Cost-Effectiveness of Implementing a Home Blood Pressure Telemonitoring Program

ABSTRACT

Objectives: To evaluate the 12-month cost-effectiveness of the implementation of a home blood pressure telemonitoring (HBPT) program in a large US integrated health care system.

Study Design: Retrospective cohort study.

Methods: Data from patients enrolled in the Kaiser Permanente Southern California HBPT program (November 2019-June 2022) were analyzed. We estimated program implementation costs and hypertension-related health care utilization and costs (in 2020 US$) 12 months pre– and post HBPT program enrollment. We compared 12-month costs and blood pressure (BP) outcomes between patients who participated in the program and those who abandoned it prior to participation, using inverse probability of treatment weights to adjust for baseline characteristics. A difference-in-differences analysis estimated mean differences in outcomes associated with the HBPT program. Incremental cost-effectiveness ratios (cost per mm Hg reduction) were calculated with 95% bootstrapped CIs.

Results: The study included 3067 patients (mean age, 56.7 years; 62.7% female; 62.1% non-Hispanic Black). HBPT program implementation costs averaged $113.35 per patient. The program reduced hypertension-related office visit costs (–$6.52; P = .016) and BP clinic visit costs (–$2.58; P = .002), despite an increase in hypertension-related virtual encounter costs ($11.80; P < .001). Mean BP reductions were 1.42 mm Hg (P = .071) for systolic BP (SBP) and 1.58 mm Hg (P = .001) for diastolic BP (DBP). Incremental cost-effectiveness ratios were $81.67 per mm Hg SBP reduction and $73.22 per mm Hg DBP reduction.

Conclusions: The HBPT program in a real-world clinical setting achieved modest BP reductions, although overall costs increased primarily due to enrollment expenses.

Am J Manag Care. 2026;32(3):146-152. https://doi.org/10.37765/ajmc.2026.89893

Takeaway Points

A home blood pressure telemonitoring (HBPT) program effectively reduced BP in real-world clinical settings, but its enrollment expenses increased overall costs.

• The HBPT program reduced BP clinic visits over 12 months.
• The program increased hypertension-related virtual encounter costs due to follow-up care, but it decreased hypertension-related office visit and BP clinic visit costs.
• Driven by the cost of patient enrollment, the HBPT program required $81.67 for every mm Hg reduction in systolic BP.

Hypertension affects nearly 50% of adults in the US, but only approximately 25% of those individuals have their blood pressure (BP) under control.¹ The economic burden of hypertension is substantial, with the annual cost associated with hypertension for the US adult population estimated at $219 billion in 2019.² To effectively manage hypertension, the 2017 American College of Cardiology/American Heart Association BP management guideline and other guidelines have advocated for self-measured BP monitoring,^3-5 which has been shown to improve BP in randomized controlled trials.⁶ Self-measured BP monitoring, especially when combined with cointerventions such as telemonitoring and pharmacist-led care, results in significant BP reductions.^7-11

Despite the potential effectiveness of self-measured BP monitoring, its adoption in the US has been slow.^12-16 Self-measured BP monitoring, with or without cointerventions by health care teams,^8-10 may be a cost-effective strategy for improving BP control by empowering patients with hypertension to participate in their health care while reducing in-person office visits. Previous simulation studies from randomized controlled trials have reported the cost-effectiveness of self-measured BP monitoring programs,¹⁷ but cost-effectiveness analyses of real-world implementation of self-measured BP programs are scarce.

In 2019, Kaiser Permanente Southern California (KPSC) piloted a home BP telemonitoring (HBPT) program to assist clinicians in the management of patients with hypertension. Understanding the costs of implementing HBPT components and evaluating the program’s cost-effectiveness are crucial for its broader implementation. This study aimed (1) to assess program enrollment costs and health care utilization and costs associated with hypertension care among HBPT program participants compared with those receiving usual care and (2) to evaluate the 12-month cost-effectiveness (cost per BP reduction) of the implementation of the HBPT program compared with usual care from a health care system perspective.

