HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 1Matchmaking and the Future of Hypertension Management Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessArticle CommentaryPDF/EPUBMatchmaking and the Future of Hypertension Management Andrew R. Murphy, MD Brian P. Suffoletto, MD, MSc Matthew F. MuldoonMD, MPH Andrew R. MurphyAndrew R. Murphy Department of Medicine (A.R.M.), University of Pittsburgh School of Medicine, PA. Search for more papers by this author , Brian P. SuffolettoBrian P. Suffoletto Department of Emergency Medicine, Stanford University School of Medicine, CA (B.P.S.). Search for more papers by this author , Matthew F. MuldoonMatthew F. Muldoon Matthew F. Muldoon, MD, HVI Hypertension Center, UPMC, 506 Old Engineering Hall, University of Pittsburgh, Pittsburgh, PA 15260. Email E-mail Address: [email protected] https://orcid.org/0000-0002-2111-6331 Division of Cardiology, Department of Medicine (M.F.M.), University of Pittsburgh School of Medicine, PA. Heart and Vascular Institute, UPMC Health Care System, Pittsburgh, PA (M.F.M.). Search for more papers by this author Originally published11 Dec 2020https://doi.org/10.1161/CIRCOUTCOMES.120.007062Circulation: Cardiovascular Quality and Outcomes. 2021;14:e007062Hypertension is a leading cause of morbidity worldwide. It affects ≈100 million US adults, most of whom have uncontrolled hypertension.1 This propels our high incidence of heart failure, stroke, renal failure, and dementia. Persistently uncontrolled hypertension, even when recognized and diagnosed, is thought to have 2 primary causes: lack of treatment intensification by providers, labeled therapeutic inertia, and poor self-management by patients (including nonadherence to antihypertensive medications and other health behaviors). Most blood pressure (BP) monitoring takes place at the medical center or office. For providers, these office-based BP readings often are not actionable given concerns related to uncertainty about their patient’s true BP.2 For patients, office-based BP readings do not provide timely feedback to assist motivation for sustained engagement in medication-taking, dietary restrictions, and daily exercise. In contrast, home BP monitoring (HBPM) can be invaluable to providers while providing key feedback for patients.3 However, it is not routinely prescribed by providers and is conducted in a haphazard fashion by patients. Here, we reflect upon developments in HBPM and their potential utility to redress poor hypertension control and, hopefully, the associated morbidity and mortality.Traditional Telemonitoring of Patients With HypertensionSince the 1990s, BP has been among the key physiological variables transmitted through telemonitoring platforms to providers (eg, home telehealth). The service requires placement of a communication device in the patient’s home that receives readings from one or several monitors, such as an automated BP device, and routes this information to a home health nurse case-manager. The overall design and function of this provider-centric program has not significantly evolved despite incorporating newer communication technologies. It still generally requires technical staff to install the equipment, establish connectivity, and field technical questions. Home health nurses review BP data, monitoring for adherence and extreme values, then communicate directly with patients. At set intervals, the patient’s BP reports can be sent to their physician, advanced practice provider, or nurse, at whose discretion action can be taken (Figure; left). Despite seeing an individual reading on the cuff at the time of measurement, the patient is not informed of averages or trends, nor encouraged to take meaning from the data to guide or reinforce health behaviors. Patients lacking an understanding of their disease, its consequences, and its treatments, may not attend provider visits, fill and take prescriptions daily, engage in self-monitoring, or practice behavioral interventions to lower BP. Providers also may be unaware of the larger trends of a patient’s BP, given the opt-in nature of the reports for many traditional home BP programs. Thus, telemonitoring for hypertension fails to aid patients in their disease self-management.Download figureDownload PowerPointFigure. Symmetrical and complementary: telemonitoring and self-management support. Flow through the system begins at the base of the figure with the patient performing blood pressure (BP) self-monitoring at home. The left side of the diagram represents the traditional model, in which BP data pass through a central server before review by a clinical care team. The later may be an interprofessional collaboration of nurses, pharmacists, advanced practice providers, or physicians. The arrows between the patient and care team represent the nonautomated bidirectional communications that may include reports of symptoms or medication side effects, changes to pharmacotherapy, and discussion of extreme readings. The right side of the diagram represents the evolving field of self-management support. It also originates with home BP monitoring routed to a central processing server but incorporates a combination of automated and personalized features. These may include educational modules, customized advice, structured medication and BP measurement reminders and organized reports of BP averages, changes, or time trends. The devices used and the mode of information transmission between devices vary significantly across programs but may include wired ethernet, Bluetooth, Wi-Fi, and cellular data, transmitted via cell phone or smart phone, smart BP cuff, personal computer, tablet, or smart home assistant (eg, Alexa and Google Home).Pivoting to Patient-Facing ProgramsA growing number of innovative approaches combine patient-generated HBPM data with self-management support. This is necessary because, despite the availability of BP cuffs, patients do not consistently receive guidance on conducting HBPM, do not record readings or create unstructured and unverifiable logs.2 Physicians may then be less likely to make medication changes because of concerns about accuracy.2 However, randomized clinical trials of programs that facilitate structured HBPM find promising improvements in BP, particularly when they include one or more of many potential aides or services.4 These services typically employ pharmacists to change drug therapy or case managers to closely follow up on HBPM adherence and deliver patient education and health behavior guidance.Compared with these personnel-intensive strategies, contemporary self-management support programs utilize automated communication technologies to efficiently assist patients with self-monitoring and hypertension self-management (Figure; right). To improve awareness and understanding, these programs automatically send the