JAMA：远程监控的干预有助于更好地改善和保持血压

据7月3日发表在JAMA（《美国医学会杂志》）上的一则研究披露，与常规治疗相比，由药剂师进行管理的居家血压（BP）远程监控组成的一种干预治疗在12个月的时间段内达到了改善血压控制和血压下降的效果，并且在该干预之后血压的改善维持了6个月的时间。

根据文章的背景资料：“高血压是最常见的慢性疾病，病人会因为该疾病病而到初级保健医生处就诊；该疾病对美国30%的成年人造成影响；据估计每年在高血压上所花费的费用要超过500亿美元。几十年的研究显示，治疗高血压可预防心血管事件；人们可以容易地得到许多耐受良好、有效而且便宜的高血压药。”

明尼阿波利斯教育与研究健康伴侣研究所（Health Partners Institute for Education and Research）的Karen L. Margolis, M.D., M.P.H.及其同事开展了一项研究，旨在确定由药剂师进行病例管理的居家血压远程监控的效果和持久性；这些病人的合并症及高血压严重程度范围在典型的初级保健实践中具有代表性。该随机性的临床试验包括了450名血压未经控制的成人；他们是从明尼阿波利斯-圣保罗的某一综合卫生体系中的所有16家初级保健诊所中的具有电子病历的1万4692名患者中招募的；这些病人接受了12个月的干预治疗以及6个月的干预治疗后的随访。

有8家诊所被随机指派为病人提供常规的治疗（n=222），另外有8家诊所被随机指派为病人提供远程监控干预治疗（n=228）。干预组患者得到了居家血压远程监控器并将血压数据传送给药剂师，后者据此数据做出抗高血压药物治疗的调整。主要检测结果为在6个月和在12个月时的收缩压控制在低于140毫米汞柱的水平上，及舒张压低于90毫米汞柱水平上（糖尿病患者或慢性肾病患者低于130/80毫米汞柱）。次级检测结果为血压的改变、病人的满意度及在18个月时血压得到控制（即干预停止后6个月时）。

在380名于6个月及12个月都现身随访的患者中，两次随访时血压得到控制患者的比例在远程监控干预组中为57.2%，而在常规治疗组为30.0%。在18个月时，血压得到控制者在远程监控干预组中为71.8%，在常规治疗组中为57.1%。在现身所有的6个月、12个月及18个月临床随防的362名患者中，在所有随访中血压得到控制的患者比例在远程监控干预组中为50.9%，而在常规治疗组为21.3%。

“如果这些结果在更长的时期中被发现具有成本效益而且持久的话，那么它应该能带动对高血压及其它慢性疾病管理的类似替代治疗模式的更广范围的测试及传播。”

JAMA  doi:10.1001/jama.2013.6549

Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial

Karen L. Margolis, MD, MPH; Stephen E. Asche, MA; Anna R. Bergdall, MPH; Steven P. Dehmer, PhD; Sarah E. Groen, PharmD; Holly M. Kadrmas, PharmD; Tessa J. Kerby, MPH; Krissa J. Klotzle, PharmD; Michael V. Maciosek, PhD; Ryan D. Michels, PharmD; Patrick J. O’Connor, MD, MPH; Rachel A. Pritchard, BA; Jaime L. Sekenski, BS; JoAnn M. Sperl-Hillen, MD; Nicole K. Trower, BA

Importance  Only about half of patients with high blood pressure (BP) in the United States have their BP controlled. Practical, robust, and sustainable models are needed to improve BP control in patients with uncontrolled hypertension.

Objectives  To determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care and to determine whether BP control is maintained after the intervention is stopped.

Design, Setting, and Patients  A cluster randomized clinical trial of 450 adults with uncontrolled BP recruited from 14 692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St Paul, Minnesota, with 12 months of intervention and 6 months of postintervention follow-up.

Interventions  Eight clinics were randomized to provide usual care to patients (n = 222) and 8 clinics were randomized to provide a telemonitoring intervention (n = 228). Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly.

Main Outcomes and Measures  Control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg (<130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. Secondary outcomes were change in BP, patient satisfaction, and BP control at 18 months (6 months after intervention stopped).

Results  At baseline, enrollees were 45% women, 82% white, mean (SD) age was 61.1 (12.0) years, and mean systolic BP was 148 mm Hg and diastolic BP was 85 mm Hg. Blood pressure was controlled at both 6 and 12 months in 57.2% (95% CI, 44.8% to 68.7%) of patients in the telemonitoring intervention group vs 30.0% (95% CI, 23.2% to 37.8%) of patients in the usual care group (P = .001). At 18 months (6 months of postintervention follow-up), BP was controlled in 71.8% (95% CI, 65.0% to 77.8%) of patients in the telemonitoring intervention group vs 57.1% (95% CI, 51.5% to 62.6%) of patients in the usual care group (P = .003). Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (−10.7 mm Hg [95% CI, −14.3 to −7.3 mm Hg]; P<.001), at 12 months (−9.7 mm Hg [95% CI, −13.4 to −6.0 mm Hg]; P<.001), and at 18 months (−6.6 mm Hg [95% CI, −10.7 to −2.5 mm Hg]; P = .004). Compared with the usual care group, diastolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (−6.0 mm Hg [95% CI, −8.6 to −3.4 mm Hg]; P<.001), at 12 months (−5.1 mm Hg [95% CI, −7.4 to −2.8 mm Hg]; P<.001), and at 18 months (−3.0 mm Hg [95% CI, −6.3 to 0.3 mm Hg]; P = .07).

Conclusions and Relevance  Home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of postintervention follow-up.