Patient perceptions of ambulatory blood pressure monitoring testing, tolerability, accessibility, and expense

Abstract

Use of 24‐hour ambulatory blood pressure monitoring is strongly endorsed by contemporary hypertension guidelines. The objective of this study was to assess patient perceptions of ambulatory blood pressure testing, tolerability, accessibility, and expense. A convenience sample of 50, consenting patients undergoing ambulatory blood pressure monitoring at the University of Alberta Hypertension Clinic in Edmonton, Canada was studied. A 16‐item structured questionnaire was administered in person or electronically. Questions regarding the tolerability of ambulatory monitoring were evaluated using a 5‐point Likert scale and wait times, expenditures, and willingness to pay were evaluated by direct questioning. Mean age was 53.1 ± 15.4 years, 32 (64%) were female, and 23 (46%) were employed. Mean 24‐hour ambulatory BP was 134 ± 12/79 ± 8 mmHg. Ambulatory monitoring caused discomfort in 40 (80%) patients and disturbed sleep in 39 (78%). Forty‐one (82%) patients perceived that the home (vs pharmacy, primary care clinic, and speciality care clinic) would be the easiest venue to access future testing. On average, patients waited 27.3 ± 23.7 days for testing; they felt that a wait time of 21.3 ± 12.3 days was appropriate. Mean time taken off work was 8.6 ± 10.8 hours. Twelve (24%) patients indicated that they would be willing to pay out‐of‐pocket to undergo testing sooner, at a mean expenditure of $120 ± 69. Nineteen (62%) patients were willing to buy a monitor and felt that a mean purchase cost of $125 ± 89 was appropriate. These findings extend current knowledge of patient perceptions of ambulatory monitoring and may help to refine and optimize future delivery of this essential test.

1. INTRODUCTION

Use of 24‐hour ambulatory blood pressure monitoring (ABPM) in the diagnosis and management of hypertension is strongly endorsed by contemporary hypertension clinical practice guidelines.1, 2 ABPM is the preferred test for diagnosing hypertension because it is prognostically superior to other BP measurement modalities and because it can differentiate between white coat effect, masked effect, and true hypertension.3 These advantages, when factored into economic models, make ABPM a dominant strategy relative to office BP measurement—meaning that ABPM testing leads to better health outcomes at a reduced cost.4

Despite the established benefits of ABPM, use of this test is uncommon.5, 6 Constrained usage of ABPM has been proposed to be due to the relatively high cost of devices, which retail for approximately $1000‐3000 USD, lack of availability, limited tolerability, and the time required for testing.6 Regarding the latter, patients undergoing ABPM testing must wear a portable oscillometric device for 24‐hours, during which blood pressure (BP) measurements are usually taken every 15‐30 minutes while awake and every 30‐60 minutes while asleep. In addition to the mandatory 24‐hour testing period, ambulatory monitoring consumes time and expense related to attending appointments for device placement, return, and discussion of results.

It is important to understand patient perceptions about ABPM to properly assess the limitations of ABPM testing and in order to improve care delivery. Although previous patient surveys have focused on ABPM tolerability,7 better understanding of wait times, the time required for testing, costs incurred and willingness to pay for faster testing is needed. Accordingly, we conducted a survey of patients undergoing ABPM in a specialty hypertension program to better understand how patients view the ABPM testing experience.

2. METHODS

University of Alberta Research Ethics Board approval was obtained prior to study initiation. A convenience sample of 50 recruited, consenting patients referred by primary care providers or specialists for ABPM to the University of Alberta Hypertension Clinic in Edmonton, Canada was studied over a 7‐month period. This specialty clinic serves a catchment area of over 1 million individuals and provides diagnostic and consultative services. This includes an ABPM program, home BP telemonitoring, and expertise in secondary hypertension and resistant hypertension. There were 206 total ABPM studies completed during this time. The most common reasons for referral are for the initial diagnosis of hypertension and to work‐up resistant hypertension.

