Providing access to Ambulatory Blood Pressure Monitoring (ABPM) for patients can be a daunting exercise in primary care. With ABPM increasingly recommended for the management of hypertension, this guide breaks down the steps required to bring ABPM to your practice.
This guide is intended for medical professionals planning to bring ABPM to their primary care or specialty practice. The guide includes resources and information from US ABPM guidelines. International guidelines may vary.
What is ABPM?
Why Use ABPM to Manage Hypertension?
The Challenges of Office BP Measurements
Office BP provides a snapshot of a patient's blood pressure and cardiovascular risk. This snapshot can offer a misleading look at something as variable as blood pressure, which changes minute to minute based on many internal and external factors. Average blood pressure is closely linked to risk of cardiovascular disease.
Relying on spot blood pressure checks rather than techniques measuring blood pressure over time can lead to over-medication, leading to patients experiencing unnecessary side-effects, or under-medication, increasing risk of cardiovascular disease for patients with undetected high blood pressure.
The Benefits of ABPM
- Studies have repeatedly shown that ABPM offers the most accurate way to diagnose hypertension.
- ABPM detects a number of BP patterns missed by office or home BP:
- Episodic hypertension
- White coat syndrome
- Masked hypertension
- Nocturnal hypertension
- Patients who have their hypertension managed have better outcomes compared to office based readings.
- For more reasons to use ABPM to diagnose hypertension, see our blog:
Who is Recommending ABPM?
1. Guidelines for Indications and Interpretation of ABPM for management of hypertension
There are now widely available guidelines for the use of ABPM in hypertension management for adult and pediatric use. Guidelines cover:
- Indications for prescribing an ABPM to patients
- Protocols recommended for ABPM studies
- Interpretation of study results.
IndicationsThe ACC/AHA guidelines recommend ABPM for:
Adults not taking antihypertensive medication with:
- Systolic BP between 130 and 160 mm Hg or
- Diastolic BP between 80 and 100 mm Hg should be screened with ABPM
2. Understanding Reimbursement and Payment
The return on investment of offering an ABPM service will depend on the reimbursement available. SunTech’s updated 2020 reimbursement FAQ includes:
- CPT codes
- ICD10 Indications
- Average Medicare payments for ABPM
Direct Patient Billing
Providers may also elect to offer ABPM as a patient chargeable procedure, for which typical charges range from $50 - $200.
3. Organizing your workflow
Adding any new service to the practice requires organization, but ABPM in particular will have additional logistics implications. Patients will need to be scheduled according to the availability of monitors at the practice.
A typical ABPM workflow
1. Patient identified as candidate for ABPM and scheduled for study.
2. Monitor programmed and fit to patient.
3. Monitor is returned to the practice.
4. Report is created and sent to EMR.
SchedulingScheduling can be managed through standard practice scheduling software, with setup typically taking 10 to 20 minutes to program the device, fit the patient and perform a test reading before sending them on their way.
Your ABPM teamYou will need to assign responsibility for managing your ABPM clinic. Determine who will be:
- Scheduling ABPM and managing devices and patient visits.
- Facilitating and setting up ABPM studies at the practice.
- Processing returned ABPM devices and retrieving the 24-hour study report.
LocationSelect a location for ABPM setup. This is typically an exam room and will need:
- PC or Laptop
- Exam bed or Chair
4. Selecting a device
Selecting a device will depend on a number of areas, here is our review of the most important features of an ABPM:
Understanding which BP devices are accurate can be a difficult proposition. Look for a device that has been validated to protocols accepted by the FDA and other international standards organizations. ISO 81060-2 is the most widely accepted validation protocol, but other validation protocols do exist. Other validation protocols may however have less stringent requirements for passing.
What is a validation?
A validation is a clinical study that assesses the accuracy of a blood pressure device. Different validation protocols exist, but may have more or less stringent pass requirements. Our review of the implication of each major validation protocol available is below.
