Providing access to Ambulatory Blood Pressure Monitoring (ABPM) for patients can be challenging in primary care. The growing evidence for the prognostic power of ABPM is leading to new approaches to support clinicians with the best data for their patients.
We spoke with clinicians and their patients about a feasibility study into delivering ABPM at community pharmacies with the Oscar 2 Ambulatory Blood Pressure Monitor.
Dr. Dave Dixon, PharmD
Dr. Dixon's drive to increase access to ABPM for patients in the US led to a feasibility study at Virginia Commonwealth University in partnership with Bremo Pharmacy.
What led you to set up this service?
I’ve been involved in helping patients manage their hypertension for my whole career. My prior experience with ambulatory blood pressure monitoring was in a study looking at the effect of certain drugs based on the timing of doses during the day. I ran across a paper on increasing access to ABPM through community pharmacies and discussed with other providers in my practice that this was a valuable service that wasn’t available in the US.
What were the goals of setting up the service and study?
We wanted to conduct a feasibility study and to understand whether this model would work in the US. Understanding whether providers would refer their patients was a goal of the study alongside whether pharmacists would be comfortable with conducting ABPM studies. We also wanted to particularly focus on the patient experience of an ABPM service provided by pharmacists. We developed a patient questionnaire to gain information on their experience with not just the monitor, but also with the pharmacist providing the service.
Why is ABPM important to hypertension management?
I’ve seen in my practice the challenge of getting patients to perform home blood pressure readings themselves. Often even if the patient has a monitor and wants to check their blood pressure, we don’t see measurements brought to their appointment or we receive only blood pressure readings from the patient’s memory. In order to address issues of whether that patient has white coat or masked hypertension we need better clinical data.
More importantly, there’s been a lot of literature to support the idea that the 24-hour blood pressure profile and in particular night-time blood pressure predicts cardiovascular risk better than office-based blood pressure. ABPM is the perfect fit for being able to know what is going on with the patient at home and outside the clinical setting.
How does the service work?
We aimed to keep the process simple for the provider, who fills out a referral form we developed. The form is sent to the community pharmacy, who reach out to the patient to schedule a visit. We wanted to ensure we could plan ABPM visits in advance to best manage the pharmacists time and keep it convenient for the patient.
During the patient visit, a pharmacist or pharmacy technician will perform intake and set up the monitor on the patient, providing guidance to the patient.
When the device is returned by the patient, a pharmacist will provide interpretation and recommendations to the referring provider alongside the 24-hour blood pressure report.
The report provides objective evidence for the patient to say, “OK, wow, I really am hypertensive”. It helps patients to grasp the significance of the condition and may help adherence to treatment.
Oscar 2 24-hour Blood Pressure Report
[Click to Enlarge]
What is the benefit to the patient of the service?
Having your blood pressure taken at the office can be a stressful experience, while self-measuring blood pressure at home can be a great deal of work for patients. ABPM allows the patient to see the full spectrum of their blood pressures, not just during the day, but also at night. Particularly for patients that are not convinced of their high blood pressure, the report provides objective evidence for the patient to say, “OK wow I really am hypertensive”. It helps patients to grasp the significance of the condition and may help adherence to treatment down the road.
How did you recruit providers and pharmacists to refer to your service?
It was very important to have face to face time with providers. We set aside time during lunch periods to visit and talk with providers about ABPM and which patients they would refer to an ABPM service. Fortunately, the response from providers was very favorable. Many of the providers we spoke with wanted access to ABPM but did not have the ability to offer it directly to patients or an established service to refer patients to.
Pharmacists currently play a big role in assisting patients in selecting a home blood pressure device and training patients on taking home blood pressure, but there was less familiarity with ABPM. Pharmacists were enthusiastic about the data provided by a wearable blood pressure monitor and we also provided training to all our pharmacists and pharmacy technicians taking part in the service which helped ensure they were confident in working with ABPM.
“The number of referrals we received from providers really took us by surprise”
What was the reaction from the patient?
Patients really enjoyed learning more about how their blood pressure changes throughout the day. Having the objective graph really helped to either reaffirm a diagnosis of hypertension for the patient or confirm suspected white-coat hypertension.
Patients were typically able to tolerate ABPM well. We went into detail with sleeping arrangements with patients to ensure they understood what to expect during the study and would adhere to the 24-hour study schedule.
A Success Story
An older adult female was concerned about low blood pressure symptoms and was being treated with several anti-hypertensive medications. The patient’s provider was reluctant to reduce her medication regimen based on the patient’s history but referred her to the program to get a better picture of blood pressure.
The patient’s report indicated a 24-hour average of well below normal with significant dips throughout the day indicating the patient was hypotensive. The report allowed the patient’s provider to discontinue some medications and potentially prevent an adverse drug reaction. The patient was extremely pleased to have objective evidence of symptoms and the provider had the confidence to make a change to the patient’s medication.
How did you decide what protocols to follow for ABPM?
There are a lot of recommendations available, however we followed the recommendations of European Society of Hypertension (ESH), particularly for intervals during the nighttime portion of the study.
Was it a challenge for Pharmacists to fit in a new service to provide to patients?
Pharmacists were able to integrate ABPM into their workflow extremely well. Pharmacists are increasingly providing additional healthcare services, particularly immunizations, and the fall can be extremely busy, so we expected integrating a new service to be a challenge. We found that pharmacy technicians were able to take on a larger role in managing the new service which ensured pharmacists could focus on interpreting the ABPM results and spend time providing other healthcare services.
How did you manage reimbursement for the study?
While there is coverage for ABPM from payers, we did struggle with reimbursement due to restrictions on pharmacists directly claiming reimbursement. We are looking at multiple options, such as partnering with a medical group to assist with reimbursement and we also are exploring an out of pocket model for patients with an expectation of a $50 charge for an ABPM study.
Why did you choose the Oscar 2?
I had experience in the past with other monitors where the durability was not great. I also had observed that the usability of the software was often limited. I was aware of the Oscar 2 and searched PubMed for studies using the Oscar 2 and found the usability and durability were highly rated. We also found the cuff sizes on the Oscar 2 were better suited to our patients, with larger cuff sizes to accommodate patients with a larger arm size.
What has been your experience of using Oscar 2?
Oscar 2 has provided the ability to capture readings very consistently throughout the study, certainly better than other monitors I have used in the past. We would absolutely recommend the Oscar 2.
What do you have planned to follow the completion of this study?
We have manuscripts planned to document the development and implementation of the service as well as clinical outcomes. We are looking to expand the study with a collaboration with a local cardiology practice to take a more detailed look at clinical outcomes as well as the safe use of anti-hypertensive drugs.