Pharmacists and patients partner for better home BP monitoring

Takes team effort to get most out of home blood pressure readings

The American Heart Association recommends home blood pressure monitoring for all patients with hypertension, and with good reason: studies show that home blood pressure monitoring can improve outcomes and medication adherence. Yet overall, more than one-half of Americans with hypertension do not meet treatment goals, suggesting a need for more education.

Enter pharmacists, who have demonstrated in studies such as the Hypertension Adherence Program in Pharmacy and Collaboration Among Pharmacists Physicians To Improve Outcomes Now trials that their intervention in blood pressure management and collaboration with physicians can help hypertensive patients lower their blood pressure.

“The theme that has emerged in the hypertension literature is that when you engage the patient and the provider, and you encourage them to act quickly and decisively to treat uncontrolled [hypertension], you start to really move the needle,” said Steven M. Smith, PharmD, MPH, BCPS, assistant professor of pharmacy and family at the University of Florida in Gainesville.

“Pharmacists often achieve better results than usual care, in part because they are able to engage patients more frequently than primary care physicians,” Smith added.

By virtue of their regular interaction with patients, community pharmacists can provide crucial information and assistance, but they need to get the word out about what they can do, said Tyler Harris Gums, PharmD, MS, ASH-CHC, assistant professor in the Division of Health Outcomes and Pharmacy Practice at University of Texas at Austin.

“A lot of patients view the community pharmacist as only a druggist. While pharmacists are drug experts, they are also wonderful references for other ambulatory practices. The community pharmacist can be the clinical advisor not only for how to take blood pressure, but how to record and interpret these measurements over time,” Gums said.

But pharmacists have to want that level of involvement, Gums added. “Their time can easily disappear in daily routine dispensing tasks, so this has to be important. The pharmacist has to want to provide help and go after [opportunities to provide] it.”

Gums suggested targeting patients who may need help. “Set up pharmacist counseling alerts in your pharmacy dispensing system for new blood pressure medications so that patients are counseled on home blood pressure readings, or, if they already have a monitor, make sure they understand how to use it.”

A study published in the July 2017 American Journal of Hypertension made medical news headlines when researchers reported that many home blood pressure monitors in their study were off by 5 mmHg roughly 70% of the time and off by 10 mmHg about 30% of the time. The researchers cited variables such as the size and shape of the patients’ arms, as well as patient age and the condition of the patient’s arteries as possible reasons. In 2016, a study published in PLoS One revealed that 30% and 32% of home monitors rendered measurements that were off by 5 mmHg or more for systolic and diastolic blood pressure, respectively. 

Pharmacists would do well to advise patients to stick with validated monitors, said Smith.

“I suggest going by the Dabl Educational Trust list. Their website can help eliminate the monitors that are known not to be validated,” Smith said.

Gums encourages patients to work with their physicians. “I tell patients to take their cuffs to their doctor’s office and measure it against the office cuff. You have to measure with the same ruler.”

How the cuff fits is crucial, said Kelly L. Scolaro, PharmD, associate professor of pharmacy practice at LECOM School of Pharmacy in Bradenton, FL. “Getting the wrong cuff size is one of the top mistakes people make. Pharmacists can help with fitting the cuff by measuring the patient’s arm.”

Beyond the basic necessity of accuracy and fit, the best features for each patient will largely be a matter of preference, said Scolaro.

“Depending on the patient’s comfort level and tech savviness, some might just want one with just a memory function. My grandmother wanted one with big numbers and big buttons and wrote her readings in a little book, but a Millennial might want an app and a way to record their readings on their phone,” Scolaro said.

It’s all well and good if patients buy and use a home blood pressure monitor, but their purchase will be in vain if no one acts on the data.

Smith tries to help his patients keep their readings in perspective.

“Usually I tell them not to worry much about an individual high reading here and there, but if, over an entire week, it’s consistently over 135/85 mmHg, they should see their physician,” Smith said. “Encourage patients to err on the side of caution and at least talk to a nurse.”

Scolaro said that it takes a team effort that includes collaboration with physicians to get the most advantageous use out of home blood pressure readings.

“Physicians and other prescribers can be deluged with data. We as pharmacists need to position ourselves to help them deal with it,” Scolaro said. “If patients come to see us every month, we can look at the data and make recommendations.”

Smith agrees. “When you talk to physicians, you can tell them you have the patient set up on home monitoring, and they have been monitoring for X amount of time and are consistently demonstrating elevated blood pressure. Then you can ask if there is an opportunity to titrate the drug up or adjust therapy.”

Gums pointed to the potential for success when there is a strong partnership between the pharmacist and the patient. “If we know a pharmacist can have an impact and help patients lower their blood pressure, and we know self-monitoring can help lower blood pressure, what if we combine the two? It could be an even more powerful intervention.”

For the full article, please visit www.pharmacytoday.org for the May 2018 issue of Pharmacy Today.