Opinion
VIEWPOINT
Use of Home Blood Pressure Results
for Assessing the Quality of Care for Hypertension
Kevin O. Hwang, MD, Primary care practices are increasingly participating in
MPH pay-for-performance programs linked to quality mea-
UTHealth McGovern sures, such as hypertension control. Practices report on
Medical School,
these metrics for benchmarking and eligibility for finan-
University of Texas at
Houston-Memorial cial incentives as part of accountable care organiza-
Hermann Center for tions, delivery system reform incentive payment pro-
Healthcare Quality and grams, and other initiatives. In this Viewpoint, we
Safety, Houston, Texas.
recommend that quality measure stewards allow health
care organizations to use home blood pressure moni-
Eric J. Thomas, MD,
MPH toring (HBPM) when assessing and reporting on hyper-
UTHealth McGovern tension control. This recommendation is based on rig-
Medical School, orous evidence for the prognostic value of HBPM;
University of Texas at
Houston-Memorial current practice patterns; and the preferences of stake-
Hermann Center for holders, including health care organizations, clinicians,
Healthcare Quality and and patients.
Safety, Houston, Texas.
Office-Based Blood Pressure Measurement
Laura A. Petersen,
MD, MPH The measures for hypertension control from
Center for Innovations the Healthcare Effectiveness Data and Information Set;
in Quality, the National Committee for Quality Assurance; and the
Effectiveness and
Medicare Merit-Based Incentive Payment System en-
Safety, Michael E.
DeBakey VA Medical dorsed by the National Quality Forum, “Controlling High
Center, Baylor College
of Medicine,
Houston, Texas.
Although the clinical merits of HBPM
are clear, establishing standards for
Editorial page 1757 HBPM in quality reporting will require
balancing evidence and feasibility.
Blood Pressure,” rely on the most recent office blood
pressure (OBP) reading, but do not accept readings from
HBPM. Given that BP readings are obtained as part of
routine office care and are readily extracted from elec-
tronic health records, it made sense to use OBP for the
first iteration of the quality measure. However, using OBP
readings alone ignores scientific and technological ad-
vancements in BP measurement. Evidence-based guide-
lines recommend HBPM to confirm the diagnosis of hy-
pertension and guide treatment, because 10% to 50%
of patients with high OBP have normal BP outside the
office.1 It is likely that such a high false positive rate would
Corresponding
not be tolerated for screening and treatment planning
Author: Kevin O.
Hwang, MD, MPH, for other chronic diseases.
UTHealth McGovern Clinicians understand that a single OBP reading is in-
Medical School, adequate for assessing hypertension control. Yet, un-
University of Texas at
Houston-Memorial
der the current Healthcare Effectiveness Data and In-
Hermann Center for formation Set measure, a patient with a single OBP
Healthcare Quality and reading of 140/89 mm Hg and normal HBPM readings
Safety, 6410 Fannin,
(white coat effect) would be misclassified as having un-
UPB 1100.41, Houston,
TX 77030 (kevin.o controlled hypertension. It is frustrating for clinicians to
.hwang@uth.tmc.edu). successfully control BP as measured at home and know
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that the patient will not meet criteria for controlled BP
because of a single abnormal OBP reading. Relying on
OBP can also produce a misleading risk assessment.
A large cohort study (n = 63 910 patients) showed that,
compared with untreated normotensive individuals, un-
treated patients with white coat hypertension had a
higher risk of mortality (hazard ratio, 1.79 [95% CI,
1.38-2.32]), but patients treated with BP medications
who had white coat hypertension had no excess risk
(hazard ratio, 1.06 [95% CI, 0.82-1.37]).2
Therefore, patients treated with BP medications
with white coat hypertension should not be grouped
with those who have sustained uncontrolled hyperten-
sion for clinical decisions or quality reporting. Using
HBPM will help avoid this misclassification error. Simi-
larly, ignoring HBPM readings could misclassify pa-
tients with high HBPM and normal OBP readings
(masked hypertension) as having controlled hyperten-
sion. Using only OBP may cause misclassification of pa-
tients with respect to BP status and health risk, facilita-
tion of overtreatment and undertreatment, production
of an invalid estimate of the quality of care being pro-
vided, and reduction of the patient-
centeredness of care.
Home Blood Pressure Monitoring
The advantages of HBPM are numer-
ous. First, because HBPM eliminates the
white coat effect and captures multiple
measurements over several days, it can
produce a more accurate assessment of
BP control and cardiovascular risk than OBP.3 Second,
HBPM allows clinicians, including pharmacists, nurse
practitioners, and physician assistants, to adjust treat-
ment between widely spaced physician office visits, a
strategy that produces sustained, clinically significant im-
provements in BP control and promotes interdisciplin-
ary teamwork in primary care. 4 Third, studies of
92 primary care clinicians 5 and 200 patients with
hypertension6 suggest that both groups prefer HBPM
for evaluating BP status. Fourth, HBPM may promote ef-
ficiency by reducing the need for in-person clinic visits
(eg, visits solely for a BP reading) and may accelerate the
time to achievement of target BP goals. Fifth, provid-
ing care in settings outside the clinic has been linked to
improved patient satisfaction and patient engagement
in their care plan.
HBPM does have pitfalls, but many can be ad-
dressed with approaches that have been applied to OBP
measurement. First, even though some HBPM devices
are inaccurate, many have been validated with the same
protocols (from the Association for the Advancement of
Medical Instrumentation, the European Society of
(Reprinted) JAMA November 6, 2018 Volume 320, Number 17 1753
 Opinion Viewpoint