METHODS

Study Setting

KPSC is an integrated health care system that delivers medical services to its members through 16 hospitals and more than 200 outpatient facilities. Comprehensive electronic health records (EHRs) capture all aspects of care provided to more than 4.8 million members. Additionally, medical care received outside the system is documented through medical claims, making this information available for research. The KPSC Institutional Review Board approved and granted a waiver of informed consent for this study.

The KPSC HBPT Program

The HBPT program at KPSC was launched in November 2019 at 4 medical centers and initially focused on enrolling African American patients. The goal was to facilitate patient participation in hypertension care and improve BP control. By March 2020, the program was expanded to all 16 medical centers in the region. Eligible members were 18 years and older and had a smartphone, an email address, a kp.org account, a preferred language of English or Spanish, and uncontrolled hypertension (BP ≥ 140/90 mm Hg). Medical assistants screened members for eligibility and facilitated enrollment by clinical staff either in person or through a virtual appointment. To select the appropriate cuff size during enrollment, clinical staff measured the member’s arm circumference (or used the member’s weight if virtual) and provided them with a validated BP device and cuff (Omron HEM-9200T or HEM-9210T) in the clinic or via mail. Members completed the consent process through a smartphone application. Participants were instructed by clinical staff who enrolled them in the HBPT program to measure their BP at home 3 days each week, twice in the morning and twice in the evening before taking antihypertensive medications. Participants demonstrated their ability to measure their BP with the home BP device during the enrollment process or were instructed to complete a test measure after they downloaded the smartphone application. These BP readings were synced to a smartphone application, which directly transmitted the data to the EHR system. A follow-up virtual visit (via telephone or video) was conducted after 2 weeks to ensure that the enrollment process was complete and that the BP device and mobile application were paired correctly. Additionally, participants’ BP readings were reviewed, and their medications were titrated as needed by either their primary care physician or an advanced practice provider. Providers monitored home BP through the EHR and reached out to participants when necessary. Participants were disenrolled from the HBPT program after achieving at least 2 one-week mean home BP readings less than 135/85 mm Hg approximately 4 weeks apart, with the last submitted home BP also being less than 135/85 mm Hg.

Study Population

For this cost-effectiveness study, we included participants in the HBPT program between November 2019 and June 2022. Considering an as-treated approach,¹⁸ we divided all participants into 2 groups: (1) Those who were enrolled in the program, consented via the smartphone application, and uploaded at least 1 BP reading were categorized as the HBPT intervention group; and (2) those who started enrollment but disengaged from the program by not consenting or not uploading any BP readings were categorized as the abandoned group. The abandoned group was used as the comparator group and referred to as the usual care group (eAppendix Figure [eAppendix available at ajmc.com]). The potential confounding and selection bias between the 2 groups were controlled using statistical methods.

Study Perspective and Time Horizon

This study adopted a health care system perspective for a time horizon of 12 months from program enrollment. Therefore, the analysis included the costs of implementing the HBPT program and the costs associated with hypertension-related health care encounters. Because we considered the costs incurred by the health care system, we did not consider out-of-pocket expenses, societal costs, or productivity losses. No discount rate was applied due to the short-term follow-up.

Outcomes

We assessed the HBPT program’s effectiveness by measuring mm Hg reductions in systolic and diastolic BP (SBP and DBP, respectively) using in-clinic BP measurements at enrollment and at 12 months post enrollment. We selected the last BP values closest and prior to 12 months post enrollment. When there were multiple BP values during the same visit, we selected the lowest BP to avoid potential white coat hypertension. As a process measure, we evaluated antihypertensive medication use at enrollment and 12 months post enrollment using the Therapeutic Intensity Score (TIS). TIS is a validated summary measure that accounts for the number of antihypertensive medications in a patient’s regimen and the dose of each medication that the patient is receiving relative to the maximally recommended dose.¹⁹ Given that the most common days’ supply for antihypertensive medications at KPSC is 100 days, we compared outpatient prescription fill data across 2 time windows: 4 months before to 1 month after the enrollment date and at 12 months post enrollment.

