by Mike Miesen –
Use of an at-home telemonitoring blood pressure device significantly reduced out-of-control high blood pressure, according to a recent study in the Journal of the American Medical Association. It’s another data point showing the potential of telemedicine to have a profound effect on American medicine, by positively modifying health behaviors, providing real-time data to clinicians through “automated hovering,” and helping Americans get and stay healthy – all of which holds the promise of bending the cost curve.
Led by Karen Margolis, MD, MPH, a Senior Investigator at Health Partners Institute for Education and Research, the cluster-randomized study investigated whether using a cloud-connected, at-home blood pressure monitor paired with pharmacist and case manager support would lead to controlled blood pressure more than typical care, which involved check-ups with a physician.
Those using the telemonitoring device were 90% more likely to have controlled blood pressure at both the six and twelve-month checkups than the control group (57.2% and 30%, respectively), and had, on average, statistically significant lower systolic and diastolic readings.
Crucially, the effect persisted after the 12-month intervention. At 18 months – six months after the devices were taken back – those in the telemonitoring group were just as likely to have controlled blood pressure as at 12 months, and were 139% more likely to be in-control for the six, twelve, and eighteen-month checkups than the control group. The learned techniques and behavior changes brought about during the interventions were sticky.
The results are encouraging for the 67 million Americans with hypertension – one-third of all American adults. The disease is associated with 348,000 deaths each year, and a majority with it have trouble maintaining healthy blood pressure levels. It’s a disease of age – the older you get, the more likely you are to have it – so as the Boomers enter Medicare in droves, American taxpayers will increasingly foot the $47.5 billion (and growing) bill for direct medical expenses related to hypertension.
The intervention wasn’t cheap: spend was about $1,350 per participant. But, as a whole, it could be cost-neutral or cost-negative, if it led to fewer emergency department visits and inpatient stays. The study didn’t look at these savings, nor did it identify the cost implications of substituting physician labor with pharmacist labor, a limitation of the study. In an email interview, Dr. Margolis indicated that a more formal cost analysis will be released in the future.
Another limitation of the study is that the population was “generally well-educated with high income levels,” making it unclear if the results can be generalized to the entire American population. Future studies will likely need to enroll a broader cross-section of hypertensive adults.
Understanding why the intervention worked is critical. Dr. Margolis said that she believed “…the combination of frequent self-monitoring and pharmacist action based on the measurements creates a really powerful feedback loop. Both the patients and the pharmacists were getting positive reinforcement with this system.” As patients learn more about their condition and how to manage it, they become partners in care with providers.
Fortunately, interventions like this increasingly make financial sense for hospitals and primary care providers. Provisions in the Affordable Care Act have Medicare experimenting with bundled payments for hypertension, so clinicians will have the flexibility to treat patients optimally, rather than being forced to conform to ossified fee-for-service schemes that reward quantity over quality. Accountable Care Organizations, also a part of the Affordable Care Act, incent keeping patients healthy and, when they do get sick, treatment with effective, low-cost interventions.
Telemedicine allows what Professor Kevin Volpp refers to as “automated hovering:” clinicians can automatically monitor their patients’ conditions during “the other 5,000 hours” when a patient isn’t at the clinic, stepping in when the data shows a need. “I think this method of caring for chronic conditions is going to become much more common as the technology improves and goes down in cost,” Dr. Margolis said.
One concern with automated hovering is that, rather than having too little information about a patient, the clinician could have too much – like drinking water from a fire hose. Dr. Margolis said that providers have “concerns about being responsible for monitoring a massive influx of data from patients.”
But this is ultimately a design problem, not an inherent fatal flaw; data can be whittled down and summarized in a way that clinicians and patients find most useful. As Dr. Margolis put it, “we will have to really be careful to design smart systems to make it easy to interpret the data and to handle values that require urgent attention.”
There’s another reason to be optimistic about telemonitoring and automated hovering: this intervention is basically the simplest iteration of it, with one-way data transmitted to a clinician. It’s possible that an app like Withings’s Blood Pressure Monitor could improve adherence even further by quizzing the patient, offering algorithm-based suggestions, and providing a conduit for secure messaging between patient and clinician.
This space is nascent but growing, fueled by technological innovation, payment system reforms, and studies that show its efficacy. Used as one tool in America’s quest to get healthy and stay healthy, telemedicine may be a crucial component in helping bend the cost curve.