Implementing Ambulatory Blood Pressure Monitoring in Primary Care Practice
In-office blood pressure readings are often inaccurate or insufficient. Here's a way to get a better picture of how your patients are doing and get paid for it.
Fam Pract Manag. 2020 May-June;27(3):19-25.
Author disclosures: no relevant financial affiliations disclosed.
While patients can check their blood pressure (BP) at home or at the drug store, primary care clinicians still rely mostly on in-office BP readings for hypertension management. But office readings are often inaccurate for a variety of reasons, including white coat hypertension, time constraints, and problems with measuring devices or technique. Increasing evidence supports another approach: 24-hour ambulatory BP monitoring (ABPM).1
The United States Preventive Services Task Force (USPSTF) updated its guidelines in 2015 to recommend that primary care clinicians use ABPM to rule out white coat hypertension before prescribing medications for patients with newly elevated office BP readings, unless the need for such therapy is obvious.2 Last year the Centers for Medicare & Medicaid Services (CMS) announced it was expanding reimbursement for ABPM to include assessment of suspected masked hypertension, which is the opposite of white coat hypertension (elevated out-of-office BP with non-elevated office BP). This new reimbursement policy has caused a surge of interest in ABPM from primary care practices. In this article, we review the clinical indications for ABPM and the procedures involved in it. We then provide a step-by-step guide for incorporating ABPM into a primary care practice in a financially sustainable manner.
Ambulatory blood pressure monitoring (ABPM) is an evaluation method in which patients are fitted for an arm cuff connected to a device that checks their blood pressure (BP) regularly for 24 hours at home.
ABPM is more accurate than in-office BP readings, because it excludes white coat hypertension and masked hypertension.
ABPM also allows for evalution of patients' blood pressure while they are awake versus asleep, which can be valuable for risk assessment.
Start-up costs are a barrier to adding ABPM to primary care practices, but clinicians with a significant number of commercially insured patients can recoup those costs relatively quickly.
WHAT IS ABPM?
ABPM is an assessment method in which BP measurements are taken at regular intervals when patients are awake and asleep, during a typical 24-hour period.3 Patients wear a small monitor connected by tubing to a BP cuff on their arm. The monitor triggers the cuff to inflate and take a reading, typically every 20 to 30 minutes. Then it stores BP and heart rate data.
ABPM devices typically give an alert about 30 seconds before the cuff inflates, allowing patients to sit or stand still with their arm straight during the BP readings. Patients are otherwise advised to go about their usual activities and remove the device only for bathing or vigorous exercise. There is no need for a rest period or special positioning during ABPM. After the 24-hour
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