Economics of Self-Measured Blood Pressure Monitoring_ A Community Guide Systematic Review

COMMUNITY GUIDE – SYSTEMATIC REVIEW

Economics of Self-Measured Blood Pressure

Monitoring: A Community Guide Systematic Review

Verughese Jacob, PhD, MPH,

Sajal K. Chattopadhyay, PhD,

Krista K. Proia, MPH,

David P. Hopkins, MD, MPH,

Jeffrey Reynolds, MPH,

Anilkrishna B. Thota, MBBS, MPH,

Christopher D. Jones, PhD, MSW,

Daniel T. Lackland, DrPH,

Kimberly J. Rask, MD, PhD,

Nicolaas P. Pronk, PhD, MA,

6,7

John M. Clymer, BA,

Ron Z. Goetzel, PhD, MA

9,10

and the Community Preventive Services Task Force

Context: The health and economic burden of hypertension, a major risk factor for cardiovascular

disease, is substantial. This systematic review evaluated the economic evidence of self-measured

blood pressure (SMBP) monitoring interventions to control hypertension.

Evidence acquisition: The literature search from database inception to March 2015 identiﬁed 22

studies for inclusion with three types of interventions: SMBP used alone, SMBP with additional

support, and SMBP within team-based care (TBC). Two formulae were used to convert reductions in

systolic BP (SBP) to quality-adjusted life years (QALYs) to produce cost per QALY saved. All

analyses were conducted in 2015, with estimates adjusted to 2014 U.S. dollars.

Evidence synthesis: Median costs of intervention were $60 and $174 per person for SMBP alone and

SMBP with additional support, respectively, and $732 per person per year for SMBP wit hin TBC. SMBP

alone and SMBP with additional support reduced healthcare cost per person per year from outpatient

visits and medication (medians $148 and $3, respectively; median follow-up, 12–13 months). SMBP

within TBC exhibited an increase in healthcare cost (median, $369 per person per year; median follow-

up, 18 months). SMBP alone varied from cost saving to a maximum cost of $144,000 per QALY saved,

with two studies reporting an increase in SBP. The two translated median costs per QALY saved were

$2,800 and $4,000 for SMBP with additional support and $7,500 and $10,800 for SMBP within TBC.

Conclusions: SMBP monitoring interventions with additional support or within TBC are cost

effective. Cost effectiveness of SMBP used alone could not be determined.

Am J Prev Med 2017;53(3):e105–e113. Published by Elsevier Inc. on behalf of American Journal of Preventive

Medicine

CONTEXT

igh blood pressure (BP) is an important risk

factor for cardiovascular disease (CVD) and

stroke in the U.S., accounting annually for more

than $193 billion in medical care and about $123 billion

in lost productivity in 2011–2012.

The control of high

BP with medication and other treatments can prevent

and avert a substantial part of this societal burden,

even

From the

Community Guide Branch, Division of Public Health Informa-

tion Dissemination, Center for Surveillance, Epidemiology, and Laboratory

Services, Centers for Disease Control and Prevention (CDC), Atlanta,

Georgia;

Division of Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, CDC, Atlanta, Georgia;

Division for Heart Disease and Stroke Prevention, Ofﬁce of Noncommu-

nicable Diseases, Injury, and Environmental Health, CDC, Atlanta,

Georgia;

Medical University of South Carolina, Charleston, South

Carolina;

Emory University, Alliant Health Solutions, Atlanta, Georgia;

HealthPartners Institute, Minneapolis, Minnesota;

Harvard T.H. Chan

School of Public Health, Boston, Massachusetts;

National Forum for Heart

Disease and Stroke Prevention, Washington, District of Columbia;

Johns

Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and

Truven Health Analytics, Bethesda, Maryland

Names and affıliations of Task Force members are available at: www.

thecommunityguide.org/task-force/community-pre ventive-services-task-

force-members.

Address correspondence to: Verughese Jacob, PhD, MPH, Community

Guide Branch, CDC, 1600 Clifton Road, Mailstop E69, Atlanta GA 30329.

E-mail: [email protected].

0749-3797/$36.00

https://doi.org/10.1016/j.amepre.2017.03.002

Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine Am J Prev Med 2017;53(3):e105–e113 e105

as costs are projected to increase with hypertension-

related outcomes, such as stroke, in a growing and aging

population.

