Self-measured blood pressure monitoring (SMBP)

Transcription

1 Self-measured blood pressure monitoring (SMBP) Michael Rakotz, MD, FAHA FAAFP Vice President, Improving Health Outcomes, American Medical Association Assistant Clinical Professor, Department of Family and Community Medicine, Feinberg School of Medicine, Northwestern University Laken Barkowski, RN Improvement advisor, Improving Health Outcomes, American Medical Association November 16, 2017

2 Disclosures Michael Rakotz: Laken Barkowski: None None 2

3 Agenda 1. New recommendations from the 2017 AHA/ACC HTN Guideline 5 minutes 2. Why use SMBP? 20 minutes 3. Implementing a SMBP program - 20 minutes 4. Case studies for the effective use of SMBP 10 minutes 5. Activity: Live Demo of SMBP Web Tools 10 minutes 6. Closing the SMBP data loop 5 minutes 7. Overcoming common SMBP barriers 10 minutes 8. Q&A 10 minutes 3

4 Objectives Explain the importance of measuring blood pressure (BP) accurately and the evidence for using SMBP Describe approaches to implement a SMBP program Demonstrate how to use SMBP to diagnose and manage hypertension (HTN) Discuss techniques for communicating SMBP measurements to the clinical team Propose tools and resources care teams can use for effective implementation and use of SMBP Cite common barriers to successful implementation of SMBP in clinical practice and how to overcome them 4

5 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults American College of Cardiology Foundation and American Heart Association, Inc.

6 Categories of BP in Adults* COR LOE Recommendation for Definition of High BP I B-NR BP should be categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP. BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated mm Hg and <80 mm Hg Stage 1 Hypertension mm Hg or mm Hg Stage 2 Hypertension 140 mm Hg or 90 mm Hg *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of 2 careful readings obtained on 2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.

7 Prevalence of Hypertension Based on 2 SBP/DBP Thresholds* SBP/DBP 130/80 mm Hg or Self- Reported Antihypertensive Medication SBP/DBP 140/90 mm Hg or Self-Reported Antihypertensive Medication Overall, crude 46% 32% Men (n=4717) Women (n=4906) Men (n=4717) Overall, age-sex adjusted 48% 43% 31% 32% Women (n=4906) Age group, y % 19% 11% 10% % 44% 33% 27% % 63% 53% 52% % 75% 64% 63% % 85% 71% 78% Race-ethnicity Non-Hispanic White 47% 41% 31% 30% Non-Hispanic Black 59% 56% 42% 46% Non-Hispanic Asian 45% 36% 29% 27% Hispanic 44% 42% 27% 32% The prevalence estimates have been rounded to the nearest full percentage. *130/80 and 140/90 mm Hg in 9623 participants ( 20 years of age) in NHANES BP cutpoints for definition of hypertension in the present guideline. BP cutpoints for definition of hypertension in JNC 7. Adjusted to the 2010 age-sex distribution of the U.S. adult population. BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health and Nutrition Examination Survey; and SBP, systolic blood pressure.

8 Out-of-Office and Self-Monitoring of BP COR LOE Recommendation for Out-of-Office and Self-Monitoring of BP I A SR Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. COR I LOE A Recommendation for Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP Follow-up and monitoring after initiation of drug therapy for hypertension control should include systematic strategies to help improve BP, including use of HBPM, team-based care, and telehealth strategies. Clinic HBPM 120/80 120/80 130/80 130/80 140/90 135/85