Ambulatory monitoring is provided at no cost to patients in this program. The program is administered and managed by hypertension specialist physicians who send a written interpretation of the test to the referring provider. Referrals for ABPM are accepted from primary care providers or specialists practicing in Edmonton and surrounding region. To undergo ABPM testing, referred patients attend an appointment in the clinic located within a university hospital setting to receive written and verbal instructions from nurses who have additional training in hypertension care provision. These nurses follow a standardized protocol to perform ABPM testing that includes patient education regarding the need for the test and proper test procedures. Patients are instructed to go about their typical daily activities, avoid strenuous exercise, and keep their arm relaxed and motionless during each measurement. They are asked not to remove the monitor once applied, not to get the monitor wet, and to fill out a structured timed diary of events (including medications ingested).

Patients have a SunTech Oscar 2 (SunTech Medical) monitor applied to their non‐dominant arm and have initial readings performed. The device is returned to the same clinic after the 24‐hour monitoring period has elapsed. BP measurements are performed every 20 minutes while awake and every hour while asleep. Daytime and nighttime periods are defined based on patient self‐report (via a patient diary). Criteria for a successful study are a 70% overall capture rate, with at least 21 daytime readings and seven nighttime readings. The diagnostic thresholds for hypertension are BP levels ≥130/80 mmHg overall and/or ≥135/85 mmHg during daytime.

To recruit potential subjects for the study, clinic nurses mentioned the study during the initial ABPM test visit. If patients were interested in hearing more about the study, their contact information was forwarded to the study team. Reasons for declining to learn more about the study or declining to participate were not sought or captured. After obtaining informed consent, demographic data and ABPM results were abstracted from the electronic medical record and a 16‐item questionnaire was administered either in person or via email. The questions (Appendix S1) assessed patient perspectives on tolerability using a 5‐point Likert scale (1 to 5, with 5 being least tolerable) and evaluated access, cost, and willingness to pay (in Canadian dollars) for earlier testing through direct questioning. When assessing access, even though all APBMs were performed in a speciality clinic, we asked the patient for their perception of the easiest place (home, local pharmacy, family physician's office, and specialists office) to access the test (eg, if future testing was needed). Tolerability questions were adapted from a previously published survey.7 When the participants elected to complete the paper version of the questionnaire, a research assistant was present to collect the survey. Participants were not guided through the questionnaire by the research assistant.

Results were summarized descriptively and quantitatively by calculating mean scores and standard deviations. SAS software version 9.3 (SAS Institute) was used to perform analyses. Subgroup analyses were conducted by employment status.

3. RESULTS

In terms of data completeness, there were six responses for the question on acceptable wait times that were non‐numeric (responses varied from “yes” to “depends on the severity of health risk”) and one non‐numeric response for the question on time required for travel and setup that were not included in the analysis.

Mean age of the study sample was 53 ± 15 years, 32 (64%) were female, and 23 (46%) were employed. Mean 24‐hour ambulatory BP was 134 ± 12/79 ± 8 mmHg, mean daytime BP was 139 ± 13/83 ± 9 mmHg, and mean nighttime BP, 120 ± 15/67 ± 10 mmHg.

Compared to those not employed, employed subjects were younger (47 ± 10 vs 58 ± 17 years), more likely male (43% vs 30%), and had similar BP levels (133 ± 13/76 ± 9 vs 136 ± 11 vs 81 ± 6 mmHg).

3.1. Testing experience

Response scores are summarized in Table 1. Forty patients (80%) reported that wearing the device caused discomfort and 39 (78%) of respondents indicated that ambulatory monitoring disturbed sleep and activity. Two patients removed the device during the 24‐hour period—one transiently to remove his shirt and, the other, to get to sleep (the minimum number of nighttime readings was still met).

Table 1.