Costs, in 2020 US$, were calculated in 2 stages: (1) initial enrollment costs, which included device and staff costs; and (2) costs associated with hypertension-related health care utilization in the 12 months following enrollment. To estimate enrollment cost, we used device and shipping cost data collected within the HBPT program. Staff costs for facilitating patient enrollment into the HBPT program were estimated based on the mean salary of medical assistants²⁰ and the 2020 Medicare Fee Schedule.²¹ To calculate hypertension-related costs, we attached costs to hypertension-related health care encounters, namely (1) in-person office visits, during which a primary diagnosis of hypertension was recorded (International Statistical Classification of Diseases, Tenth Revision [ICD-10] codes I10, I11, I12, I13); (2) visits to a team-based BP clinic; and (3) virtual encounters (phone, video, or telephone advice visit), during which a diagnosis of hypertension was recorded. Costs associated with health care utilization were also assigned based on the Healthcare Common Procedure Coding System codes from the 2020 Medicare Fee Schedule.²¹ The parameters and codes used for cost estimation are shown in eAppendix Tables 1 through 3.

Finally, we estimated the incremental cost-effectiveness ratios (ICERs; cost per mm Hg reduction), which indicate the additional cost in US$ required to achieve a unit of BP reduction through the HBPT program compared with usual care.

Covariates

Patient sociodemographic and clinical characteristics were identified on the enrollment date or within the prior 12 months. These included age, sex, race and ethnicity, smoking status, body mass index, neighborhood-level household income by linking members’ home addresses via geocoding and US census block data,²² medical insurance, and preferred language. We defined chronic conditions (diabetes, cardiovascular disease, heart failure) based on ICD-10 diagnosis or procedure codes from EHR data for the prior 12 months. The number of antihypertensive medication classes and number of in-person office visits were also defined using the prior 12-month data from the EHR. SBP at the last clinic visit prior to or at the time of enrollment was used as a covariate.

Statistical Analyses

Sociodemographic and clinical characteristics of the study population were described by calculating means and SDs for continuous variables and frequencies and percentages for categorical variables. To adjust for differences between the usual care and intervention groups at the time of enrollment, we calculated propensity scores using logistic regression and derived inverse probability of treatment weights (IPTWs). Two IPTW sets were defined, w₁ and w₂, with w₁ used in the analysis of health care utilization and associated costs and w₂ used to analyze BP outcomes. To estimate w₁, health care utilization prior to enrollment was not included as a covariate; for w₂, SBP at enrollment was not included as a covariate. A full list of covariates used for IPTWs and their definitions is provided in eAppendix Table 4. We assessed the balance of weights by calculating standardized differences before and after applying IPTWs. Absolute standardized differences below 0.1 after applying IPTWs were considered to indicate balanced covariates between the 2 groups.²³

General linear models (GLMs) were employed to analyze health care utilization, associated costs, and BP outcomes. The choice of family for the model was based on the modified Park test, and GLM link functions were selected based on the Pearson correlation test, Pregibon link test, and modified Hosmer-Lemeshow test.²⁴ Given that the study period included years greatly impacted by the COVID-19 pandemic, which heavily influenced health care utilization, we adopted a difference-in-differences design to estimate the incremental health care use and its costs that could be attributed to the HBPT program. We defined 12-month preenrollment and postenrollment periods (ie, the previously defined time horizon) and predicted health care utilization, costs, and BP outcome for the usual care and intervention groups.

Using nonparametric bootstrapping with 2000 replications, we derived 95% CIs for the estimates of incremental costs and outcomes and visualized bootstrapped costs and effects in the cost-effectiveness plane. We report ICERs calculated based on the point estimates of incremental costs and effects. We used these ICERs and the figures from the cost-effectiveness plane to assess the cost-effectiveness of the HBPT program. Sensitivity analyses were conducted among those with uncontrolled BP at the time of enrollment (SBP ≥ 140 or DBP ≥ 90 mm Hg). Statistical analyses were performed using Stata 18 (StataCorp LLC).