For example, hypertension control efforts

have contributed to the decline in stroke mortality because

distributions of population systolic BP (SBP) have shifted.

Self-measured blood pressure (SMBP) monitoring

interventions use BP monitoring devices operated by

patients to improve the management of high BP. This

process provides clinicians with accurate and frequent

measurements, increases patient engagement in their own

care, and prompts patients to adopt healthful lifestyles.

A recent systematic review

5,6

conducted for the Agency for

Healthcare Research and Quality showed that SMBP

monitoring interventions, typically in the home, were

effective in improving BP outcomes in patients with high

BP, reducing SBP by 3.2–4.6 mmHg and diastolic BP by

1.3–2.3 mmHg.

However, there has been no published

review of the economics of these interventions.

The objective of the present paper is to assess the cost

and economic beneﬁt of SMBP monitoring interventions

based on a systematic review of the literature.

EVIDENCE ACQUISITION

Concepts and Methods

This study was conducted using Community Guide methods for

systematic economic reviews, available at www.thecommunity

guide.org/about/economic-reviews. A review team (the team)

was constituted, including subject matter experts on CVD and

hypertension from various agencies, organizations, and academic

institutions together with experts in systematic reviews from the

Community Guide Branch at the Centers for Disease Control and

Prevention. The team worked under the oversight of the Com-

munity Preventive Services Task Force.

Interventions with SMBP monitoring involve use of personal BP

measurement devices to improve the treatment of high BP.

Patients are trained to use these devices in familiar settings, such

as their homes. Readings are shared with their healthcare providers

during clinic visits, by telephone, or electronically, and are

monitored and used in treatment decisions to improve BP control.

These interventions also may involve support such as medication

and lifestyle counseling, patient education for self-management,

and telephone or web-based tools.

Such SMBP interventions often are delivered within team-based

care (TBC) for BP control, in which primary care providers and

patients work together with other providers to improve the

efﬁciency of care delivery and self-management support for patients.

A novel feature of the present review is the categorization of

SMBP monitoring interventions into interventions implementing

SMBP alone, SMBP with additional support, and SMBP within

TBC. Distinction is drawn between additional support and team-

based care because the latter is far more comprehensive and

resource intensive than SMBP interventions that add web- or

phone-enabled patient support. Further, SMBP alone and SMBP

with additional support are both capital intensive, whereas SMBP

within TBC is more labor intensive.

Although the focus of the Agency for Healthcare Research and

Quality effectiveness review

5,6

of SMBP interventions was on

treatment and management of high BP, this economic review also

recognizes the diagnostic function of home BP monitors because

identiﬁcation of “white coat hypertension” and masked hyper-

tension

a,8,9

in a population can have substantial implications for

healthcare resource use.

Figure 1 depicts the intervention, the population, and transi-

tions in health status ascribed to the intervention (Intervention

Effectiveness), below which appear associated resource use and

Figure 1. Economics of SMBP monitoring interventions to improve BP control.

BP, blood pressure; CVD, cardiovascular disease; LY, life years; QALY, quality-adjusted life years; SMBP, self-measured blood pressure; TBC, team-

based care.

Patients with isolated high blood pressure in the medical setting and in the

presence of medical personnel are said to have “white coat hypertension.”

Patients with controlled blood pressure measured in the clinic and

uncontrolled blood pressure when measured outside the clinic are said to

have “masked hypertension.”

Jacob et al / Am J Prev Med 2017;53(3):e105–e113e106

www.ajpmonline.org

economic beneﬁts (Economic Outcomes). This economic review

takes a societal perspective, which means costs and economic

beneﬁts are aggregated regardless of who pays and who beneﬁts.

The following research questions are considered based on the

economic effects of the intervention illustrated in Figure 1:

 What is the cost to implement the intervention?

 What is the effect of the intervention on healthcare cost?

 What is the effect of the intervention on productivity of patients

at their workplaces?

 What is the net economic beneﬁt of the intervention?

 What is the cost effectiveness of the intervention? In particular,

what is cost per quality-adjusted life year (QALY) saved?