9 Normal BP (BP <120/80 mm Hg) Normal BP (BP <120/80 mm Hg) Promote optimal lifestyle habits Promote optimal lifestyle habits Reassess in 1 y (Class IIa) BP thresholds and recommendations for treatment and follow-up Elevated BP Stage 1 hypertension (BP /<80 (BP /80-89 mm Hg) mm Hg) Elevated BP (BP /<80 mm Hg) Nonpharmacologic therapy Nonpharmacologic (Class I) therapy (Class I) Reassess in 3 6 mo (Class I) Nonpharmacologic therapy (Class I) Stage 1 hypertension (BP /80-89 mm Hg) Clinical ASCVD or estimated 10-y CVD risk Clinical 10%* ASCVD or estimated 10-y CVD risk 10%* No Yes No Yes Nonpharmacologic Nonpharmacologic therapy and BP-lowering medication (Class I) Stage 2 hypertension (BP 140/90 mm Hg) Stage 2 hypertension (BP 140/90 mm Hg) Nonpharmacologic Nonpharmacologic therapy therapy and BP-lowering medication (Class I) Reassess in 3 6 mo Reassess in (Class I) 3 6 mo (Class I) Note that patients with DM or CKD are automatically placed in the high-risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy. Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different classes. Patients with stage 2 hypertension and BP 160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP target. Assess and optimize adherence Noto therapy Assess Consider and intensification optimize of adherence therapy to therapy Reassess in 1 mo Reassess in (Class I) 1 mo (Class I) BP goal met No Yes BP goal met Consider intensification of therapy Reassess in 3 6 mo Yes (Class I) Reassess in 3 6 mo (Class I)

10 BP Goal for Patients With Hypertension COR I IIb LOE SBP: B-R SR DBP: C-EO SBP: B-NR DBP: C-EO Recommendations for BP Goal for Patients With Hypertension For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher a BP target of less than 130/80 mm Hg is recommended. For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable.

11 BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10-year ASCVD risk 10% 130/80 <130/80 No clinical CVD and 10-year ASCVD risk <10% 140/90 <130/80 Older persons ( 65 years of age; noninstitutionalized, ambulatory, 130 (SBP) <130 (SBP) community-living adults) Specific comorbidities Diabetes mellitus 130/80 <130/80 Chronic kidney disease 130/80 <130/80 Chronic kidney disease after renal transplantation 130/80 <130/80 Heart failure 130/80 <130/80 Stable ischemic heart disease 130/80 <130/80 Secondary stroke prevention 140/90 <130/80 Secondary stroke prevention (lacunar) 130/80 <130/80 Peripheral arterial disease 130/80 <130/80 ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

12 Why use SMBP? 12

13 Why use SMBP? BP variability exists in all patients 13

14 Why use SMBP? What factors can you think of that contribute to a person s BP variability? 14

15 Blood pressure variability Significant short and long term BP variability exists in all patients Physical activity Emotional stimuli Sleep Central BP oscillations Mechanical forces from ventilation 15

16 Measuring BP accurately

17 Measuring BP accurately

18 Why use SMBP? Almost all patients will experience some degree of alerting response White coat hypertension: Office BP >130/80 mm Hg in a patient whose out of office BP is < 130/80 But some will experience none at all Masked hypertension: Office BP < 130/80 mm Hg in a patient whose out of office BP is > 130/80 18

19 Why use SMBP? White coat effect Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A. Alerting reaction and rise in blood pressure during measurement by physician and nurse. Hypertension 1987.Feb;9(2):

20 Why use SMBP? Minimizing variability and standardizing BP technique to measure BP accurately are critical for two reasons: 1. Accurate BP readings are needed to make sound clinical decisions 2. For office BPs to be predictive of future cardiovascular events (outcomes) they must be representative of a patient s actual BP 20

21 What is SMBP? Patient self-measurement of their blood pressure outside of the clinical setting Patients receive training on how to properly self-measure from their clinical team Patients share these BP readings with their healthcare provider 21

22 Why use SMBP? Measurements are taken in the patient s usual environment Eliminates white coat effect Provides multiple BPs over a longer period of time (more representative of patient s true BP) 22

23 Why use SMBP? SMBP improves BP control There is sufficient evidence of the effectiveness for SMBP to improve BP when used alone (training provided for proper use and communication) There is strong evidence for the effectiveness of SMBP to improve BP when combined with additional support (i.e., patient counseling, education, or web-based support). Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension. Annals of Internal Medicine 2013, 159(3): and CDC community guide task force

