications with physician oversight can improve BP levels.

	The results of this study add to the literature on the value of technology to help promote self-care and to improve BP control.

 We were able to use simple phone-based IVR technology to allow patients to stay connected to the healthcare system and to implement this technology across 3 distinctly different healthcare settings. Patients were able to get prompt feedback about their BP levels after entering their measurements into the system. In addition, they received follow-up calls from the clinical pharmacist if  their BP readings remained above guideline-recommended goals. Prior assessments of technology interventions have used the Internet or personal digital assistant devices and have generally been successful. However, these technologies may not be readily available to all patients with hypertension, and most of these investigations were performed within a single healthcare system,

 limiting the generalizability of the findings. In our study, patients could access the IVR system through a landline phone or cell phone, which increases the generalizability of our results to other healthcare settings because most patients have access to a phone. The generalizability of the study  results also is enhanced by the inclusion of a broadly representative population of patients with uncontrolled hypertension that included participants with diabetes and chronic kidney disease, populations that have been excluded in prior intervention studies.

A multisite multimodal intervention of patient education, home monitoring, measurement reporting to an IVR system, and pharmacist follow-up achieved greater BP reductions vs usual care.

Kari L. Olson, BSc (Pharm), PharmD

Articles

Cost-effectiveness Evaluation of a Home Blood Pressure Monitoring Program

A Multimodal Blood Pressure Control Intervention in 3 Healthcare Systems