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.

KEY POINTS

  • 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

ABOUT THE AUTHOR

Dr. Kronish is associate director of the Center for Behavioral Cardiovascular Health at Columbia University Irving Medical Center in New York. Cindy Hughes is an independent consulting editor based in El Dorado, Kan. Kristal Quispe is coordinator of clinical and research personnel for the cardiology division at the Columbia University Department of Medicine in New York. Dr. Viera is chair of the Department of Family Medicine and Community Health at Duke University School of Medicine.

Author disclosures: no relevant financial affiliations disclosed.

References

show all references

1. Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35–e66...

2. Siu AL. U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:778–786.

3. Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P. Role of ambulatory and home blood pressure monitoring in clinical practice: a narrative review. Ann Intern Med. 2015;163:691–700.

4. Piper MA, Evans CV, Burda BU, et al. Screening for High Blood Pressure in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Report No. 13-05194-EF-1. Agency for Healthcare Research and Quality; December 2014.

5. Wang YC, Shimbo D, Muntner P, Moran AE, Krakoff LR, Schwartz JE. Prevalence of masked hypertension among U.S. adults with nonelevated clinic blood pressure. Am J Epidemiol. 2017;185(3):194–202.

6. Whelton PK, Carey RM, Aronow WS, et al. Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2018;71(6):e13–e115.

7. Franklin SS, Thijs L, Hansen TW, O'Brien E, Staessen JA. White-coat hypertension: new insights from recent studies. Hypertension. 2013;62(6):982–987.

8. Fan HQ, Li Y, Thijs L, et al. Prognostic value of isolated nocturnal hypertension on ambulatory measurement in 8,711 individuals from 10 populations. J Hypertens. 2010;28(10):2036–2045.

9. Shimbo D, Kent ST, Diaz KM, et al. The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007–2010. J Am Soc Hypertens. 2014;8(12):891–897.

10. Parati G, Stergiou G, O'Brien E, et al. European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring. J Hypertens. 2014;32(7):1359–1366.

11. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31(9):1731–1768.

12. Kronish IM, Kent S, Moise N, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens. 2017;11(9):573–580.

 
 

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