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SAN DIEGO -- COVID-19 provided the push for some to adopt self-measured blood pressure (BP) monitoring, presenting an opportunity to overhaul hypertension care and surveillance nationwide -- if stakeholders can only get it to stick.

When the pandemic began in March 2020, "COVID brought total destruction to usual patient care ... But usual care isn't always best practice," said primary care physician Kelsey Bryant, MD, MPH, of Mount Sinai Physicians in New York City.

Speaking at the annual Hypertension Scientific Sessions hosted by the American Heart Association (AHA), Bryant emphasized that audience members, a self-selecting group interested in hypertension, are not the only ones managing BP in an institution. She shared the bleak results of an informal survey of 26 clinicians at her practice: over 57% did not know how to direct a patient to purchase a valid BP monitor, and nearly 77% were not aware that guidelines -- existing long before the pandemic -- address how frequently the patient should measure and interpret BP.

Nevertheless, for BP telemonitoring during COVID-19, her institution devised a way to partner with a third-party benefit manager that streamlines the necessary paperwork and communicates with insurance so that device orders can be routed to a vendor that ultimately delivers home BP monitors to patients.

Bryant shared the early failures of this process: in 2021, out of over 600 orders for BP monitors, only 479 were actually received. Just over half of the subset of patients contacted said they actually had the order fulfilled.

After providing feedback to the third-party benefit manager, Bryant's group is now ordering approximately 70 monitors a month with a 90% fulfillment rate, the unfulfilled mostly due to the patient's lack of coverage related to previous receipt of a monitor within the last 5 years or the barrier of a copay.

Indeed, cost and reimbursement can be major deterrents to access to self-measured BP monitors.

Without insurance, valid monitors can cost patients over $100 full-price, and there is no applicable National Coverage Determination from CMS. Some insurance plans offer coverage but that is state-dependent; in New York state, for example, plans that cover self-measured BP monitors require durable medical equipment prescriptions and letters of medical necessity, according to Bryant, who added that BP monitors cannot simply be e-prescribed to retail pharmacies.

Fellow session speaker Capt. Fleetwood Loustalot, FNP, PhD, of the CDC and U.S. Public Health Service, lamented the status of self-measured blood pressure as an intervention that is underutilized despite a strong evidence base.

Available CMS data show that nearly 80% of beneficiaries had hypertension in both 2020 and 2021, yet only 0.01% of those with hypertension were billed for self-measured BP training, device setup, and calibration in 2020 -- going up slightly to 0.02% in 2021. Meanwhile, the incidence of Current Procedural Terminology coding for self-measured BP for ongoing treatment decisions went from 0.01% to less than 0.01% between the 2 years, Loustalot said.

He suggested that there may be problems at hand for self-measured BP to drop off this way after initial use.

"Simply getting them monitors is not enough," Bryant agreed.

One barrier to uptake may be knowing what actions need to be taken after the collection of data.

During the Q&A portion of the session, one audience member (self-identified as a physician working at a federally qualified health center in San Diego) noted that her group has been able to get the grant funding to provide self-measured BP monitors to the majority of patients who need them. The real struggle, however, has been finding an algorithm for screening and intervention after all the data have come in.

"Can I just have an algorithm?" she asked panelists, prompting heavy applause in the room. "I've spoken to lots of organizations trying to solve the same problem," she noted, adding that the people who have these codes tend to keep them to themselves.

In response, AHA representative Eduardo Sanchez, MD, MPH, announced that there is such an algorithm available for distribution.

The bigger picture of what self-measured BP can ultimately do, besides help in hypertension control, is set up health systems to adapt in other ways to ensure success in the future, according to Loustalot.

He said that CDC's surveillance activities, including the longstanding National Health and Nutrition Examination Survey, have seen declining response rates from participants over time. There will need to be significant changes to the conduct of these programs, he noted, perhaps in line with the growing push for self-collected electronic health information.

There will be limitations to such data collection. Even so, it may still be useful for national surveillance of hypertension, Loustalot suggested. Somewhere out there, there may be an ideal way to conduct mass self-measured BP that makes sense for all those involved.

But "should we wait for the ideal? Absolutely not," he said.

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