The target population of the interventions for this review are

patients diagnosed with hypertension in primary care. Studies

focused on patients with established CVD, gestational hyper-

tension, and those receiving dialysis were excluded as were those

focused on patients with illnesses that prevent them from using the

home BP devices. Only published studies of interventions imple-

mented in high-income countries were included. No restrictions

were placed on study design. Studies included in the economic

review had to contain information that would address one or more

of the review’s research questions. The measurement and estima-

tion of economic effects associated with each of the research

questions are described in detail below.

Intervention Cost. SMBP interventions require devices, mate-

rials, and labor to implement, which are captured in estimates for

intervention cost (Figure 1). The components of intervention cost

for SMBP-alone interventions are the BP monitoring device,

patient training on correct use of the device, any telemetry device

to transmit the BP readings, and the cost of generating summary

reports for the care provider. SMBP with additional support adds

the cost of other devices (e.g., smartphones); staff; development of

interactive software; and other information technology necessary

to support patient self-care in addition to providers’ time to review

patients’ BP reports to aid counseling and treatment. SMBP within

TBC adds the cost of administrative and medical staff engaged in

TBC activities. Estimates of intervention cost are considered

reasonably complete if they include these components that are

cost drivers: the BP device in the case of SMBP-alone interven-

tions; the BP device and patient support in the case of SMBP with

additional support; and the BP device, patient support, and TBC

activities for SMBP within TBC.

Healthcare Cost. Figure 1 shows the changes in healthcare

resource use expected from the intervention, leading to change in

healthcare cost. The components of healthcare cost are outpatient

visits; medications; labs; emergency room (ER) visits; and inpatient

stays. The effect of SMBP interventions on healthcare cost likely

occurs through several channels. Identiﬁcation of white coat and

masked hypertension can alter the number of patients who need

treatment. Changes in medication adherence, lifestyle, and BP

control related to the intervention have effects on medication

utilization, outpatient visits, and labs in the short term and on

inpatient and ER visits in the longer term. The directions these

changes take are empirical questions. For example, improved

adherence to medication may increase reﬁlls and medication cost.

On the other hand, improved BP control may prompt the provider

to reduce medication. In the case of outpatient visits, the expect-

ation is that home-based BP monitoring will reduce clinic visits

solely for BP checks. Or it could be that home readings that exceed

the threshold may alarm patients and increase contact with the

clinic. In the long term, however, the expectation is that these

interventions improve BP control and hence avert CVD events,

resulting in averted inpatient and ER visits. Therefore, this

economic review addresses the interventions’ net effect on health-

care cost, both in the short and long term. Based on completeness

of reporting in the included studies, estimates of healthcare cost for

SMBP alone and for SMBP with additional support interventions

were considered reasonable if they included outpatient visits and

medication; those for SMBP within TBC interventions were

considered reasonable if they included outpatient visits, medica-

tion, and inpatient stays.

Total Cost and Cost Effectiveness. The quantity and quality

of years lived increase when CVD morbidity and mortality are

averted by effective SMBP interventions. Cost-effectiveness anal-

ysis seeks estimates for cost per QALY saved, where cost (total

cost) is the sum of intervention cost and change in healthcare cost.

An intervention is considered cost effective if the cost per QALY

saved is less than a conservative threshold of $50,000.

11,12

The

present review translated reductions in SBP to QALYs saved

assess cost effectiveness for studies that reported the change in BP

resulting from intervention. Two translations from the published

literature were used: Translation (1), for which a reduction of 1

mmHg of SBP¼0.009 QALY saved

; and Translation (2), for

which a reduction of 1 mmHg of SBP¼0.093 QALY saved.

Estimates based on both translations were evaluated, as a

sensitivity measure, because the two equations relating change in

SBP to QALYs were based on trial populations that differed in age

and in the method used to derive QALY weights. The 20-year cost

per QALY saved was based on total cost and increase in QALY per

person per year summed over 20 years at a 3% discount rate. For

the second formula, the increase in QALY was already reﬂected

over life time of patients.

Productivity in the Workplace. Finally, reduced morbidity

and mortality related to SMBP interventions translate to higher

productivity of patients at their jobs as a consequence of reduced

illness and absences, better performance when at work, and

increased working years. A complete cost–beneﬁt assessment, as

in a cost–beneﬁt ratio, considers changes needed in resources to

carry out the intervention, as well as the changes in healthcare cost

and worksite productivity.

