Management of Cardiovascular Risk Factors Is Leaving the Office: Potential Impact of Telemedicine

Authors


  • Presented in part at the American Society of Hypertension 26th Annual Scientific Meeting, May 22, 2011. Symposium entitled: “Control of Hypertension Is Leaving the Office: The Role of Home Blood Pressure and Telemedicine.”

Lawrence R. Krakoff, MD, Professor of Medicine, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574
E-mail:lawrence.krakoff@mssm.edu

Abstract

J Clin Hypertens (Greenwich). 2011;13:791–794. ©2011 Wiley Periodicals, Inc.

Effective control of hypertension and the other cardiovascular risk factors has been dependent on primary medical care as provided by family practitioners and internists. The progressive reduction in availability of primary care for adult populations in the United States threatens the likelihood of better control of the risk factors and potential loss of opportunity for prevention of cardiovascular disease. Recent progress has been made in the use of home blood pressure monitoring for improvement in classification of risk for hypertensive patients. Several studies establish the feasibility of home pressure monitoring combined with telemedicine for improving control of hypertension. Some studies have explored the role of self-care for adjustment of medication, as well. The potential growth of this strategy for effective control of hypertension with reduced need for face-to-face encounter time in primary care is a promising solution to the reduction in primary care providers. Management of hyperlipidemia and diabetes by telemedicine is also being explored, particularly for rural areas, but may also be effective in urban settings. Development of technology for home monitoring together with electronic communication to providers and mechanisms for education, feedback, and warnings offers a promising solution to the possible crisis in prevention of cardiovascular disease due to the loss of traditional primary care.

Prevention and control of hypertension in adult populations is a crucial factor for reducing the incidence of fatal and nonfatal cardiovascular disease throughout the world. For developed nations, managing the burden of hypertension has been dependent on primary care providers and those in family practice or internal medicine. Only the more complicated patients or those with target organ pathology or identifiable hypertension are usually cared for by specialists in cardiovascular disease, nephrology, or endocrinology. The decreasing availability of primary care physicians for management of hypertension and other highly prevalent risk factors, such as type 2 diabetes mellitus and hyperlipidemia, is rapidly emerging and is a significant problem.1,2

Home Blood Pressure for Hypertension

In response to the increasing need for better control of hypertension, nurse clinicians, pharmacists, and other non-MD health care professionals are becoming more important in sharing the burden.3 Nonetheless, visits to providers for treatment of hypertension will invariably be limited by the time available for clinical encounters. Clinic visits are often inconvenient and even costly for patients, especially for those who work or have other daily responsibilities. Working patients find it difficult to take time off for visits. The time for travel to clinics or offices and cost of travel (reflected in rising gasoline prices) are also barriers to care.4

Clinic visits for healthy patients take time for the provider. For a given patient, more contact time means fewer hours available for those with urgent or emergent conditions. A provider who sees patients 37.5 hours per week for 46 weeks (due to vacations, time for education, and sick days) has 1725 hours per year for direct patient contact. More time is needed for record keeping and communications. Figure 1 displays the number of patients that this provider can manage in relation to the number of hours per patient for direct face-to-face contact. Clearly, an efficient system is needed if providers or provider teams are to manage larger numbers of patients effectively.

Figure 1.

 Relation between number of patients who can be seen for various visit-times per year.

Most nonretired hypertensive patients are healthy and fully functioning in work and family life. The growing use of home blood pressure monitoring (HBPM) offers one pathway for expanded diagnosis and treatment of hypertension and potentially reduced demand for clinic visits. It is estimated that more than 50% of the households of hypertensive patients in the United States now have a home blood pressure device.5 There is an extensive literature for HBPM that provides necessary evidence for its importance. In prospective surveys, home blood pressures are better correlated with long-term cardiovascular outcomes when compared with clinic pressures.6,7 HBPM is effective in reclassifying patients with office pressures in the hypertensive or the prehypertensive range into white coat hypertension or masked hypertension.8,9 Overviews or meta-analyses report that HBPM lowers on-treatment systolic and diastolic blood pressure by small but significant decrements when compared with usual management of hypertension.10,11 HBPM seems to be most successful when combined with enhanced education and feedback provided by nurse clinicians12 or pharmacists3 who provide support through phone calls, e-mails or Web-based communications. One of the earliest assessments of the cost-effectiveness for HBPM in the pre-internet era reported that this strategy resulted in fewer clinic visits but more phone calls.13 This trend is supported by a more recent study from Denmark in which HBPM reduced consultations but increased nonvisit communications.14

One of the problems that limited HBPM in the past was the lack of uniform, accurate, and reliable communication of results to the provider. The first devices available for HBPM had no recording capability. Patients kept their own records. Recording of measurements by patients was unreliable due to either failure to take pressures on schedule or selection bias of favorable pressures.15,16 Development of devices for HBPM that record and store measurements has overcome the problem of selection bias. However, this method requires extra steps. Some devices can print lists of measurements for review by the provider. Others can transmit results to a personal computer at home and be sent to the provider by telephonic or Web-based transmission. Alternatively, the devices can be brought to the clinic for downloading and storage.8 Both of these methods have been used in clinical research studies.