Tolerability of ambulatory blood pressure monitoring

Question	1 (No)	2	3 (Moderate)	4	5 (Very)	Mean (SD)
Was wearing the monitor uncomfortable?	10 (20)	9 (18)	19 (38)	11 (22)	1 (2)	3.0 (1.1)
Was wearing the monitor painful?	24 (48)	11 (22)	7 (14)	6 (12)	2 (4)	2.0 (1.2)
Did the noise from the monitor disturb you?	17 (24)	14 (28)	10 (20)	8 (16)	1 (2)	2.2 (1.2)
Was wearing the monitor embarrassing?	37 (74)	6 (12)	3 (6)	3 (6)	1 (2)	1.5 (1.0)
Did the monitor interfere with your daily activities/work?	11 (22)	12 (24)	15 (30)	11 (22)	1 (2)	2.6 (1.1)
Did wearing the monitor interfere with your sleep?	11 (22)	5 (10)	10 (20)	20 (40)	4 (8)	3.0 (1.3)

Forty‐seven (82%) patients rated “home” as their first or second choice for the venue they perceived would most easily facilitate test administration, followed by pharmacy (27 patients; 54%), family physician office (19; 38%), and specialist (13; 26%) (Table 2).

Table 2.

Perceived convenience of venue to access ambulatory monitoring

Location	Rank
	1 (Most convenient)	2	3	4 (Least convenient)
Pharmacy	4 (8)	23 (46)	13 (26)	10 (20)
Home	35 (70)	6 (12)	2 (4)	7 (14)
Family physician office	6 (12)	13 (26)	25 (50)	6 (12)
Specialty clinic (eg, hypertension clinic)	5 (10)	8 (16)	10 (20)	27 (54)

3.2. Time spent and expenses incurred

The mean time spent waiting for ambulatory monitoring was 27.3 ± 23.7 days, slightly longer than the 21.3 ± 12.3 day mean wait time that patients indicated was appropriate. Mean time required to travel to and from appointments and for device setup and removal was 3.5 ± 5.5 hours. Thirty‐eight (76%) subjects paid for parking, with a mean cost of $12 ± 5. Of the 23 (46%) respondents who were employed, the mean time taken off work was 8.6 ± 10.8 hours.

3.3. Willingness to pay

Twelve (24%) patients indicated that they would be willing to pay for ambulatory monitoring to receive the test earlier; the mean specified amount they were willing to spend was $120 ± 69. Nineteen (62%) patients responded affirmative when asked if they were willing to buy the monitor for home use; the mean purchase cost felt to be appropriate was $125 ± 89 (range $30‐300).

3.4. Subgroup analyses by employment status

When exploratory analyses were conducted by employment status, no major differences were found in tolerability. Some small differences were found in access measures (Table 3), including longer time required to perform ABPM that was likely travel‐related because parking costs were similar.

Table 3.

Access measures according to employment status

Variable	Employed (n = 23)	Not Employed (n = 27)
Time (d) spent waiting for ABPM testing (mean ± SD)	22.7 ± 12	31.3 ± 30.0
Wait time (d) felt to be acceptable (mean ± SD)	17.5 ± 9.3	25.0 ± 11.0
Time (h) required to travel to and from appointments and for device setup and removal (mean ± SD)	5.5 ± 7.8	2.0 ± 1.4
Willing to pay for ABPM testing (No., %)	5 (22)	7 (26)
If yes, Canadian dollar amount willing to pay (mean ± SD)	122 ± 77	120 ± 69
Willing to buy ABPM device (No., %)	12 (44)	7 (30)
If yes, Canadian dollar amount willing to pay (mean ± SD)	158 ± 124	106 ± 60
Parking cost in Canadian dollars (mean ± SD)	12 ± 4	12 ± 5