RESULTS

Study Population

We included a total of 3067 participants (mean age, 56.7 years; 62.7% female; and 62.1% non-Hispanic Black): 1214 participants in the usual care group and 1853 participants in the HBPT group (Table 1). The mean age was lower in the HBPT intervention group than in the usual care group (56.0 vs 57.8 years), and the intervention group had a higher percentage of commercial insurance (66.2% vs 59.9%) and a lower percentage of diabetes (21.9% vs 30.5%), cardiovascular disease (3.3% vs 4.3%), and heart failure (2.2% vs 2.6%). The numbers of hypertension medication classes (≥ 4 classes: 14.8% vs 12.9%) and in-person office encounters in the last year (mean, 8.5 vs 7.5) were higher in the intervention group than the usual care group. SBP at the time of enrollment was similar between the intervention and usual care groups (142.9 vs 142.5 mm Hg). On average, patients spent 4 months in the HBPT program.

HBPT Program Enrollment Costs

We assessed the HBPT enrollment costs. Costs for device and shipping were estimated to be $80.85 ($61.03 device cost and $19.82 shipping cost). Costs for treating patients were estimated to be $32.50 considering staffing time of 10 minutes to identify, contact, and schedule an appointment for both in-person and virtual enrollment options. The enrollment costs were estimated to be $113.35 per person.

Health Care Utilization and Costs

We assessed baseline characteristics before and after applying IPTWs (eAppendix Table 5). All characteristics were well balanced after applying IPTWs with absolute standardized differences less than 0.10. Baseline characteristics after applying IPTWs are shown in eAppendix Table 6.

The adjusted mean (SE) number of hypertension-related office visits per person decreased from 0.16 (0.01) to 0.13 (0.01) in the HBPT intervention group but increased in the usual care group from 0.12 (0.01) to 0.15 (0.01), resulting in an overall decrease of 0.05 (0.02) hypertension-related office visits (P = .016) (Table 2). Similarly, the adjusted mean (SE) number of BP clinic visits decreased from 0.27 (0.01) to 0.17 (0.01) in the intervention group and remained stable in the usual care group (0.25 before and 0.24 after), leading to an overall decrease of 0.10 (0.03) BP clinic visits (P = .002). The adjusted mean (SE) number of hypertension-related virtual encounters increased from 0.14 (0.01) to 0.53 (0.04) in the intervention group, with no changes observed in the usual care group (0.15 before and after), resulting in an overall increase of 0.39 (0.04) hypertension-related virtual encounters (P < .001).

Adjusted mean (SE) reductions in costs for the HBPT intervention group were $6.52 ($2.70) for hypertension-related office visits (P = .016) and $2.58 ($0.82) for BP clinic visits (P = .002) (Table 2). Adjusted mean (SE) costs for hypertension-related virtual encounters in the HBPT intervention group increased by $11.80 ($1.28) (P < .001). Total adjusted mean (SE) hypertension-related health care costs increased from $30.46 ($1.61) to $36.23 ($1.86) in the intervention group and from $26.00 ($1.74) to $29.06 ($2.02) in the usual care group, with an overall increase of $2.70 ($3.36) (P = .422).

BP Reduction

Adjusted mean SBP at enrollment was 142.80 mm Hg for both the usual care and HBPT intervention groups (Table 2). At 12 months post enrollment, mean (SE) SBP was 135.39 (0.51) mm Hg in the usual care group and 133.97 (0.38) mm Hg in the intervention group, resulting in an overall SBP reduction of 1.42 (0.79) mm Hg (P = .071). The overall adjusted DBP reduction was 1.58 (0.50) mm Hg (P = .001). The overall adjusted TIS was higher by 0.11 (0.03) in the intervention group compared with the usual care group (P < .001). Sensitivity analysis for those with uncontrolled BP at enrollment also showed small SBP and DBP reductions in the HBPT intervention group (mean [SE] SBP reduction: 1.64 [0.99] mm Hg [P = .099]; DBP reduction: 1.32 [0.64] mm Hg [P = .037]) (eAppendix Table 7).

