Hypertension is a major contributor to worldwide cardiovascular mortality, however, only one-third of patients with hypertension have their blood pressure treated to guideline recommended levels. To improve hypertension control, there may need to be a fundamental shift in care delivery, one that is population-based and simultaneously addresses patient, provider and system barriers. One potential approach is home-based disease management, based on the triad of home monitoring, team care, and patient self-care. Although there may be challenges to achieving the vision of home-based disease management, there are tremendous potential benefits of such an approach for reducing the global burden of cardiovascular disease

DJ Whellan

EC Okonofua

JM Walsh

John S Rumsfeld

P Michael Ho

PS Wang

T Bodenheimer

English

PubMed

Crossref

BioMed CentralBMC Public Health
ssOpen AcceCommentary
Beyond inpatient and outpatient care: alternative model for 
hypertension management
P Michael Ho* and John S Rumsfeld
Address: Cardiology Section, Denver VA Medical Center, 1055 Clermont Street (111B), Denver, Colorado 80220, USA
Email: P Michael Ho* - Michael.Ho@UCHSC.edu; John S Rumsfeld - John.Rumsfeld@va.gov
* Corresponding author    
Abstract
Hypertension is a major contributor to worldwide cardiovascular mortality, however, only one-
third of patients with hypertension have their blood pressure treated to guideline recommended
levels. To improve hypertension control, there may need to be a fundamental shift in care delivery,
one that is population-based and simultaneously addresses patient, provider and system barriers.
One potential approach is home-based disease management, based on the triad of home
monitoring, team care, and patient self-care. Although there may be challenges to achieving the
vision of home-based disease management, there are tremendous potential benefits of such an
approach for reducing the global burden of cardiovascular disease.
Text
Hypertension is a principal risk factor for the develop-
ment of coronary heart disease and stroke, and is a major
contributor to worldwide cardiovascular mortality [1]. It
affects up to 37% of the global adult population and it is
estimated that 7.1 million deaths are due to hypertension,
which is 13% of total global fatality [1]. The continued
worldwide burden of hypertension is surprising given
awareness of the importance of blood pressure (BP) con-
trol by public health agencies, the medical community
and the public, coupled with the availability of safe and
effective therapies. Currently, there are over 10 classes of
anti-hypertensive medications and it is estimated that
achieving a sustained 12 mm Hg decrease in systolic BP
will prevent 1 death for every 11 patients treated [2].
Despite these known benefits, only one-third of patients
with hypertension have their blood pressure treated to
guideline recommended levels [2].
Improved hypertension management thereby remains a
primary global public health goal, but how to best achieve
broad hypertension control remains uncertain. The study
by Heinz et al. adds to our knowledge about potential
approaches to the management of blood pressure [3]. The
study found that, among a high-risk cohort of hyperten-
sive patients with left ventricular hypertrophy in Ger-
many, 68% of patients had their BP controlled after an
intensive inpatient rehabilitation stay while 45% of out-
patients had their BP controlled after a mean follow-up of
52 days.
Superficially, one is tempted to conclude that there may
be a role for initial inpatient management of hypertension
to ensure better chronic BP control. However, the study by
Heinz et al. does not support such a conclusion. In this
observational study, patients who received inpatient BP
management had significantly lower BP from the start of
the observation period, and the proportional reductions
in BP were equal between the two groups over the follow-
Published: 19 October 2006
BMC Public Health 2006, 6:257 doi:10.1186/1471-2458-6-257
Received: 12 September 2006
Accepted: 19 October 2006
This article is available from: http://www.biomedcentral.com/1471-2458/6/257
© 2006 Ho and Rumsfeld; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
BMC Public Health 2006, 6:257 http://www.biomedcentral.com/1471-2458/6/257up period. Thus, the authors correctly concluded that the
principal finding of this study were: 1) patients who had
inpatient BP management, despite more prevalent cardio-
vascular disease and comorbidites, had lower BP than
those who had outpatient management from the outset;
and 2) there was, "a high proportion of patients that did
not achieve treatment goals" in both groups [3]. While the
rates of BP control in this study were higher than those
reported in the literature, 32% of the inpatient group and
55% of the outpatient group were left with uncontrolled
hypertension.
This begs the question of why hypertension management
is so difficult. The answer may lie in the fact that BP con-
trol is related to patient, provider and healthcare system
factors, all of which must align to achieve BP goals. From
a patient perspective, hypertension is often a silent disease
and patients may not take antihypertensive medications
as directed because their positive effects are not as obvious
as potential side effects from the medications. Moreover,
patients with hypertension often have co-morbid diseases
(e.g., diabetes) that require additional medications, fur-
ther increasing the complexity of medication regimens.
Patients may also have conditions such as depression that
directly impact adherence to therapy [4]. From a provider
perspective, potential explanations for difficulty control-
ling hypertension include therapeutic inertia, where pro-
viders fail to intensify therapy despite persistently elevated
BP readings, and the 'tyranny of the urgent', where office
visits are focused on acute complaints, the need to address
multiple chronic conditions, and administrative work
such as medication refills, leaving hypertension manage-
ment a lower priority [5,6]. Finally, multiple system-level
issues can negatively impact hypertension management.
Examples of these include lack of access to care, reliance
on episodic patient-provider visits, care delivered in silos
(e.g. specialist versus generalist), and failure to engage
patients in their own management.
Small studies of quality improvement (QI) interventions
for hypertension have addressed some of these barriers
and have achieved modest results [7]. Multi-modal inter-
ventions have been the most successful with the following
general hierarchy of effectiveness: team management,
patient education, and provider-centered interventions
[7]. Team management has generally consisted of assign-
ing patient care responsibilities to someone other than the
patient's physician, with this person also taking responsi-
bility for patient education and follow-up. Overall,
patients in the intervention groups achieved median
reductions of 4.5 mm Hg for systolic and 2.1 mm Hg for
diastolic blood pressures [7]. Despite the efficacy of some
hypertension interventions, they can be resource intensive
and their broad applicability and effectiveness in clinical
practice are unclear. Certainly, they have not been widely
adopted and the gaps in BP control persist.
To improve hypertension management, there may need to
be a fundamental shift in care delivery, one that is popu-
lation-based and simultaneously addresses patient, pro-
vider and system barriers. One potential approach is to
shift from reliance on traditional, episodic visits to home-
based disease management for all patients with hyperten-
sion. To achieve this, health information technology
would need to be employed for chronic home monitoring
and management (e.g. interactive voice response technol-
ogy, home telemonitoring devices, or the Internet), dras-
tically reducing the need for office visits by patients. Then,
teams comprised of pharmacists, nurses, nurse practition-
ers, and/or physician assistants, with physician oversight,
would make management decisions based on home mon-
itoring and remote patient communication. Of note, this
creates an efficiency whereby a team can remotely manage
many more patients than can possibly be done in the
office setting. In addition, intensity of care can be tailored
depending on the clinical need, with frequent manage-
ment interventions to achieve blood pressure control in
the initial phase, and lower levels of surveillance later on
for patients who have achieved BP goals and are feeling
well. As important, patients would practice self-care (e.g.
home blood pressure measurement, medication adher-
ence, daily weights, reporting of exercise and diet) and
receive education about hypertension management and
lifestyle modifications through the home monitoring
technology. Office visits for hypertension would be used
to complement home-based management and for clinical
situations where a face-to-face visit is required.
Taking this a step further, hypertension is usually one of a
number of conditions that contribute to a patient's overall
risk for cardiovascular disease. To address the growing
number of patients with multiple risk factors, there needs
to be a shift away from focusing on single disease condi-
tions towards global cardiovascular disease risk assess-
ment and reduction. The majority of patients with
hypertension often have co-existing conditions such as
diabetes, high cholesterol, smoking, and/or sedentary life-
styles that require chronic ongoing care and these condi-
tions may also benefit from the triad of home monitoring,
team care, and patient self-care. Rather than treating
hypertension as an isolated condition, the home-based
disease management program can be tailored to a
patient's cardiovascular disease risk profile and treatment
intensity can be titrated accordingly.
There are obvious challenges to achieving the vision of
home-based disease management. For example, physi-
cians would need to embrace health information technol-
ogy and team management as principal methods ofPage 2 of 3
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routine patient care. Moreover, health care policies must
align financial incentives to support such programs,
including the infrastructure to support the technology and
appropriate reimbursement for utilizing such systems to
provide chronic care management. However, the gains of
pursuing such a vision may be tremendous, including 1)
efficiencies of management, 2) potential for broad appli-
cation for populations of patients and across multiple
chronic conditions, 3) early detection of patient prob-
lems/decompensation at home, 4) allowing physicians to
concentrate on sicker patients, acute conditions, and diag-
nostic workups in the office, 5) ensuring continuity of
care, and 6) directly activating patients to engage in self-
care.
Perhaps the most compelling reason to push for a shift to
home-based disease management is that current care
models are clearly insufficient. The study by Heinz et al.
tells us that even intensive inpatient management doesn't
get the job done. The growing pressures on clinicians
within office and hospital settings are likely to relegate
hypertension management even lower on the priority list.
At the same time, disease management trials for heart fail-
ure support the idea that home monitoring coupled with
team care and patient self-care can improve patient out-
comes [8]. It is notable that healthcare systems with
aligned incentives to take responsibility for 'covered lives'
rather than episodes of care, like Kaiser Permanente and
the Veterans Health Administration, are rapidly moving to
such chronic disease management programs for their
patients. Over 16 million people die worldwide each year
from cardiovascular disease [9]. If we are to make an
impact in reducing the global burden of cardiovascular
disease, the time for change is now and home-based
chronic disease management offers an alternative model
of care with tremendous potential benefits.
References
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Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2458/6/257/pre
pubPage 3 of 3
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Beyond inpatient and outpatient care: alternative model for hypertension management