4. DISCUSSION

Prior studies have demonstrated that ambulatory BP monitoring is the least acceptable of the major measurement modalities (office, home, and ambulatory) and this reduced acceptability is primarily related to the need for frequent measurements, which cause discomfort, constrain activity, and disturb sleep.8, 9, 10 Thus, the principle factor that underpins the prognostic advantage of ambulatory monitoring (multiple readings, especially at night) is also the major reason for its reduced acceptability.11, 12 Conversely, patients do recognize the benefits of ambulatory monitoring because confidence that this technique represents a true reflection of usual BP and an accurate diagnostic assessment is much higher than for office BP.13 From the provider perspective, resource‐related factors (eg, cost, reimbursement, and provider time) and patient‐related factors (eg, willingness, discomfort, and lack of time) have been identified as the major barriers to performing ambulatory monitoring.6

Our findings are similar to those of prior patient surveys in terms of testing tolerability, with the major tolerability limitation in our sample being sleep disturbance. The more novel findings of this study relate to venue of testing, wait times, expenditures, and willingness to pay, including the finding that most patients perceived that they would prefer to have testing performed at home or in the pharmacy. Of note, no major differences in employed vs not employed respondents were found. Home testing is, in theory, feasible but has it challenges, including how to optimize device fitting, test execution, and device delivery and pick‐up. We would envision that it could be performed by a trained technician or community health worker rather than a provider that is more costly. It deserves further exploration given the considerable amount of time patients reported spending off work and traveling to and from appointments. In‐pharmacy testing is commonly performed in some jurisdictions and has distinct advantages in terms of increasing testing availability and convenience.14

In our sample, less than one‐quarter of patients were willing to pay to receive earlier ambulatory monitoring and this low number could be a function of patients’ willingness to wait or of the relatively short wait times experienced. Those that were willing to pay were also willing to spend a reasonably large amount (approximately $120) for the test. Notably, this is high relative to a recently introduced $80 reimbursement fee code in the province of Alberta. It is also roughly double the median payment provided to physicians in a 2007‐2010 analysis of US Medicare claims ($52 USD).15 As low reimbursement rates have been proposed to be a cause of constrained use, these findings indicate that, relative to patient perceptions, reimbursement thresholds may be too low. Nearly two‐thirds of the sample indicated a willingness to pay for the device outright; however, the $125 proposed mean purchase cost is well below the cost of current devices which, in Canada, typically retail for $1500‐3000 and, therefore, not congruent with market prices.

A limitation of this study is that it was conducted within a tertiary care ambulatory monitoring program in Alberta, Canada. Although this program receives referrals from both primary and specialty care, generalization of the results beyond the Canadian specialty care setting should be performed with caution. Although ABPM is not offered free of charge in all Canadian provinces, it is offered free of charge in our program and a recently introduced fee code has extended coverage across Alberta. Survey results should be interpreted in the context that patients are accustomed to receiving free care within Canada's universally accessible medical system and results may differ in jurisdictions where patients are more accustomed to paying for medical care. Additional limitations include the relatively small sample size, particularly to perform subgroup analyses, and the fact that the questionnaire was kept simple and based on prior research (ie, we did not use sophisticated questionnaire design metrics).

The findings of this study extend knowledge of patient perspectives on ABPM. Given that ABPM is an essential test that is underutilized, our findings may help to inform future work aimed at improving the testing experience.

CONFLICT OF INTEREST

JR, LB, TC, and RP are supported by an alternative funding plan from the Government of Alberta and the University of Alberta. JR and RP are cofounders of a blood pressure measurement start‐up company, mmHg Inc, creating software and hardware innovations to improve blood pressure measurement. No ABPM based products are currently on the market.

AUTHOR CONTRIBUTIONS

RP and JR designed the study. All authors collaborated on the questionnaire design. JR, RB, and, OM collected and collated the data. RP analyzed the data and drafted the manuscript. All authors revised and approved the final manuscript.

Supporting information

 

Ringrose JS, Bapuji R, Coutinho W, et al. Patient perceptions of ambulatory blood pressure monitoring testing, tolerability, accessibility, and expense. J Clin Hypertens. 2020;22:16–20. 10.1111/jch.13760