Economic results and conclusions are presented separately for

SMBP alone, SMBP with additional support, and SMBP within

TBC. All monetary values are in 2014 U.S. dollars, adjusted for

inﬂation using the Consumer Price Index,

and converted from

foreign currency denominations using purchasing power par-

ities.

All analyses were conducted in 2015.

Search Strategy

The original search strategy from the review of effectiveness,

5,6

available at www.thecommunityguide.org/ﬁndings/cardiovascu

lar-disease-self-measured-blood-pressure-with-additional-sup

port, was extended for the economic review. In addition to the

original search in MEDLINE and Cochrane, new sources were

EconLit and databases maintained at the Centre for Reviews and

Dissemination at the University of York. The search period was

extended to March 2015 from February 2013, the end of the

original search. Studies of interventions that met the deﬁnition,

Jacob et al / Am J Prev Med 2017;53(3):e105–e113 e107

September 2017

were conducted in high-income countries,

and contained informa-

tion on economic cost or economic beneﬁt of intervention were

included in the review. Reference lists of included studies were also

searched, as were action guides from the Million Hearts Initiative

s19,20

and studies recommended for inclusion by subject matter experts.

EVIDENCE SYNTHESIS

Results

A total of 1,246 papers were screened, yielding 22 studies

in 29 papers

21–49

for inclusion (Figure 2). Appendix

Table 1 (available online) provides a summary of the

study characteristics in terms of design, intervention

group size and age, length of intervention, comparison

group, setting, and what economic outcomes were actu-

ally measured within the study and which were modeled.

The substantial majority of the studies were RCTs with

usual care as the comparison group, and patient care took

place in the primary care setting. The average age of the

study patients was about 57 years. Papers that covered

the same population and intervention are considered

single studies and are identiﬁed in Appendix Tables 3–6

(available online). Eight studies from 11 papers

21–31

provided economic evidence for SMBP alone, eight

studies

32–39

for SMBP with additional support, and eight

studies

22,27,33,40–49

for SMBP within TBC. Although

several studies reported intervention cost and effects on

healthcare cost, none reported productivity effects. No

studies performed a cost–beneﬁt analysis that included

productivity effects. Only one

study modeled the out-

comes to cost per QALY saved. Translated cost

per QALY saved estimates were derived for the 11

studies

22–24,27,29–31,33,35,36,38,41,42,44,49

that provided both

change in SBP and the total cost of the intervention.

Studies used BP devices as a tool to guide treatment, as a

diagnostic tool, or both. Appendix Table 2 (available

online) provides additional details on how the home BP

devices were used in the interventions and how that may

have affected economic outcomes considered in this review.

Most studies were of patients with high BP, based on usual

clinic measurements. Most of the SMBP-alone studies

included the diagnostic impact in addition to treatment

impact, based on home BP readings. No studies of SMBP

with additional support and only one study of SMBP within

TBC reported economic outcomes that included the impact

of home BP devices used as a diagnostic tool.

Table 1 provides estimates of intervention cost and

change in healthcare cost following the intervention. The

median cost to implement the intervention increased

from $60 per person for SMBP alone, to $174 per person

with the addition of patient support, and to $732 per

person per year implemented within TBC. A substantial

part of intervention cost for both SMBP alone and SMBP

with additional support was the cost of the BP monitor.

One study

46–48

of SMBP within TBC was excluded as an

outlier for intervention cost because it reported a very

high cost of intervention that included diabetes case

management and telemedicine hardware and software

developed speciﬁcally for the study. The change in all-

cause healthcare cost reported for this study was included

in median estimates because hypertension is a major risk

factor for CVD and subsequent healthcare utilization for

those with diabetes. Individual study details along with

components of intervention cost included in the estimate

are presented in Appendix Table 3 (available online).

Detailed estimates for change in healthcare cost related

to intervention are shown in Appendix Table 4 (available

online). Most studies on SMBP alone, and SMBP with

Figure 2. Economic evidence search yield.

AHRQ, Agency for Healthcare Research and Quality; SME, subject matter expert.

