UnChartIn 2003, JNC 7 recommended Ambulatory Blood Pressure Monitoring (ABPM) for a number of clinical situations:
- Suspected white-coat hypertension in patients with hypertension and no target organ damage
- Apparent drug resistance (office resistance)
- Hypotensive symptoms with antihypertensive medication
- Episodic hypertension
- Autonomic dysfunction
Show me the money….
One of the main critiques was that it increased cost of care without necessarily improving outcomes. At that time, it looked like it might cost patients $100 to $300. The portable monitor with software might cost $5000. And it might cost $60-$100 for time/materials for a provider. (I wonder why they calculate it so high?) Medicare did start covering it for white-coat hypertension but would only re-imburse $60.
Let that sink in: a portable blood pressure cuff with memory for a few hundred readings costs $5000 in 2003. For comparison, a Palm Pilot in 1996 cost $300. And the original Palm Pilot could run a portable blood pressure cuff without breaking a sweat. And store months of data. And have great usability. ABPM isn’t necessarily an expensive technology. Feels like getting charged $14 for a bandaid because you’re at the ER. Price gouging…..
Go forward to 2011. A Welch-Allyn ABPM that’s compatible with e-MDs costs $2-3000 + $500 for software to connect it to the EMR. Where’s the innovation? Considering other technology, shouldn’t the price be lower?
Well, it can be.
If you search on Amazon for ‘ABPM’ you’ll find this $400 import from China. We just got one at my clinic. The hardware is reasonably nice. It’s small, lightweight, sturdy. The usability on the machine is not that great but it still would take under a couple minutes to get it ready for a new patient including popping in some AA batteries.
Once you get to hooking it to your computer, it gets downright ugly. Horrible install instructions. Confusing software, arcane organization. Unsigned Driver that Windows complains about when you try to install it.
But it’s $2100 cheaper than Welch-Allyn. I could have 6 of them for the same price. And as ugly as the software is, a person could make it work pretty quickly after they learned the quirks. It’s cheap enough that the complaints about reimbursement start to ring hollow.
There may still be coverage issues for patients (not all insurances have the same coverage) but this ends up costing like a chest XR and has significant value for solving clinical problems about compliance and efficacy for hypertension.
Just last month, Journal-Watch had an article about ABPM:
White-Coat Effect Accounts for One Third of Resistant Hypertension Cases Ambulatory blood pressure monitoring reveals the prevalence and characteristics of true versus white-coat resistant hypertension.
The prevalence of resistant hypertension (RH), defined as persistent elevation in office-measured blood pressure (BP) despite the use of three or more antihypertensive agents (including a diuretic), is not well established. To find out more, investigators used data from the Spanish Ambulatory Blood Pressure Monitoring (ABPM) Registry, funded by the developer of an ABPM platform and network. Of 68,045 patients treated for hypertension, 8295 had RH (51.4% men; mean age, 64.4; mean duration of hypertension, 11.1 years). Of these, half were obese, 13% were smokers, and 32% had type 2 diabetes.
According to ABPM findings, 62.5% of the RH patients had true RH, and 37.5% had normal values on ABPM and were considered to have white-coat hypertension. Compared with the white-coat group, the true-RH group had higher rates of cigarette smoking, diabetes, left ventricular hypertrophy, microalbuminuria, and previous cardiovascular disease. In addition, the true-RH patients were younger, were more likely to be male, and had a longer duration of hypertension.
Comment: In this large cohort of patients who underwent ambulatory blood pressure monitoring, about one in eight had resistant hypertension. Of these, one third turned out to have white-coat hypertension. These findings suggest that to ensure a correct diagnosis and to assist in management decisions, ABPM is warranted in all hypertensive patients whose BP is not controlled on three or more drugs.
– Joel M. Gore, MD
Published in Journal Watch Cardiology May 18, 2011 Citation(s):
de la Sierra A et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension 2011 May; 57:898. (Subscription may be required)