We recommend choosing a device that has at minimum a validation to the ISO 81060-2 validation, but preferably has completed the ISO 81060-2:Ergometry validation.
|ISO 81060-2||The currently accepted validation for FDA and CE registration. ISO 81060-2 is an 80 subject validation that is considered the standard validation for BP devices.|
|The ISO 81060-2:Ergometry validation is an additional 40 patient validation that is completed on top of the standard ISO 81060-2 validation. While validations are typically conducted under controlled clinic conditions, ABPM devices that have passed the 81060-2:Ergometry protocol have been tested on subjects stressed from exercise and can be considered to be accurate even outside of controlled sedentary conditions.|
|British Hypertension Society (BHS)||The validation standard developed by the British Hypertension Society. It is an older standard, but has strong requirements for passing. It also uniquely provides grades to passing devices, ranging from A/A to C/C based on the accuracy of the device.|
|European Society of Hypertension (ESH:IP)||The ESH:IP validation was developed as a smaller 40 person validation that can be completed more quickly than other validation, but has a lower statistical standard for passing. This validation is not accepted for FDA or CE registration.|
Choosing an ABPM with motion tolerance ensures you are able to collect sufficient readings to intepret your results. It can be difficult to get a reliable blood pressure reading on a patient that is moving, which is why many ABPMs have motion tolerant algorithms designed to reject noise from readings. Choose an ABPM with motion tolerance to maximize the number of successful studies.
While wearing an ABPM for a day is no-one's first choice for relaxing experience, A comfortable experience will help ensure your patient wears the monitor for the full 24 hour period as well take part in follow-up ABPM studies, if necessary. Patient Comfort can be affected by the following factors:
- The Cuff While d-ring cuffs provide the ability to remove and re-apply the cuff if needed, it can be uncomfortable for the patient to have a metal ring against their arm for the during of the 24-hour study. Some cuffs offer elastic sleeves that hold the cuff in position and allow the patient to self-apply the cuff as needed.
- Inflation Control Some ABPMs will control inflation by only inflating the pressure as high as necessary for that patient. With the inflation level based on previous measurements. Over-inflating can be painful for the patient over repeated measurements.
- Motion Tolerence The less readings, the better, when it comes to ABPM studies. Repeating readings because of movements during readings will result in lower patient comfort.
Although the monitor typically receives the most attention when considering a purchase, clinician time is spent mostly interacting with the software. Software that supports an efficient workflow will minimize non-valued added time and allow the best return on investment possible.
- EMR Integration can take minutes off the setup and processing for each study as well as cut down on manual entry errors. While you may not wish to perform an integration for your first ABPM, as your service grows, the ability to pull patient information from the EMR and automatically assign reports can be invaluable. This one feature can cut down the time you spend on data entry by 80%!
- Study Templates allow the user to re-use existing settings and therefore setup studies in seconds. Templates can also cut down on errors in the setup of ABPM studies and ensure patients do not need to repeat studies due to incorrect setup.
- Automatic Interpretive Summary provides an automatic interpretation of the ABPM data according to AHA, JNC or ESH guidelines. Automatic Interpretive Summary provides a speedy way to review ABPM study data.
- Customizable Reports will allow you to create a study report that has the information you need to make informed decisions on your patients, without pages and pages of unnecessary information.
- Automated Export Format is a feature that speeds up export by reducing the time it takes to export a report to your specifications.
- Client <-> Database software will allow you to access all your patients on your PCs across the clinic. This is a useful feature if you want the freedom of fitting ABPM devices in multiple exam rooms.
- Tech Support can be the difference between a successful or a turbulent start. Make sure your chosen supplier has videos, quick start guides, and most importantly a tech support line that understands the product!
- Security Audits are an area where many medical device projects can get hung up, so check that your supplier is able to provide security audit documents ahead of time and can provide a contact for technical questions.
When asking for a quote, make sure you include any software licenses and missing accessories. Some ABPM suppliers require additional software licenses to use their devices. If you end up needing to add devices and PCs in the future, additional expense can add up quickly!
Check system pricing includes these items:
- Belt/Shoulder Strap
- USB Cable
- PC Software
- EMR Integration (if required)
- 2 year+ Warranty
Train your team. Guides and videos from your ABPM supplier can help make the process quick and smooth. Training should cover:
- Discussing ABPM with patients
- Programming devices for studies
- Setting up the device for a study
- Exporting reports to the EMR
SunTech has documents to help you training your team. You can find links to SunTech ABPM training documents below:
SunTech offers a pack of sample documents to use in your practice.
Patient Information Leaflet
Information on ABPM intended for patients.
Patient Study Guide
Guide for patients on what to expect and how to experience a successful study. Instructions on removing and refitting the cuff.
Patient Care Agreement (example)
A sample patient care agreement for patients to complete before the study. The agreement reminds the patient of the responsibilities of taking care of the monitor and returning it promptly following the study.
A printable diary to provide the patient the ability to record their activities during the study.