Tuesday, August 27, 2013

Step two of home health checks

Home Heart-Health Checks Work, but Follow-Up Is Still a Must

by CHRISTOPHER WEAVER, online.wsj.com

August 5th 2013 6:43 AM

More doctors are looking to a host of emerging gadgets patients can use to manage chronic disease at home, such as do-it-yourself blood pressure monitors.

But, making use of the reams of data they can produce remains a problem. A new study shows that patients who monitor their blood pressure at home don't get much benefit—unless their doctors provide extra services like digital monitoring and counseling.

It is a dilemma for digital medicine. As technology bridges patients and doctors across geographies and gathers ever-richer health data, efforts to translate those gains into everyday practice often lag behind. Doctors often aren't paid for such services, and extra resources needed—like extra staff—to act on data aren't always available. "Many practices aren't yet fully prepared for the onslaught of data when patients are really online and providing a lot of monitoring data," said Jorge Plutzky, a cardiologist at Brigham and Women's Hospital in Boston, who wasn't involved in the study.The analysis published Monday in the Annals of Internal Medicine found that patients who got such extra support coupled with home blood-pressure monitoring saw significant benefits after a year, while it wasn't clear home monitoring without added medical practice infrastructure helped much at all in the long term.

While home monitoring for conditions such as diabetes has been a staple of disease management, increasingly sophisticated devices are able to channel information about serious ailments directly to doctors. Wireless scales catch changes in weight that can be symptoms of worsening heart failure, home monitors track heart-rhythm disorders for patients with defibrillators and pacemakers, and a new generation of blood pressure cuffs can seamlessly link patients with high blood pressure to clinics.

Controlling blood pressure is key to reducing patients' risks for heart attacks and strokes. Even temporary spells of high blood pressure, known as hypertension, are thought to increase such risks. One-third of adult Americans—more than 76 million—have hypertension, or blood pressure of 140/90 mm Hg or higher, according to the Centers for Disease Control and Prevention. Drugs, diet and exercise leave only half of those patients with well-controlled blood pressure.

Blood pressure is hard to pin down. It fluctuates throughout the day, and many patients believe it rises when they visit the doctor. Conversely, measurements taken at office visits every few months can be inaccurate and may suggest blood pressure is controlled even when it is soaring at other times.

Some doctors are looking to technology as a solution. In April, Diego Remolina, an internal-medicine doctor at Central de Salud Esperanza, a Chicago clinic, asked a patient, Maria de Lourdes Segura, a 46-year-old homemaker, to start monitoring blood pressure at home with a new machine that transmits data to the clinic, hoping to help control her hypertension and diabetes.

The patient said her hypertension was tied to anxiety due to office visits, and an older home monitor that didn't connect to the clinic seemed to have a wide range of readings that gave Dr. Remolina more questions than answers. With the new system, provided by a local group called the Medical Home Network, Dr. Remolina was "able to tell her with confidence that she needed a different approach to her high blood pressure treatment," he said. Dr. Remolina, who prescribed a third blood-pressure drug, said he had been reluctant to add the medicine earlier because of the risk of side effects.

The new approach works for Ms. Segura, too. "You really start thinking more about all of it"—taking medicine on time, adhering to a healthier diet and exercising—"when you know the doctor is interested in looking at" the readings, Ms. Segura said, speaking in Spanish, through a translator.

In the Annals' analysis, studies of patients given home testing, but no extra help other than ordinary physicians' visits, saw modest declines in their blood pressure after six months, but the improvement vanished after a year. Experts said they believe the temporary improvement was tied to better patient adherence to medication regimens, at least at first.

Studies in which patients used home monitors along with web-based connections to their clinics, counseling or other services, seemed to produce a more lasting benefit. In the most robust studies, patient's systolic pressure improved by 3.4 points to 8.9 points after a year, compared with usual care. The Annals' study, a systematic review 52 previous clinical studies through February, was funded by the federal Agency for Healthcare Research and Quality.

The study shows home blood-pressure monitoring can be useful, said Katrin Uhlig, a nephrologist at Tufts Medical Center in Boston and the lead author of the analysis. But, to see major benefits, "you would actually need the additional staff. You would need the infrastructure for transmission of values and have systems in place to act on readings in a responsible way," Dr. Uhlig said.

The other deterrent is technology, Dr. Magid said. When he first studied home monitoring about five years ago, his research team had to push patients to write down measurements, and either report them over the phone or fax notes to researchers. That study showed only a modest improvement. But, in a study published earlier this year in the journal Circulation, Dr. Magid's team used a new system that automatically sent blood-pressure data to a team of pharmacists, who could recommend changes to medication regimens. The results were much stronger, with patients at 10 Kaiser clinics seeing systolic pressure decline by an average of 12 points more than a group that received usual treatment over six months. The research was funded by the American Heart Association
Few physicians have such systems now, in part because insurers tend not to pay for care unless patients physically show up for office visits, said David Magid, a Colorado-based researcher for Kaiser Permanente, the managed-care organization. "There is a financial disincentive for doctors when patients do home blood-pressure monitoring," he said.

While a new array of home monitors have features such as blue-tooth connectivity or companion iPhone apps, the basics still work for most patients, said Tracy Stevens, a heart association spokeswoman and cardiologist at St. Luke's Health System in Kansas City, Mo. "You can get a fabulous blood pressure cuff that's accurate, easy to use and fully automatic for $50," Dr. Stevens said. More sophisticated home-use models range to as much as $300.

For patients who want to use home monitoring, but don't have access to a medical practice with the infrastructure to run a sophisticated monitoring program, Dr. Stevens suggests a low-tech solution. "Have a little spiral notebook dedicated for your blood pressure. Write down the dates, times and your measurements, and show it to your doctor," she said.

Write to Christopher Weaver at christopher.weaver@wsj.com

A version of this article appeared August 6, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: Doctor's Order: Test at Home But Don't Forget to Call.

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