Compliance and Home Blood Pressure Monitoring Research Paper

Abstract

Hypertension is one of the most frequently diagnosed diseases and a major cause of premature death worldwide (World Health Organization [WHO], 2019). Consequently, the treatment and prevention of this disease is a global objective. Blood pressure measurements are used to diagnose and treat hypertension and evaluate the effectiveness of a doctor’s performance. Nevertheless, patient adherence to therapy also has a significant role in disease control. Various methods are used to increase compliance, including self-blood pressure monitoring. It is a simple and demonstrative method for maintaining a proper level of the patient’s consciousness and awareness regarding his disease. This paper examines the impact of daily home blood pressure monitoring on compliance with medication regimens for hypertension in adults diagnosed with hypertension.

Introduction

Hypertension is a medical condition in which blood pressure in the arteries is constantly elevated. This disease increases the risk of developing cardiovascular, brain, kidney, and other serious diseases. As mentioned by World Health Organization (WHO, 2019), in 2015, 1 in 4 men and 1 in 5 women had hypertension, and fewer than 1 in 5 people have the problem under control. In conjunction with this, proper treatment, monitoring, and surveillance are vital factors in reducing morbidity and mortality.

Treatment of hypertension is a complex process requiring attention and consistency, and therefore not all patients can remain compliant with it. Blood pressure measurement is the most affordable, quickest, and convenient way of assessing the treatment impact. If there is no blood pressure control, the probability of complications and death increases, and in this regard, its constant monitoring becomes a capable tool in disease management (WHO, 2019). This paper investigates the influence of daily self-blood pressure measurement on compliance with antihypertensive medication intake since it is one of the most prospective and accessible methods for the patient. In advanced nursing practice, the problem is of great practical importance due to the prevalence of the disease in everyday work.

Methods

Most of the sources relating to the paper topic were found using Google Scholar and the National Center for Biotechnology Information (NCBI). All sources listed were selected according to the criteria of conformity and concordance with the issue. The keywords used for the search were: self-blood pressure monitoring, home blood pressure monitoring, compliance, and adherence. About 50 articles were related to the issue in a given period from 2015 to 2020. However, this is not enough to reliably and distinctly answer the question posed by the problem. Most of the available materials are intended for research based on blood tests or new biotechnologies. For example, in addition to home blood pressure monitoring, it was possible to find studies related to other methods of compliance control, such as electronic monitoring of the medication intake. The sources chosen for this paper are selected due to their relevance and significance to the problem.

Review of Selected Literature

The Largest Study in Recent Years

Jo, S. H. et al. (2019) investigated whether self‐blood pressure monitoring (SBPM) can improve the control rate of blood pressure (BP), adherence to antihypertensive medications, and the awareness of the importance of BP control. A total of 7751 Korean patients (aged 18‐90 years old) participated in the study. They were given automatic electronic BP monitors and were recommended to measure their BP daily at home for 3 months. Changes in office BP, attainment of target BP, adherence to taking antihypertensive drugs, and awareness of BP were compared before and after SBPM (Jo et al., 2019).

The investigation was a nationwide single‐arm prospective observational study (Level VI evidence). Authors assessed drug adherence by the self‐reported questionnaire, which was well‐validated and is widely used in clinical practice despite some shortcomings regarding the ease of distortion by the patient and susceptible errors by visit time interval (Jo et al., 2019). Self‐BP was recommended to be measured twice a day, in the morning, 5‐10 minutes after waking up, and just before going to sleep.

The main findings of the study are that SBPM for 3 months is associated with improved patient awareness, drug adherence, and BP control. As a result, drug non‐adherence, defined as the number of days per week in which medication was skipped or lessened, decreased significantly after SBPM from an average of “0.86 to 0.53 days per week” (as cited in Jo et al., 2019, p. 1300). Drug adherence improved as the self-blood pressure monitoring rate increased.