Cost-Effectiveness of the HBPT Program

The HBPT program incurred higher costs than usual care, with incremental costs of $116.05 (95% CI, $109.54-$122.56) per patient (Table 3). Given the SBP and DBP reductions associated with the HBPT program, the ICERs of the HBPT program were $81.67 per mm Hg SBP reduction and $73.22 per mm Hg DBP reduction. The visualization of bootstrap analysis of incremental costs and effects shows that most data points fall in the upper right quadrant of the cost-effectiveness plane, indicating higher costs and positive effect (Figure). Sensitivity analysis for those with uncontrolled BP at enrollment showed slightly lower ICERs for SBP reduction ($70.99 per mm Hg SBP reduction) and slightly higher ICERs for DBP reduction ($87.99 per mm Hg DBP reduction) (eAppendix Table 8).

DISCUSSION

The current study evaluating the HBPT program in a real-world clinical setting within a US integrated health care system found that the program is more costly, primarily due to enrollment expenses. The costs associated with increased virtual encounters were small and offset by reductions in in-person hypertension-related office and BP clinic visits. The HBPT program also demonstrated targeted intensification of hypertension medications (ie, increase in TIS) and modest but positive effects on BP reduction, with a decrease in SBP of 1.42 mm Hg, for an ICER of $81.67 per mm Hg reduction in SBP.

Previous studies have reported the BP reduction and ICERs of self–BP monitoring or telemonitoring. However, directly comparing our results with those of previous studies is challenging due to variabilities in interventions, methodological approaches, time horizons, study perspectives, costs evaluated, and outcomes. For instance, US studies of randomized controlled trials of self–BP monitoring with team-based care reported more significant BP reductions (–9.7 mm Hg) at 12 months²⁵ but a higher ICER of $135 (in 2018 US$) per mm Hg reduction in SBP and $365 in DBP.²⁶ Another randomized controlled trial conducted in a US integrated health care system showed a 12.4–mm Hg reduction in SBP at 6 months,²⁷ with an ICER of $20.50 (in 2013 US$) per mm Hg reduction in SBP.²⁸

Compared with these previous studies, our findings from the implementation of a HBPT program in a real-world clinical setting showed smaller effectiveness in BP reduction. The KPSC HBPT program was originally targeted to recruit patients with uncontrolled BP, similar to previous randomized controlled trials, but ended up enrolling 36% of patients who did not meet the BP criteria and had SBP less than 140 mm Hg and DBP less than 90 mm Hg. Additionally, we used a comparator group of patients who started enrollment but disengaged from the program. Because the patients in the comparator group started enrollment, these patients may still be health-seeking and different from the typical usual care population,which could make the HBPT program’s effect appear smaller. Furthermore, patients who successfully managed their home BP were disenrolled from the program. On average, patients spent 4 months in the HBPT program, which may have contributed to the smaller effectiveness in BP reduction.

Our analysis focused on evaluating HBPT implementation costs, hypertension-related health care office visits, and virtual encounters, which can impact organizations directly in the short term. Our findings showed that the HBPT program increased virtual encounters due to enrollment and follow-up care. However, it also decreased in-person hypertension-related office visits and BP clinic visits, resulting in no significant increase in overall health care utilization costs. The primary contributors to HBPT program costs were BP device expenses and staffing costs associated with program enrollment, although staffing costs may have varied by site depending on implementation differences. Although this study did not account for broader health care utilization, such as emergency visits or hospitalization costs, our estimated ICERs can be considered conservative because we anticipate fewer emergency visits or hospitalizations associated with lower BP. Nonetheless, the ICER of $81.67 (in 2020 US$) per mm Hg reduction in SBP is comparable to those seen in other cost-effectiveness studies of educational interventions for lifestyle and/or medication adherence in hypertension, which reported a median cost of $62 (in 2014 US$) per mm Hg reduction in SBP.²⁹

Strengths and Limitations

This study has several strengths and limitations. We evaluated the real-world implementation of the HBPT program within a health care system, assessing direct costs and cost-effectiveness, which can benefit other health care organizations. However, the HBPT program was not implemented consistently across all medical centers and throughout the study period. A standardized care protocol might have yielded more positive effects on BP outcomes. Second, the analysis was limited to a 12-month time horizon, capturing only short-term effects. A longer time horizon would be necessary to observe reductions in cardiovascular events associated with BP reduction. Also, because a high number of patients abandoned the intervention, we compared 2 groups of patients: those who received the HBPT intervention vs those who abandoned the program. And with the expansion of the HBPT program during the COVID-19 pandemic, maintaining patient engagement through virtual encounters (vs in-person encounters) was challenging. Importantly, our analysis can be understood as an as-treated analysis instead of intention to treat because we quantified the effect of actually receiving the intervention.¹⁸ Lastly, although we balanced the observed demographic and clinical characteristics to address potential biases between these 2 groups, there may be unobserved confounders such as distrust in technology, which may have affected the study findings.