24 Why use SMBP? SMBP can increase precision in the diagnosis of hypertension 1. Confirming elevated office readings (USPSTF recommendation) 2. Differentiates between white coat and sustained HTN 3. Helps to identify patients with masked HTN. Parati G, Stergiou GS, Asmar R, et al. European society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertenss 2010;

25 Why use SMBP? SMBP is more predictive of cardiovascular outcomes than traditional office BPs 1. Target organ damage 2. Risk of future cardiovascular events 3. Mortality Sharman JE, Howes FS, Head GA, et al. Home blood pressure monitoring: Australian expert consensus statement. Journal of Hypertension 2015; 33:

26 Why use SMBP? SMBP can be used to assess BP control 1. Provides a reliable estimate of effectiveness of antihypertensive treatment 2. Assesses control at different times across a 24 hour period 3. Allows for better treatment decisions to be made in a timely fashion Sharman JE, Howes FS, Head GA, et al. Home blood pressure monitoring: Australian expert consensus statement. Journal of Hypertension 2015; 33: Parati G, Stergiou GS, Asmar R, et al. European society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertenss 2010;

27 Why use SMBP? SMBP improves adherence to therapy 1. Empowers patient to be more involved to self-manage 2. Improves medication adherence with clinical support Sharman JE, Howes FS, Head GA, et al. Home blood pressure monitoring: Australian expert consensus statement.journal of Hypertension 2015; 33: Parati G, Stergiou GS, Asmar R, et al. European society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertenss 2010;

28 Questions? 28

29 Implementing a SMBP program 29

30 Implementing a SMBP program 1. Considerations before initiating a SMBP program 2. Building a SMBP program 3. Which patients benefit from SMBP 4. Training patients to self-measure correctly 5. Interpreting SMBP readings 30

31 Considerations before initiating a SMBP program Identify at least one physician and one care team member to serve as champions, these individuals will learn about SMBP and train others Budget for 2-3 SMBP loaner devices (approximately $75) per physician. These devices can be used by patients who have not yet been diagnosed with HTN or cannot afford a device. Plan time for : Training staff on SMBP (1 hour) Training patients on SMBP (5-6 minutes per patient) Ensuring device accuracy, if the patient is using their own device (approximately 5 minutes) Averaging and documenting patient s SMBP readings (5 minutes) Preparing the device for the next patient, if implementing a loaner program (5 minutes) 31

32 Considerations before initiating a SMBP program Other considerations How will patients be identified as candidates for SMBP? Who will train the patients on proper self-measurement? How will you get the readings (and the device, if using a loaner program) back from the patient? Is an appointment required? With who? Who will be responsible for averaging, documenting and notifying the physician of the SMBP average? How will follow-up occur? Who will be responsible for disinfecting the returned loaner devices? Where will the loaner devices be stored? 32

33 Building a SMBP program Patients with HTN should be encouraged to purchase their own SMBP device If possible, patients without a confirmed diagnosis of hypertension or who cannot afford their own device should be offered a loaner device Recommend/choose a validated, automated upper arm BP device (preferably with memory and averaging) Do not recommend/use a wrist cuff (unless brachial readings impossible) Finger devices should never be used Appropriate fitting cuff is essential Train staff to measure patient s mid-upper arm circumference to ensure accurate cuff size is purchased/used If a patient is purchasing a device inform them that they must bring it into office for accuracy testing (even though validated) 33

34 34

35 Managing loaner devices Note: Loaner devices should be cleaned between each patient at a low to intermediate level of disinfection according to the CDC 35

36 Building a SMBP program Checking a home BP device for accuracy in a patient Even a device that has passed an accepted validation test may not provide accurate readings in every patient and may not be properly sized Every SMBP device must be tested in the office for accuracy in the individual using it The device is brought it and multiple readings are taken using the office standard method of testing and alternated with the patient self-measuring on their device If there is < 5 mm Hg difference between the two methods when the readings are averaged the device is safe to use. Accuracy checks should be done after purchase and then annually 36