The fact that it is not a randomized controlled trial is a limitation of the study. The accuracy of patients’ measurement of BP at home also was not examined. There could be recall errors or intended untruthful replies (Jo et al., 2019). The long‐term benefits of SBPM cannot be determined since the trial was only performed for 3 months. 20% of patients of the study participants were already using SBPM before the investigation (Jo et al., 2019). These patients could have been more diligent, which could have biased the results.

Improved Adherence in Specific Treatment Regimen

Spirk, D. et al. (2018), in their work, aimed to evaluate the influence of home blood pressure monitoring (HBPM) on patients’ awareness and attainment of BP value goals. The authors conducted a study using antihypertensive treatment with irbesartan alone or in combination with hydrochlorothiazide. 1,268 patients over 18 years of age with newly diagnosed or previously treated uncontrolled arterial hypertension were enrolled in the Factors Influencing Results in antihypertenSive Treatment (FIRST) study (Spirk et al., 2018) (Level IV evidence). It was performed by 348 general practitioners and internal medicine specialists across Switzerland. 60% of patients were instructed to use the devices for HBPM.

The study purposes included estimating a patient’s awareness and attainment of BP goals, and the efficacy and tolerability of antihypertensive treatment after three months (Spirk et al., 2018). General practitioners and internal medicine specialists were invited to screen and enroll up to 5 patients per physician for 10 months. At the baseline visit, an individual BP goal according to the current BP and the individual risk profile was defined, and a suitable antihypertensive medication and the use of HBPM were then chosen at the discretion of treating doctors (Spirk et al., 2018). The study results, including a large population of hypertensive patients living in Switzerland, show that promoting HBPM leads to better disease awareness and compliance with therapy. Even if antihypertensive drugs were well balanced in both groups, a better blood pressure control was observed in the group using HBPM as compared to the group without instructions for the HBPM use (Spirk et al., 2018). The study’s limitations include the non-randomized observational short-term character of the investigation, subjective selection of treatment chosen, and geographical constraint.

Compliance as an Advantage from the Use of BP Home-Devices

The aim of Zalloum, N. A., Farha, R. A., Ruqa’a, A. M. A., Khdair, A., & Basheti, I. A (2015) in their study was to investigate the effect of home monitoring of blood pressure on adherence to antihypertensive medications and control of the disease among patients attending a tertiary health facility. This is a cross-sectional correlation investigation conducted at the cardiovascular clinics of Jordan University Hospital (Level IV evidence). The authors used a questionnaire investigating participants’ disease level of control, disease duration, frequency of HMBP use, type of measuring devices used, the effect of HMBP on adherence to antihypertensive medications, and lifestyle changes (Zalloum et al., 2015). 205 hypertensive patients who practice HMBP were recruited into the study, 60% of them were aged 50-69 years. Almost 50% of the patients have been using digital devices for blood pressure monitoring. The mean rate of HMBP was 15 times per month, but almost 80 % of the patients did not document their blood pressure values (Zalloum et al., 2015).

As for the result, patients with higher levels of education, as well as patients with lower BP values, showed significantly higher adherence to their antihypertensive medications. Consequently, it supports the fact that compliance with antihypertensive medications is one of the advantages resulting from the use of BP home devices (Zalloum et al., 2015). The authors note that the role of the pharmacist should have been investigated in this study to give a clear, complete picture of the result. Since the pharmacist is the last specialist seen before the BP self-measuring device use, they can affect the accuracy of measurements by selecting a specific device for each patient. Another limitation concerns non-stringent conclusions made due to the specifics of the data gathered.