The requirement of extra steps to transmit HBPM measurements to providers for review, evaluation, and feedback in the management of hypertension may be a barrier to greater acceptance of HBPM by patients. Direct transmission of HBPM measurements to providers as a simplified process has now been achieved either by telephone lines17,18 or by mobile phone-Web–linked transmission.19,20 Data transmission is in real-time within seconds after the pressure is taken. Results of pressure measurements can be reviewed by providers in various ways with various strategies for feedback. Warning or “danger” thresholds can be set so that lower or satisfactory pressures need not be reviewed more than necessary. Signals to the patient provide the feedback that pressure is satisfactory or needs medical intervention. Figure 2 displays the features of an HBPM system combined with telemetry using a wireless, mobile “smart” phone to link home measurements to a provider in a very simple model. The rapid growth and acceptance of the Internet and wireless Web-based communication supports the rationale for this strategy in eventual widespread use. Such systems have potential for linkage to the electronic health records now required for patient care in developed nations. This will make documentation in the patient’s medical record easier, but will also allow more effective review to optimize care with a single source database. Web-based health databases for use by patients as consumers are growing rapidly. Patients must enter their own information and results, and these repositories are not yet linked to electronic health records of providers.5 However, users of these health datasites can allow their provider to share access and get a glimpse of the patient’s own perceptions of their status.

Figure 2.

 Scheme for home blood pressure monitoring with telemetry for interaction between patients and providers, using a smart cell phone–based strategy.

Self-Management for Hypertension

Self-management of antihypertensive medications using results of HBPM has been explored and adds another component to improved control of hypertension. The first report of this approach described how patients were instructed in an algorithm for changing medication and used HBPM diaries for reporting.21 Twenty participants were managed by self-titration with HBPM and 11 with usual care. During 8 weeks, a small reduction in systolic pressure (approximately1 mm Hg) occurred in the intervention group and a small (approximately 2 mm Hg) increase occurred in the control group (P<.04). No other significant differences were found. The Telemonitoring and self-management in the control of hypertension (TASMINH2) trial compared HBPM telemetry combined with self-management (263 participants) and usual care (264 participants) from general practices in the United Kingdom.22 Using objective office pressures at baseline and 12 months, the intervention group had a greater reduction in both systolic pressure (−5.4 mm Hg, P<.004) and diastolic pressure (−2.7 mm Hg, P<.001) than the usual care group. Self-management has been widely accepted for management of diabetes. This concept is now given evidence-based support for management of hypertension.

HBPM with transmission of results to providers together with opportunities for self-management offers the vista of a major potential for increased control of hypertension for patients healthy enough so that frequent office/clinic visits are not needed. There will be hurdles to this growth, but acceptance of HBPM by both patients and providers is promising. In the TASMINH2 trial, 71% of patients using HBPM together with self-titration preferred this management compared with 41% who preferred usual care.22 Providers in some care systems find HBPM to be highly acceptable for management.23 Reimbursement for providers is a crucial issue as episode-based income for office visits or consultations will be replaced by some form of subscription enrollment.

Not all patients with hypertension may choose to participate in a program of HBPM even with supplemental education and feedback. In the recruitment for a large trial of HBPM with support by pharmacists, older groups, or patients with lower socioeconomic status or less-advanced education were less likely to participate in a Web-based intervention to improve hypertension control. In part, the reluctance or inability of these groups to participate was due to lack of access to a computer.24 There are alternatives to either clinic visits or HBPM, especially for those employed in large businesses or who have ready access to public sites, such as shopping centers or malls. Local satellite laboratories might add blood pressure measurement with transmission to the provider to their menus, perhaps at the same time as blood samples are obtained. This would add to convenience in managing lipids and diabetes. Perhaps blood pressure and weight could be added to the laboratory report? Secure health care kiosks might be placed at appropriate locations for capturing additional information for providers to review.25,26 At the present time, HBPM is the most advanced of these resources for “remote” care of hypertension.

Telemedicine for Metabolic Risk Factors

Reducing risk of cardiovascular disease includes effective control of dyslipidemia and diabetes mellitus. These metabolic risk factors are assessed by blood tests, often performed at local laboratories that send results to the provider. The provider reviews the findings and can provide feedback or make needed changes in medication by telephone or e-mail. Prescriptions can be sent via e-prescribing. Interval visits to a clinic or office can be minimized and based on urgent issues or appropriate periodic assessments. Implementation of telemedicine for management of the metabolic risk factors has been explored for rural populations who often live and work far from provider’s offices or clinics.27 Urban and suburban dwellers might also find that the time and costs saved for using telemedicine to manage metabolic risk factors will be appealing. More research and practical experience is needed to address this strategy.

Summary

The landscape of medical management for the three major cardiovascular risk factors: hypertension, type 2 diabetes mellitus,28,29 and lipid disorders either in primary or secondary prevention,30,31 is changing due to implementation of highly useful, inexpensive, and reliable technology. It is readily evident that more efficient and effective preventive care is crucial and that self-care and personal control and knowledge are gaining ground. We should be optimistic that insightful and wise use of technology can overcome the growing deficit in numbers of primary care providers, particularly in the United States, to preserve the health of those at risk for cardiovascular disease in decades to come.

Ancillary