37 37

38 Which patients benefit from SMBP? Patients without a diagnosis of HTN: Patients with elevated office BPs who are suspected of having HTN (to make Dx) Suspected white coat hypertension Suspected masked hypertension Patients with a diagnosis of HTN Any patient- increase engagement, adherence to treatment or improve BP control To assess treatment effect on BP control Difficult to control BPs to determine if treatment resistant HTN is present 38

39 Training patients to self-measure correctly Find out what they know about SMBP and if they have any concerns about it Tell them how often and when to measure Two sets of measurements twice a day One set in the morning and one in the evening, preferably before taking BP meds Each set consists of two measurements performed one minute apart This should be done daily for seven consecutive days (minimum of three days) Teach them how to prepare themselves for the measurement No exercise, large meals, caffeine, alcohol, nicotine, decongestants for 30 minutes before the measurement Empty bladder, if needed, then rest for 5 minutes sitting comfortably 39

40 Training patients to self-measure correctly Show them how to use the device and properly put the BP cuff on Tell them how to position themselves during the measurement Sit with back supported, legs uncrossed and feet flat on the floor Rest arm on a table or another flat surface at the level of the heart with palm facing up No talking, reading, texting or watching TV during the measurement Show them how to document their blood pressure immediately after each reading Provide instructions on what to do if their blood pressure is too high, too low or if they are experiencing associated symptoms Tell them how to communicate their results back to the practice after the week is complete Use teach back and return demonstration to ensure patient understanding 40

41 41

42 42

43 43

44 Interpreting SMBP readings What are normal BPs using SMBP? BPs < 120/80 mm Hg are considered normal What is HTN or uncontrolled BP using SMBP? BPs > 130/80 mm Hg are considered elevated 44

45 45

46 Implementing a SMBP program Review You should now have a better understanding of 1. Considerations before initiating a SMBP program 2. Building a SMBP program 3. Which patients benefit from SMBP 4. Training patients to self-measure correctly 5. Interpreting SMBP readings 46

47 Questions? 47

48 Case studies for the effective use of SMBP 48

49 Effective use of SMBP Diagnosing HTN in clinical practice Rita is a 59 YO Caucasian woman with a 1 year history of multiple elevated office BPs in the / mm Hg range. She has high cholesterol but refuses a statin. She has refused SMBP until now, instead insisting on lifestyle modifications to increase aerobic fitness, weight loss, and a low sodium DASH diet. She has not accomplished any of her goals in these areas and her BPs in the office remain elevated. EXAM: BP 156/94 mm Hg, Pulse 80, RR 16, BMI 28 No abnormal physical exam findings No retinopathy at last eye exam Normal UA Normal EKG 49

50 Diagnosing HTN COR LOE Recommendation for Out-of-Office and Self-Monitoring of BP I A SR titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for 50

51 Diagnosing HTN Rita has no SMBP device. What do you recommend? Provide her a loaner device or advise she obtain a validated, automated SMBP device that is sized correctly If she purchases a device, she must return to the office with her device to be checked for accuracy She needs to be trained to use it properly, including what to do before, positioning during, and how to record the measurements She needs to be told when and how often to test her BP She needs to be told to return after a week of measuring to review the results She needs to be told what to do in case she has dangerously abnormal BPs that persist or symptoms develop 51