Hypertension in Pregnancy

Since arterial hypertension during pregnancy is a no less important problem, the OPTIMUM-BP study on this topic was conducted. Pealing et al. (2019) assessed the feasibility of a blood pressure self-monitoring intervention for managing pregnancy hypertension. It was an unmasked randomized controlled trial comparing a self-monitoring of blood pressure (SMBP) intervention versus usual care (Level II evidence). 86 women with chronic and 72 women with gestational hypertension from 4 UK centers were randomized (2:1) intervention to control (Pealing et al., 2019). In this case, self-monitoring involved daily home blood pressure measurements with recording via study diary or telemonitoring. Participants persisted with the intervention for 80% or more of their time from enrolment until delivery in 86% and 76% of those with chronic and gestational hypertension, respectively (Pealing et al., 2019).

As a consequence, medication adherence and beliefs about medication scores were at a high level but showed no difference between study groups. The research briefly concerns the chosen topic but still provides the necessary results. The trial outcome is limited by the inability to mask the participants or clinicians to the randomization group due to the nature of the intervention (Pealing et al., 2019). The inaccuracy of reported BP measurements also may take place.

Medication Adherence in Malaysia

Muhammad, J., Jamial, M. M., & Ishak, A. (2019), in their study, evaluated HMBP influence on office blood pressure control and treatment compliance among hypertensive patients. The investigation was conducted as a randomized, non-blinded two-arm parallel controlled trial performed in a primary care clinic in Malaysia (Level II evidence). 88 patients of stage I and stage II hypertension aged above 18 years were recruited. Patients were divided into the intervention and control groups. Each patient was seen at baseline and after 2 months. Medication adherence was measured using a novel validated Medication Adherence Scale (MAS) questionnaire (Muhammad et al., 2019). The automatic BP monitor Omron model HEM-7120 (Omron Healthcare Co. Ltd.) was used for the measurement of home BP, and the automatic BP monitor Omron model HEM-7203 – for the office BP. Both groups showed a significant improvement in the mean Medication Adherence Scale (from baseline to 2 months), and the intervention group showed a slightly greater change compared to the control group. However, there was no significant change in the mean difference in the Medication Adherence Scale between both groups at the end of the 2-month study period (Muhammad et al., 2019).

The reported outcomes resulting from HBPM in medication adherence differ among previous studies since there is a higher compliance rate at the baseline. Most of the patients had been followed up before and were highly motivated to control their hypertension (Muhammad et al., 2019). Authors also state that the study is limited since, according to Marquez-Contreras et al. (2006), the self-report is poorly predictive of non-compliance compared to the pill-count approach (Muhammad et al., 2019).

Racial Diversity

The study conducted by Abel, W. M., Joyner, J. S., Cornelius, J. B., & Greer, D. B (2017) investigates self-care management strategies used by Black women in the USA and their consistent adherence to antihypertensive medication-taking. There are no known research studies considering predominantly Black women’s behavior while they have the highest prevalence rate of hypertension (HTN), contributing to a higher risk of organ damage and death (Abel et al., 2017). The authors used a qualitative descriptive design (Level VI evidence) since it “allows a straightforward description of study participant experiences in their own language without the interpretation of existing theories” (Abel et al., 2017, “Methods”).

Four focus groups with a total of 20 Black women aged 25-71 years were formed, each woman was audiotaped. Transcripts were analyzed using qualitative content analysis. Participants were included in the study if they scored perfect adherence on the medication subscale of the Hill–Bone Compliance to High Blood Pressure Therapy Scale (Abel et al., 2017). For each of the four focus groups, the investigator served as a moderator with one or two female research assistants (registered nurses with master’s degree preparation and trained to serve as observers and note-takers). The investigator used semistructured, open-ended questions developed from the literature and framed around the tenets of Orem’s Self-Care Deficit Theory (Abel et al., 2017).

The majority of participants owned a BP device, measured their BP once per day or several times per week, and kept a log to report their BP numbers to the healthcare provider by email or during office appointments. As for the result concerning the paper’s problem, home BP monitoring is mentioned as beneficial in terms of reduced BP, improved BP control, and adherence to antihypertensive medication (Abel et al., 2017). Limitations of the study include small sample size, the discrepancy between general population characteristics, and the subjective nature of the Hill–Bone Compliance to High Blood Pressure Therapy Scale.