Jacob et al / Am J Prev Med 2017;53(3):e105–e113e108

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additional support, included costs of outpatient visits and

medication when estimating the change in healthcare

cost. Most studies of SMBP within TBC included out-

patient visits, medication, and inpatient stays. The

median change in healthcare cost from SMBP alone

was a decrease of $148 per person per year (Table 1). All

but one

22,27

of the eight estimates

21–27,29–31

showed

decreases, indicating SMBP alone was healthcare cost

saving, with some of the savings likely from identiﬁcation

of “white coat hypertension.” The median change in

healthcare cost from SMBP with additional support was a

reduction of $3 per person per year, based on six

estimates

33,35–39

; individual estimates were mixed, with

three estimates

36,37,39

indicating healthcare cost

decreased and three indicating healthcare cost increased

or was unchanged. For SMBP within TBC,

seven

22,27,33,41,46–48

of eight estimates

22,27,33,41,42,44,46–49

reported a positive change in healthcare cost, indicating

the intervention was healthcare cost increasing with a

median increase of $369 per person per year.

The summary of estimates for intervention cost plus

change in healthcare cost attributable to intervention (total

cost) is presented in Table 2. Details for individual studies are

in Appendix Table 5 (available online). For SMBP-alone

interventions, the median total cost was –$72. Five

21,23,24,29 –31

of six estimates

21–24,27,29–31

were negative, indicating the

intervention was cost saving, with savings likely to include

the use of home BP monitors as a diagnostic tool. The

median total cost for SMBP with additional support was $44,

with ﬁve

33,35,36,38,39

of six estimates

33,35–39

being positive,

indicating the intervention increased costs. In the case of

SMBP within TBC interventions, median total cost was $430,

with all seven estimates

22,27,33,41–44,49

positive and, therefore,

cost increasing.

Table 2 also summarizes the 20-year cost per QALY

saved (based on two methods

14,15

described previously

for translating reductions in SBP to QALYs saved).

Details for individual studies are shown in Appendix

Table 6 (available online). Two studies

23,29

of SMBP

alone showed that SBP decreased following intervention

and that averted healthcare cost exceeded intervention

cost, whereas three studies

22,24,27,30,31

indicated SMBP

alone was not cost effective. Of these three studies, SBP

was higher at the end of the intervention in two

studies,

24,30,31

and the third study

22,27

had a cost per

QALY saved 4$50,000. For SMBP with additional

support, the median costs per QALY saved, based on

the two translation methods, were $2,800 and $4,000,

with every individual estimate

33,35,36,38

o$50,000, indi-

cating cost effectiveness. Median cost per QALY saved

for SMBP within TBC was $7,500 and $10,800, respec-

tively, for the two translation methods, based on six

estimates from four

22,27,33,41,42,44,49

studies. Of the six

estimates, four estimates from the four stud-

ies

22,27,33,41,42,44,49

were o$50,000 and two estimates

from one study

42,44,49

were 4$50,000; the weight of

evidence indicates cost effectiveness.

DISCUSSION

The review of effectiveness found that SMBP monitoring

interventions improved BP outcomes based on studies

that used the devices as a tool to manage the treatment of

high BP.

5,6,50

This economic review included economic

outcomes from the use of home BP devices as a

diagnostic tool in addition to their use in guiding

treatment. This diagnostic feature was prominent only

in the SMBP-alone studies.

The U.S. Preventive Services Task Force recommends

conﬁrmation of high BP before beginning treatment,

with measurements taken outside the clinic setting using

ambulatory or home BP monitoring.

Self-measured

blood pressure devices could, in practice, be distributed

to primary care patients identiﬁed with elevated BP by

Table 1. Intervention Cost and Change in Healthcare Cost

Intervention

Intervention cost,

Median (IQI) No. of

studies

Change in healthcare

cost, Median (IQI) No. of

studies

Median

time

horizon,

months

No. of

modeled

studies

Studies with comparison

to other than usual care

SMBP alone $60 ($55 to $74)

21–24,27–31

–$148 (–$316 to –$89)

21–27,29–31

12 2

21,25,26

Clinic plus ambulatory BP

SMBP with

additional

support

$174 ($63 to $362)

32–36,38,39

–$3 (–$58 to $62)

33,35–39

35,39

None

SMBP within

team-based

care

$732 ($279 to $946)

22,27,33,40–42,44,45,49

$369 ($57 to $548)

22,27,33,41,42,44,46–49

18 None None

Per person.