Hypertension, or the British Hypertension Society) used for OBP de-
vices. Second, some patients do not know how to use HBPM de-
vices, but they can be coached on proper technique. Third, pa-
tients may selectively or erroneously report BP values, but many
home devices store multiple BP readings, which can be reviewed on
the device screen, uploaded to a computer, or transmitted directly
to electronic health records. Fourth, although the out-of-pocket cost
for HBPM devices is prohibitive for some patients, given the cen-
tral role of HBPM in hypertension care, health care insurers should
cover the costs for patients prescribed BP medications. Commu-
nity organizations can also provide free or low-cost devices.
Improving Blood Pressure Reporting and Quality of Care
Although the clinical merits of HBPM are clear, establishing stan-
dards for HBPM in quality reporting will require balancing evi-
dence and feasibility. Most health care systems are not ready to
wholly supplant OBP with HBPM. A hybrid approach is likely
needed, in which organizations report HBPM readings for
patients when available and report OBP for other patients. This
would allow participants to adopt HBPM in a way that matches
their priorities and resources. Inclusion of HBPM in the hyperten-
sion control measure may encourage clinicians to promote the
use of HBPM. If health care organizations see a reputational or
financial benefit of HBPM in their improved quality metrics, the
benefits could stimulate creative ways to provide home monitor-
ing to patients. A quality measure using HBPM could specify a
minimum frequency and number of readings. HBPM readings
taken twice in the morning and twice in the evening for
3 to 7 consecutive days accurately gauges BP control and is likely
a good measure.7 Another area of consideration is the threshold
for normal HBPM measurements. An OBP of 140/90 mm Hg
would correspond to an HBPM reading of 135/85 mm Hg.8 Orga-
nizations could establish processes for triaging and responding to
critically high or low HBPM readings.
This proposal for the increased use of HBPM in the assess-
ment of hypertension control resonates with efforts to integrate
patient-reported outcomes into quality assessment. Measures for
depression screening, falls, pneumococcal and influenza vaccine,
and smoking status depend on what patients report. The same
philosophy holds for hypertension.
Continued reliance on OBP for quality assessment and
reporting may give misleading estimates of hypertension control
and health risk; lead to overtreatment or undertreatment; and
divert the attention of health care organizations, clinicians, and
patients away from the unmistakable benefits of HBPM. A shift
from OBP to HBPM would be consistent with evidence-based rec-
ommendations, current practice patterns, and clinician and
patient preferences. As the evidence in favor of HBPM continues
to accumulate, it is time to update how the quality of hyperten-
sion care is evaluated and reported.

ARTICLE INFORMATION REFERENCES clinical uncertainty in treatment decisions for

Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Funding/Support: The work reported here was
supported by the US Department of Veterans
Affairs, Veterans Health Administration, Health
Services Research and Development Service
(HSR&D) by the Center for Innovations in Quality,
Effectiveness and Safety (CIN 13-413), Michael E.
DeBakey VA Medical Center, and VA HSR&D IIR
15-438.
Role of the Funder/Sponsor: The funders of the
study had no role in the preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Disclaimer: The views expressed in this article are
those of the authors and do not necessarily reflect
the position or policy of the US Department of
Veterans Affairs or the United States government.
Additional Contributions: We are grateful to
LeChauncy Woodard, MD, MPH, for her comments
on an earlier version of this article.
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