CONCLUSIONS

The HBPT program in a real-world clinical setting resulted in a modest increase in hypertension medication doses and reduction in BP. The costs associated with increased virtual encounters were small and offset by reductions of in-person hypertension-related visits, making the overall cost increase attributable to the HBPT program enrollment expenses. Future analyses should focus on the program’s effectiveness in health-related outcomes and its cost-effectiveness.

Acknowledgments

The authors acknowledge the HBPT program leads and participants.

Author Affiliations: Kaiser Permanente Southern California Department of Research & Evaluation (JA, ATN, TNH, RAJ, HZ, MTM, JMM, KR), Pasadena, CA; Department of Health Systems Science (JA, HZ, KR) and Department of Clinical Science (JWB), Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Kaiser Permanente Panorama City Medical Center (ALO-S), Panorama City, CA; Kaiser Permanente West Los Angeles Medical Center (JWB), Los Angeles, CA.

Source of Funding: This project was supported by a grant from the Care Improvement Research Team of Kaiser Permanente Southern California.

Prior Presentation: Preliminary findings were presented as a poster (EE249) at the ISPOR— The Professional Society for Health Economics and Outcomes Research 2024 Annual Conference (May 5-8), Atlanta, GA.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JA, ATN, MTM, ALO-S, KR); acquisition of data (RAJ, HZ, JMM); analysis and interpretation of data (JA, ATN, TNH, RAJ, HZ, MTM, ALO-S, JWB, KR); drafting of the manuscript (JA, ATN, JWB); critical revision of the manuscript for important intellectual content (ATN, TNH, RAJ, HZ, MTM, ALO-S, JWB, KR); statistical analysis (JA, ATN, RAJ, HZ); provision of patients or study materials (JMM); obtaining funding (JA, KR); administrative, technical, or logistic support (TNH, JMM); and supervision (ALO-S).

Address Correspondence to: Jaejin An, BPharm, PhD, Kaiser Permanente Southern California, 100 S Los Robles, 2nd Floor, Pasadena, CA 91101. Email: jaejin.x.an@kp.org.

REFERENCES

1. Sekkarie A, Fang J, Hayes D, Loustalot F. Prevalence of self-reported hypertension and antihypertensive medication use among adults - United States, 2017-2021. MMWR Morb Mortal Wkly Rep. 2024;73(9):191-198. doi:10.15585/mmwr.mm7309a1

2. Wang Y, Lee JS, Pollack LM, Kumar A, Honeycutt S, Luo F. Health care expenditures and use associated with hypertension among U.S. adults. Am J Prev Med. 2024;67(6):820-831. doi:10.1016/j.amepre.2024.07.005

3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e484-e594. doi:10.1161/CIR.0000000000000596

4. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75(6):1334-1357. doi:10.1161/HYPERTENSIONAHA.120.15026

5. McEvoy JW, McCarthy CP, Bruno RM, et al; ESC Scientific Document Group. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912-4018. doi:10.1093/eurheartj/ehae178

6. Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e595-e616. doi:10.1161/CIR.0000000000000601

7. Shimbo D, Artinian NT, Basile JN, et al; American Heart Association and the American Medical Association. Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association. Circulation. 2020;142(4):e42-e63. doi:10.1161/CIR.0000000000000803

8. McManus RJ, Mant J, Franssen M, et al; TASMINH4 Investigators. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391(10124):949-959. doi:10.1016/S0140-6736(18)30309-X

9. Tucker KL, Sheppard JP, Stevens R, et al. Self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. PLoS Med. 2017;14(9):e1002389. doi:10.1371/journal.pmed.1002389

10. Magid DJ, Ho PM, Olson KL, et al. A multimodal blood pressure control intervention in 3 healthcare systems. Am J Manag Care. 2011;17(4):e96-e103.