Per person per year.

BP, blood pressure; IQI, interquartile interval; SMBP, self-measured blood pressure.

Jacob et al / Am J Prev Med 2017;53(3):e105–e113 e109

September 2017

clinic readings and not yet conﬁrmed with ambulatory

BP monitoring. In this scenario, the ability of these

devices to identify patients with white coat and masked

hypertension would have important implications for the

economics of SMBP interventions, potentially reducing

treatment cost for white coat and increasing treatment

cost for masked hypertension. The diagnostic and treat-

ment features of the devices were captured in the

subgroup analysis by Arietta et al.,

who modeled an

SMBP intervention for adult members of a health plan.

The savings from the diagnostic and treatment features

of SMBP were reﬂected in a favorable return on invest-

ment for young adults, driven by savings from correct

diagnosis of hypertension, and favorable return on

investment for Medicare members, driven by treatment

beneﬁts.

Limitations

A relatively large body of evidence for SMBP alone

showed that averted healthcare cost exceeded the cost to

implement these interventions. However, healthcare cost

in most of the studies did not include inpatient stays or

ER visits, and the change in healthcare cost was measured

over a relatively short period of about 12 months and also

included the use of BP devices as a diagnostic tool.

Longer-term outcomes from using SMBP for hyper-

tension treatment, which account for all components of

healthcare, are necessary to determine beneﬁts from

improved BP control and averted CVD outcomes.

Further, two studies

24,30,31

reported increased SBP

following the intervention. The unfavorable BP outcomes

have been ascribed to identical BP thresholds chosen for

both intervention and usual care groups instead of

a lower threshold for home measurements, as currently

recommended.

The change in healthcare cost also

included savings from identifying patients with

white coat hypertension and taking some patients off

medication, even as beneﬁts of treating white coat

hypertension are still debated.

These cost savings

were therefore not highlighted for SMBP-alone

interventions.

The translation of reduced SBP to QALYs saved was

based on two published formulae that are in turn drawn

from large longitudinal trials within diabetic populations.

Even though it is possible that the overall QALYs may be

lower for diabetic patients than hypertensive patients, the

relative impact of SBP reduction on the QALYs of

diabetic patients compared with that of hypertensive

patients is uncertain. Appendix Table 1 (available online)

also includes the percentage of the study population that

were identiﬁed as diabetic, where reported. It may be

noted that three included studies explicitly excluded

diabetic patients, and 11 did not report any information.

For the remaining seven studies, the median and mean

percentages of diabetics included in their interventions

were 24% and 30%, respectively.

The direct translation of reduced SBP to QALYs saved

used in the present review may yet be an oversimpliﬁ-

cation of the complex processes by which reduced SBP

averts CVD outcomes. A related issue is whether there is

Table 2. Summary Economic Estimates: Total Cost and 20-Year Total Cost per QALY Saved

Intervention

Total cost (intervention

cost plus healthcare cost),

Median (IQI) No. of studies

Median

time

horizon,

months

No. of

modeled

studies

Studies with

comparison to

other than usual

care

Total cost per QALY saved;

summed over 20 years, Mean

or Median (IQI) No. of studies

SMBP alone –$72 (–$257 to $142)

21–24,27,29–31

12 1

Clinic plus

ambulatory BP

Translation (1):

Mean $100,000

Translation (2): Mean $144,000

22,27

Cost-saving 2

23,29

Ineffective (SBP increased)

24,30,31

SMBP with

additional

support

$44 ($6 to $250)

33,35–39

35,39

None Translation (1):

$2,800 ($525 to

$5,100)

Translation (2): $4,000 ($756 to

$7,400) 4

33,35,36,38

SMBP within

team-based

care

$430 ($244 to $1,112)

22,27,33,41–44,49

18 None Usual care with

home BP device

Translation (1):

$7,500 ($4,600

to $79,100)

Translation (2): $10,800 ($6,600

to $113,900) 4

22,27,33,41,42,44,49

Per person.

