番茄社区

A pharmacist-managed telemedicine intervention for people with uncontrolled hypertension was associated with favorable health and economic outcomes, according to 5-year results of the 450-patient .

People who underwent 6 months of home blood pressure (BP) monitoring and regular telephone contact with a pharmacist suffered numerically fewer cardiovascular events (non-fatal MI, non-fatal stroke, hospitalized heart failure, or cardiovascular death; 4.4% vs 8.6%, OR 0.49, 95% CI 0.21-1.13) and cardiovascular events including coronary revascularizations (5.3% vs 10.4%, OR 0.48, 95% 0.22-1.08) over 5 years.

"Although the reduction in cardiovascular events was substantial, the study was not powered for this outcome and the reduction was not statistically significant. However, if the reduction in cardiovascular events is not due to chance, the intervention is cost-saving over 5 years, " according Karen Margolis, MD, MPH, of HealthPartners Institute in Minneapolis, and colleagues in .

The same group that the telemedicine group had lower BP on average compared with peers getting usual care.

Although that benefit did not last beyond 24 months, statistical modeling showed that the difference in 5-year events far exceeded predictions based on observed BP.

Costing $1,511 per patient, the intervention also was associated with a 126% return on investment -- meaning that, for every dollar spent, $2.26 was returned -- and a net cost savings of roughly $1,900 per patient over 5 years.

Costs associated with cardiovascular events in the intervention group totalled $758,000 versus $1,538,000 in the control patients.

Hyperlink was a cluster-randomized trial conducted at 16 primary care clinics in the same health system. Participants were patients with uncontrolled hypertension (BP at least 140/90 mm Hg, or 130/80 mm Hg with diabetes or kidney disease).

Patients averaged 61 years of age, and 45% were women. They reported taking on average 1.5 BP-lowering drug classes. Mean BP was 145/85 mm Hg at enrollment.

The cohort was divided between the telemonitoring arm (n=228) and the usual care arm (n=222).

Those assigned to the intervention received an automated home BP monitor and were instructed to transmit measurements at least six times a week. Their managing pharmacists were allowed to prescribe and change antihypertensive therapy under a specific protocol.

During the first 6 months of the study, patients and pharmacists talked on the phone every 2 weeks until BP control was sustained for 6 weeks, after which phone conversations were reduced to a monthly schedule. After the first 6 months, this was reduced further to every 2 months, and all patients ultimately returned the BP monitors and resumed care by their primary care physician.

Hyperlink's limitations include the relatively small sample and the enrollment of few minorities and individuals of low socioeconomic class.

"Future studies of telemonitoring and pharmacist care should plan for long-term follow-up and be powered to detect differences in clinical cardiovascular events. They should also carefully measure changes in other cardiovascular risk factors, like lipids and smoking, that could be influenced by pharmacists or other care team members," according to Margolis and colleagues.

Recently, another group found that a virtual coach was not effective for hypertension self-management.

Comment