52 Diagnosing HTN Rita returns 1 week later with her flow sheet. 52

53 Her average BP for the week is 141/84 You make the diagnosis of HTN and start her on medication, continue her diet and exercise and plan to see her back in 4 weeks. Use SMBP starting 2 weeks after meds and for 1 week prior to appointment Self-Measured Blood Pressure Diagnosing HTN 7 Day Recording Log: Self-measured Blood Pressure Monitoring Patient Name: Rita Lincoln Date of Birth: 5/17/1958 AM #1 AM #2 PM #1 Day Measurement Date Systolic Diastolic AM #1 Comments Systolic Diastolic AM #2 Comments Systolic Diastolic PM #1 Comments 1 11/9/ /10/ /11/ /12/ /13/ /14/ /15/ Average: Overall average: Instructions: Save a new copy for each patient. Option 1 (Patient Completes Log): Electronically send the patient a copy of the spreadsheet with a unique filename to fill out during their self-monitoring period. Instruct the patient to fi pressure readings in the appropriate columns. Instruct the patient to electronically return the completed spreadsheet at the end of the measurement period ( , upload a scan to patie appointment). Option 2 (Staff Completes Log): In the patient's uniquely named copy of the spreadsheet, add the data provided by the patient (either in hard copy or electronically on the measurement overall average blood pressure in the patient record, either by typing the information from the spreadsheet or by scanning the spreadsheet into the patient record. 53

54 Effective use of SMBP Managing HTN in clinical practice Charles Wayne is a 63-year-old man who is slightly overweight with a BMI of 27 and who has known HTN. He comes in for a follow-up visit. His blood pressure measurements during two earlier visits were 152/90 and 156/92. He had previously been stable on one medication for the last few years, but now his BP is slowly rising. Upon a lengthy discussion he tells you he is taking his medication every day. Mr. Wayne s BP today is 154/92. Mr. Wayne has an SMBP device you tested earlier this year, but has not been using it. You ask him to it to perform SMBP for 1 week and return. 54

55 Managing HTN Mr. Wayne returns 1 week later and you review his SMBP data from his machine His mean SMBP is 142/88 You prescribe an additional medication and ask him to use SMBP and return in 4 weeks 55

56 Managing HTN How would you have him monitor using SMBP over the next 4 weeks? Sporadic testing once daily for the next two-three weeks if acceptable 1 week prior to his visit, repeat the full SMBP protocol 2x2x7days 56

57 Managing HTN Mr. Wayne returns to the office 4 weeks later for a visit with you His mean SMBP for the 7 days prior to the visit is 128/78 He feels well You have him monitor once daily for another 3 weeks and then repeat another 7 day protocol. 1 month later his SMBP mean is 126/77. Now that his BP is stable, you have him measure 2-3 times a week and see him back in 3-6 months. 57

58 Managing HTN Alternatively, you could have had Mr. Wayne return and see your MA for a quick visit to review his SMBP readings four weeks after starting the new medication. His mean SMBP for the 7 days prior to the visit is 128/78 She sends him home and sends you a message in the EHR You message him via patient portal, or have your MA do this for you, instructing he monitor once daily for another 3 weeks and then repeat another 7 day protocol. 58

59 Questions? 59

60 Live Demo 60

61 Closing the SMBP data loop 61

62 Closing the SMBP data loop Key elements of SMBP with clinical support When added to SMBP, additional clinical support strengthens it s utility and effectiveness 1. Delivery of the additional support must involve a trained clinician (e.g., physician, NP, PA, RN, MA, pharmacist or other health educator) 2. Regular communication of SMBP data to clinicians 3. A feedback loop between patient and clinician in which support and advice are customized based on the patient s reported information Centers for Disease Control and Prevention. Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians. Atlanta, GA: 62

63 Closing the SMBP data loop SMBP empowers patients to: Check their BP Communicate results Make adjustments between visits under the guidance of their clinician Self-manage their hypertension regular self-measurements of blood pressure and a simple predetermined titration plan for anti-hypertensive drugs, is more effective in lowering systolic blood pressure than is usual care Richard J McManus, Jonathan Mant, Emma P Bray, Roger Holder et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet 2010; 376:

64 Closing the SMBP data loop Ways to share SMBP readings with physician s office Telephone Secure fax Online through secure patient portal or telemedicine website Bring device to the office for staff to review measurements or download if measurement storage is available Follow-up office visit 64