Abstract Hypertension is a major contributor to worldwide cardiovascular mortality, however, only one-third of patients with hypertension have their blood pressure treated to guideline recommended levels. To improve hypertension control, there may need to be a fundamental shift in care delivery, one that is population-based and simultaneously addresses patient, provider and system barriers. One potential approach is home-based disease management, based on the triad of home monitoring, team care, and patient self-care. Although there may be challenges to achieving the vision of home-based disease management, there are tremendous potential benefits of such an approach for reducing the global burden of cardiovascular disease.</p

Rumsfeld John S

Ho P Michael

Directory of Open Access Journals

BMC Public Health

BM: Therapeutic inertia is an impediment to achieving the Healthy People

Disease Prevention and Control [http://www.who.int/dietphysicalactivity/publications/facts/cvd/en/].

Disease Statistics. American Heart Association website [http://www.americanheart.org/pre senter.jhtml?identifier=3001008]. Accessed

Improving primarycare for patients with chronic illness: the chronic care model, part 2. JAMA

Luft and Kurt Bestehorn Management of high-risk patients with hypertension and left ventricular hypertrophy in Germany: role of cardiac specialists.

Metaanalysis and review of heart failure disease management randomized controlled clinical trials. Am Heart J

MK: Quality improvement strategies for hypertension management: a systematic review. Med Care

Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors.

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Beyond inpatient and outpatient care: alternative model for hypertension management

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