Translation (1): –1 mmHg of SBP=0.009 QALY saved per year

; Translation (2): –1 mmHg of SBP¼0.093 QALY saved over patient’s lifetime.

Per person per year.

BP, blood pressure; IQI, interquartile interval; QALY, quality-adjusted life year; SBP, systolic blood pressure; SMBP, self-measured blood pressure

Jacob et al / Am J Prev Med 2017;53(3):e105–e113e110

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a lower limit for SBP below which reductions do not

produce health beneﬁts

nor save QALYs. Current

guidelines

stipulate a target SBP o140 mmHg for the

general hypertensive population, with no consensus

about the net beneﬁts of more aggressive treatment to

reach a lower target. However, it is likely patients with BP

at 160/100 will derive beneﬁt from treatment in moving

their BP to 130/80, but might not obtain additional

beneﬁt in moving BP to 120/60.

Of nine studies where

reduction in SBP was translated to QALYs saved, the

mean SBP after the effect of intervention was 4140 in

ﬁve studies,

23,33,35,36,38

135–140 in two studies,

29,41

120–

125 in two studies,

22,27,42,44,49

and o120 in no studies.

Based on these means, it is likely that reductions achieved

in SBP from the interventions in this review fell within

the beneﬁcial range and increased QALYs.

The Community Preventive Services Task Force recom-

mended TBC based on its effectiveness in improving BP

control,

and it also was found to be cost effective.

Studies of SMBP within TBC included in the present review

do not provide evidence for the contribution of SMBP to

the effectiveness or cost effectiveness of TBC because the

studies compared SMBP within TBC to usual care. How-

ever, SMBP is a common component of TBC for BP

control, as it provides a regular and ongoing activity to

engage patients in their own care. SMBP also allows the

team of providers to monitor patient response to treatment.

No studies in the present review performed a complete

cost–beneﬁt analysis that included improvements in

productivity. However, this was partly compensated by

cost per QALY estimates computed by the team from

translations of reductions in SBP to QALYs saved.

Evidence Gaps

Studies that use SMBP monitoring as a diagnostic tool in

addition to treatment should try to separate out their

contributing effects on economic outcomes. Although it

may be difﬁcult to do this analytically, the diagnostic

effect may be approximated, for example, in terms of

discontinued or newly initiated treatments. More studies

are needed for estimating return on investment for

SMBP-alone interventions, capturing longer-term

changes in healthcare cost because of changes in morbid-

ity and mortality. There is stronger evidence and greater

effectiveness when patient support or TBC is added to

SMBP monitoring, but there is no cost-effectiveness

evidence for adding various levels of such support,

indicating another item for future research.

CONCLUSIONS

When used with additional patient support or within

TBC, SMBP monitoring interventions are cost effective.

Though short-term healthcare costs averted were greater

than cost of intervention, the evidence for cost effective-

ness of SMBP interventions when used alone was mixed

and inconsistent.

The ﬁndings of this economic review, together with

the conclusions of the review on effectiveness,

support

the recommendations for use of SMBP interventions

presented by the Community Preventive Services Task

Force elsewhere in this issue.

These results and ﬁndings

can contribute to the evidence for SMBP for improved

BP management and control as clinical guidelines for the

prevention and treatment of hypertension are updated.

ACKNOWLEDGMENTS

The authors acknowledge the Division for Heart Disease and

Stroke Prevention, Center for Disease Control and Prevention

(CDC), for support and subject matter expertise. We thank

members of our coordination team in the Community Guide

Branch at CDC and from other areas of CDC, and our external

partners. The authors also thank Randy W. Elder, PhD, and Kate

W. Harris, BA, from the Community Guide Branch, and Onnalee

Gomez, MS, from the Library Services Branch, at CDC for their

assistance throughout the review.

The work of Jeffrey Reynolds was supported with funds from

the Oak Ridge Institute for Science and Education.

No ﬁnancial disclosures were reported by the authors of

this paper.

SUPPLEMENTAL MATERIAL

Supplemental materials associated with this article can

be found in the online version at

https://www.thecommunityguide.org/sites/default/files/

assets/cvd-ajpm-app-smbp.pdf.

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