65 Closing the SMBP data loop EHR Patient Portal 65

66 Closing the SMBP data loop EHR Structured Data Field 66

67 Closing the SMBP data loop Examples of SMBP plus Clinical Support One-on-one counseling Telephone calls from RNs or pharmacists to manage medications Counseling sessions in person with pharmacists Community health workers who relay information to the clinical team Web-based or telephone support based on patient-reported SMBP readings Computer telephone-based feedback system Secure patient website training plus pharmacist care management via web communication Access to web-based tools for med refill requests, text and reminders to measure BP or for appointments, secure messaging with clinician or staff Patient Education RNs providing telephone-based education on lifestyle changes to lower BP Small group classes on SMBP technique and lifestyle changes in the clinical setting Small group classes on SMBP technique and lifestyle changes in the community setting 67 Centers for Disease Control and Prevention. Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2014.

68 Closing the SMBP data loop: AHA Check Change Control Tracker 68

69 Overcoming common SMBP barriers 69

70 What BP device do you recommend? We never recommend any one brand or model Recommend a validated, fully automatic upper arm cuff Do not use a finger or wrist cuff - except in cases where arm circumference >52 cm (wrist) Use a device with memory whenever possible Some patients are better served by a large display Appropriate sized cuffs must used for BP measurements to be accurate Always measure the arm before recommending any device * Validated does not mean that a device will be accurate for every patient. Make sure your patients bring in devices to be tested for accuracy in individual patients (PVD, Arrhythmias)! 70 Parati G et al J Hum Hypertens 2010; 23: (ESH recommendations)

71 What BP device do you recommend? Clinical Validation Protocols European Society of Hypertension International Protocol (ESH) British Hypertension Society Protocol (BHS) Association for the Advancement of Medical Instrumentation Protocol (AAMI) List of validated home blood pressure devices Dabl Educational Trust website: British Hypertension Society website: Medaval: 71

72 Do insurance companies pay for SMBP devices? Some do many do not In some States Medicaid continues to pay and some private payers reimburse Have the patient call their insurer to find out and also have then ask about DME benefit 72

73 What if a patient can t afford a device? Consider a loaner program (see the Target: BP SMBP program for more information) if appropriate Contact a manufacture for discounts online or coupons 80% of devices in the US are purchased at retail pharmacies check for coupons Many validated upper arm devices can be found for under $40 Avoid extra memory, Bluetooth and other bells and whistles which can be costly 73

74 How reliable are patient s recordings of their actual SMBPs? According to peer reviewed literature patients falsify their readings UP TO 21-33% of the time in some studies* It is better to use memory, whenever possible, for this reason However, a patient can still have someone else use their machine When in doubt, consider 24 hour ABPM * Diabetes Care 2014;37:e24 e25 DOI: /dc

75 Do SMBP readings count towards quality measures like HEDIS or PQRS measures? No Self-measured BPs are excluded from quality measures This is problematic Because SMBPs are not accepted in quality measures, elevated office BPs in patients who are controlled at home will not count as controlled This creates a disincentive to use SMBP, in spite of the fact that it is better for patient care The AMA, CDC, Million Hearts and several organizations are working to solve this problem 75

76 What is the best protocol to use to measure? There is no one protocol that is the standard However, there are many guidelines (US, European, UK, Australian, ASH, Canada, Japan, Finland) These guidelines agree that the mean of two BPs in the AM and PM for 1 week is preferred A minimum of three days is acceptable if you obtain 12 measurements 76

77 A final reminder Prior to initiating SMBP, always make sure 1) The SMBP cuff is sized correctly and is accurate in the INDIVIDUAL prior to relying on the SMBP measurements to make clinical decisions 2) There is a clearly defined individualized plan between the patient and the clinical team 3) Patients must know exactly what to do if their BP is - Too high, too low, or if they are having warning symptoms 4) A shared care plan can be used to help patients know - When and how often to communicate with or return to the office for follow-up - How to communicate BPs back to the care team 77

78 Questions? or 78