Conclusions and Recommendations

In summary, it should be noted that adherence to medication in the case of hypertension is an extremely relevant topic for discussion in the scientific community. Many studies in this direction were conducted in the early 21st century, and over time, the question is still raised in the course of medicine development. In recent years, more attention has been paid to the implementation of mobile applications and automatic electronic systems in the process of forming compliance.

However, measuring blood pressure at home remains one of the most convenient, reliable, and affordable ways for patients all over the world. Thus, Jo et al. (2019) proved that self‐blood pressure monitoring is effective in the elimination of drug non‐adherence. Results of studies conducted by Spirk et al. (2018) and Zalloum et al. (2015) also confirm that promoting HBPM leads to better disease awareness and compliance with therapy. Other studies with smaller samples have similar conclusions. Upscale guidelines on hypertension based on the presented studies and earlier research promote home blood pressure monitoring as a simple but reliable and easily accessible way to monitor the course of the disease and treatment (Williams et al., 2018). Such manuals are used by specialists to help millions of patients every year.

Users of these guides include advanced practice nurses as well. The data contained in these is of high value for nurses’ work since they use expanded skills and knowledge in assessment, planning, implementing diagnostics, and providing necessary medical care. The basis of the nurse’s work is evidence-based and verified decision making, so studies considered in the paper can help to improve the quality of applied treatment. For example, a nurse can conduct lectures and training for patients and colleagues explaining the need for home blood pressure control. Advanced practice nurses are prospective specialists for the future of the US healthcare system. With the available knowledge about the topic, they will be able to reduce the load on general practitioners in primary care while improving patients’ quality of life and satisfaction. Self-blood pressure monitoring by the patient reduces the level of supervision by the medical professional, at the same time patient himself pays more attention to his condition and its maintenance. This allows achieving automatism and autonomy, owing to which the effectiveness of treatment is reached.

References

Abel, W. M., Joyner, J. S., Cornelius, J. B., & Greer, D. B. (2017). Self-care management strategies used by Black women who self-report consistent adherence to antihypertensive medication. Patient Preference and Adherence, 11, 1401.

Jo, S. H., Kim, S. A., Park, K. H., Kim, H. S., Han, S. J., & Park, W. J. (2019). Self‐blood pressure monitoring is associated with improved awareness, adherence, and attainment of target blood pressure goals: Prospective observational study of 7751 patients. The Journal of Clinical Hypertension, 21(9), 1298-1304.

Muhammad, J., Jamial, M. M., & Ishak, A. (2019). Home blood pressure monitoring has similar effects on office blood pressure and medication compliance as usual care. Korean Journal of Family Medicine, 40(5), 335–343.

Pealing, L. M., Tucker, K.L., Mackillop, L.H., Crawford, C., Wilson, H., Nickless, A., … McManus, J. R. (2019). A randomised controlled trial of blood pressure self-monitoring in the management of hypertensive pregnancy. OPTIMUM-BP: A feasibility trial. Pregnancy Hypertension, 18, 141‐149.

Spirk, D., Noll, S., Burnier, M., Rimoldi, S., Noll, G., & Sudano, I. (2018). Effect of home blood pressure monitoring on patient’s awareness and goal attainment under antihypertensive therapy: the factors influencing results in anti-hypertensive treatment (FIRST) study. Kidney & Blood Pressure Research, 43, 979-986.

Williams, B., Mancia, G., Spiering, W., Rosei, A.E., Azizi, M., Burnier, M., … Desormais, I. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension.

World Health Organization. (2019). Hypertension.

Zalloum, N. A., Farha, R. A., Ruqa’a, A. M. A., Khdair, A., & Basheti, I. A. (2015). Blood pressure home monitoring in hypertensive patients attending a tertiary health facility in Amman, Jordan: Effect on disease control and adherence rate. Tropical Journal of Pharmaceutical Research, 14(3), 533-538.