patient reports with color-coded graphs or the average of recent readings.5–7 Immediate feedback for especially high or low BP measurements can enhance understanding of individual values through instructions to repeat a measurement or recommendations to seek medical care depending upon associated symptoms.5,8 Patients may forget (or lose motivation) to measure their BP or take medications. Proactive reminders can be tailored to the individual’s preferred schedule to take measurements or medication, improving habit formation.5,6,8 Personalization can even allow periodic vacations from BP monitoring.5 Patients may nominate a family member or friend to also receive reminders and periodic BP reports for greater social support and accountability.7,8 Knowledge gaps or poor measurement technique may derail self-management, and these programs make educational materials available that cover BP measurement technique, risks of chronic under-treated hypertension, and descriptions of behavioral and medication-based treatments.5,8These patient-facing programs are often built upon behavioral and economic principles to optimize patient and provider engagement. Following the health belief model, a patient must think they are susceptible to negative consequences from uncontrolled hypertension, that measuring their BP routinely offers some benefits, and that they have confidence in measuring their BP.9 Furthermore, hypertension is generally asymptomatic and routinizing HBPM with automated cues engenders self-awareness of the links between BP, health, and health behaviors.5,10 Behavioral economists label as automated hovering the successive, proactive, and often personalized messages to facilitate or nudge a desired behavior change.11 Digital tools to assist collaborative goal processes between patient and providers could be helpful, as this seems to be important in hypertension control.12 For clinical teams to have buy-in and make adoption possible, the user interface must make access to HBPM data easy and synthesized for both rapid clinical interpretation and pay-for-performance evaluations.3,13 Ultimately, conceptually driven programs designed with close attention to both patient and provider experience will help drive clinical implementation.A program which originated in the United Kingdom now serves as the pace-setter with respect to implementation.14 Named Florence, this program was designed by providers and computer engineers to leverage the general availability of home BP monitors, the readiness of patients to be more active in their care, and the ubiquity and ease of text messaging. Patients receive daily text reminders to perform a measurement and respond with a BP reading. Based upon an agreed-upon action plan, patients receive automated responses tailored to the BP value submitted. Providers have access to a dashboard to review and adjust therapy via text, phone, or an office visit. Since 2013, broadening implementation has allowed Florence to be deployed for >50 000 individual patients across hundreds of practices in the United Kingdom, with related programs being implemented in Australia (Philip O’Connell, email communication, August 12, 2020).A Marriage ProposalGiven the tremendous challenge of uncontrolled hypertension in the United States, we propose that the time is right to merge traditional home telemonitoring with automated and technology-leveraged self-management support systems. Structured HBPM programs such as Florence are well-received by patients and providers. The advantages of self-management support programs can be looked at from the perspective of each of the main stakeholder groups. The patient receives resources and support with high personal convenience. Moreover, patients are continually engaged in BP self-monitoring, promoting self-efficacy and meaningful lifestyle change. Providers receive robust BP data that can identify white-coat and masked hypertension and reduce uncertainty and clinical inertia about appropriate medication intensification. Finally, these programs increase patient-to-provider interaction outside of face-to-face visits, enhancing both parties’ sense of co-commitment to health.Notable barriers to clinical implementation exist. Providers and their staff will not embrace these programs without user-centered design and an engaging, intuitive interface. Integration of these programs into daily practice must streamline workflow rather than further encumber providers, while also avoiding the perception of unlimited provider access for patients. Such programs must be conceived for, and tested in, heterogeneous patient populations that include those unfamiliar with personal technology. Issues of privacy and security need to be addressed, and interoperability established with major electronic health records systems. Translational research must identify the best ingredients, such as optimal feedback and reporting for patient and providers, followed by pragmatic clinical trials to determine uptake and longitudinal adherence. Remotely reported high and low BP readings instill some anxiety in patients, providers, and lawyers. Handling of such readings should capture associated symptoms (eg, presyncope, chest pain, or unusual headache) for proper risk-stratification. If providers oversee such a program, their reimbursement and pay-for-performance models should consider HBPM data.3 Alternatively, the future business model may be quite different, with reimbursement from insurance companies or patients themselves going to technology-leveraged, chronic care management companies. Without doubt, these challenges will require the concerted effort of health system leaders, medical informatics innovators, payers, and regulatory agencies.We are at a critical juncture in our nation’s clinical management of hypertension given its high prevalence, resistance to control, and resultant morbidity and mortality. Reduced reliance on brick-and-mortar, face-to-face health care is a current necessity. Solutions for hypertension must employ HBPM for patient safety, convenience, and empowerment. Both providers and patients play crucial roles and, rather than blame either party for uncontrolled hypertension, we should strive to understand the challenges each faces and create systems-level solutions that enables both to raise their game. The marriage of traditional telemonitoring with self-management support will require collaborative and sustained effort to address the noted barriers while delivering scalability and efficiency. The benefits of such a marriage are ready to be reaped and the United States would be wise to invest in such a future.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Matthew F. Muldoon, MD, HVI Hypertension Center, UPMC, 506 Old Engineering Hall, University of Pittsburgh, Pittsburgh, PA 15260. Email [email protected]edu