11. Artinian NT, Flack JM, Nordstrom CK, et al. Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nurs Res. 2007;56(5):312-322. doi:10.1097/01.NNR.0000289501.45284.6e

12. Gondi S, Ellis S, Gupta M, et al. Physician perceived barriers and facilitators for self-measured blood pressure monitoring - a qualitative study. PLoS One. 2021;16(8):e0255578. doi:10.1371/journal.pone.0255578

13. Jackson SL, Ayala C, Tong X, Wall HK. Clinical implementation of self-measured blood pressure monitoring, 2015-2016. Am J Prev Med. 2019;56(1):e13-e21. doi:10.1016/j.amepre.2018.06.017

14. Parmar S, Commodore-Mensah Y, Singh G, et al. Patient practices, perceptions, and barriers to self-measurement of blood pressure in a rural health system. Am J Hypertens. 2024;37(11):876-883. doi:10.1093/ajh/hpae085

15. Wall HK, Wright JS, Jackson SL, et al. How do we jump-start self-measured blood pressure monitoring in the United States? addressing barriers beyond the published literature. Am J Hypertens. 2022;35(3):244-255. doi:10.1093/ajh/hpab170

16. Kronish IM, Kent S, Moise N, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens. 2017;11(9):573-580. doi:10.1016/j.jash.2017.06.012

17. Hayek MA, Giannouchos T, Lawley M, Kum HC. Economic evaluation of blood pressure monitoring techniques in patients with hypertension: a systematic review. JAMA Netw Open. 2023;6(11):e2344372. doi:10.1001/jamanetworkopen.2023.44372

18. Smith VA, Coffman CJ, Hudgens MG. Interpreting the results of intention-to-treat, per-protocol, and as-treated analyses of clinical trials. JAMA. 2021;326(5):433-434. doi:10.1001/jama.2021.2825

19. Levy PD, Willock RJ, Burla M, et al. Total antihypertensive therapeutic intensity score and its relationship to blood pressure reduction. J Am Soc Hypertens. 2016;10(12):906-916. doi:10.1016/j.jash.2016.10.005

20. Occupational employment and wages statistics: occupational employment and wages, May 2020: 31-9092 medical assistants. US Bureau of Labor Statistics. Updated March 31, 2021. Accessed July 7, 2025. https://www.bls.gov/oes/2020/may/oes319092.htm

21. Physician Fee Schedule - January 2020 release. CMS. Updated January 31, 2020. Accessed January 17, 2025. https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-relative-value-files/rvu20a

22. Chen W, Petitti DB, Enger S. Limitations and potential uses of census-based data on ethnicity in a diverse community. Ann Epidemiol. 2004;14(5):339-345. doi:10.1016/j.annepidem.2003.07.002

23. Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med. 2015;34(28):3661-3679. doi:10.1002/sim.6607

24. Glick HA, Doshi JA, Sonnad SS; Polsky D, ed. Economic Evaluation in Clinical Trials. 2nd ed. Oxford University Press; 2014.

25. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310(1):46-56. doi:10.1001/jama.2013.6549

26. Dehmer SP, Maciosek MV, Trower NK, et al. Economic evaluation of the Home Blood Pressure Telemonitoring and Pharmacist Case Management to Control Hypertension (Hyperlink) trial. J Am Coll Clin Pharm. 2018;1(1):21-30. doi:10.1002/jac5.1001

27. Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA. A pharmacist-led, American Heart Association Heart360 web-enabled home blood pressure monitoring program. Circ Cardiovasc Qual Outcomes. 2013;6(2):157-163. doi:10.1161/CIRCOUTCOMES.112.968172

28. Billups SJ, Moore LR, Olson KL, Magid DJ. Cost-effectiveness evaluation of a home blood pressure monitoring program. Am J Manag Care. 2014;20(9):e380-e387.

29. Zhang D, Wang G, Joo H. A systematic review of economic evidence on community hypertension interventions. Am J Prev Med. 2017;53(6S2):S121-S130. doi:10.1016/j.amepre.2017.05.008