Research Article
The use of ambulatory blood pressure monitoring among Medicare beneficiaries in 2007–2010

https://doi.org/10.1016/j.jash.2014.09.015Get rights and content

Abstract

The US Centers for Medicaid and Medicare Services reimburses ambulatory blood pressure monitoring (ABPM) for suspected white coat hypertension. We estimated ABPM use between 2007 and 2010 among a 5% random sample of Medicare beneficiaries (≥65 years). In 2007, 2008, 2009, and 2010, the percentage of beneficiaries with ABPM claims was 0.10%, 0.11%, 0.10%, and 0.09%, respectively. A prior diagnosis of hypertension was more common among those with versus without an ABPM claim (77.7% vs. 47.0%). Among hypertensive beneficiaries, 95.2% of those with an ABPM claim were taking antihypertensive medication. Age 75–84 versus 65–74 years, having coronary heart disease, having chronic kidney disease, having multiple prior hypertension diagnoses, and having filled multiple classes of antihypertensive medication were associated with an increased odds for an ABPM claim among hypertensive beneficiaries. ABPM use was very low among Medicare beneficiaries and was not primarily used for diagnosing white coat hypertension in untreated individuals.

Introduction

More than 20 years ago, Pickering et al introduced the concept of white coat hypertension.1 White coat hypertension is defined as having blood pressure that is elevated when measured in the clinic but not elevated when assessed by ambulatory monitoring in individuals not taking antihypertensive medications.2 This is now a well–recognized phenomenon, estimated to be present in 15%–25% of patients with elevated clinic blood pressure.1, 3, 4 It is generally accepted that the risk of cardiovascular disease events in patients with white coat hypertension is relatively low compared with those with both elevated clinic and ambulatory blood pressure (ie, sustained hypertension).3 Additionally, the benefits of antihypertensive treatment in patients with white coat hypertension have been reported to be limited.5

In 2001, the Centers for Medicaid and Medicare Services (CMS) in the United States (US) approved reimbursement for ambulatory blood pressure monitoring (ABPM) when white coat hypertension is suspected.6 In 2011, based on cost–effectiveness data, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom recommended that ABPM be performed to confirm the diagnosis of hypertension in individuals presenting with clinic hypertension.7 A recently published 2013 European Society of Hypertension Position Paper further emphasized the important role of ABPM in the diagnosis of white coat hypertension, as well as in identifying other important blood pressure phenotypes (eg, masked hypertension, nocturnal hypertension, blood pressure variability).3

Given the high incidence of clinic hypertension among older adults,8 one would anticipate that ABPM use would become common after the reimbursement for suspected white coat hypertension was approved by CMS. However, it is not known how frequently ABPM is being utilized in older patients in the US. The aim of this study was to estimate national rates of ABPM use, time trends, and correlates of use among US Medicare beneficiaries. Additionally, we investigated factors associated with the performance of ABPM among Medicare beneficiaries with a diagnosis of hypertension.

Section snippets

Methods

Using previously described methods,9, 10 we conducted a study of Medicare beneficiaries in the US using the 2006–2010 national 5% random sample from the CMS. Medicare is a US federal insurance program that covers individuals 65 years of age and older, on disability, or who have end–stage renal disease. Coverage may be chosen on a fee–for–service basis or through contracts with managed care organizations (ie, Medicare Advantage). Specific data used for the current analyses include claims from

Results

Table 1 shows the percentage of beneficiaries in the 5% Medicare sample included in the current analysis with and without an ABPM claim by calendar year. For 2007, 2008, 2009, and 2010, the percentage of Medicare beneficiaries with ABPM claims was 0.10%, 0.11%, 0.10%, and 0.09%, respectively.

Discussion

There are several principal findings of our study. First, the percentage of US Medicare beneficiaries with ABPM claims was very low and did not change from 2007 through 2010. Second, individuals with an ABPM claim were more likely to have medical comorbidities including coronary heart disease, stroke, and chronic kidney disease, more hypertension diagnoses, and filled four or more classes of antihypertensive medications. Third, although a diagnosis of white coat hypertension was more common in

References (26)

  • A.P. Carson et al.

    Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis

    Hypertension

    (2011)
  • P. Li et al.

    Effect of the Medicare Part D coverage gap on medication use among patients with hypertension and hyperlipidemia

    Ann Intern Med

    (2012)
  • G.R. Shroff et al.

    Temporal trends in ischemic stroke and anticoagulation therapy among Medicare patients with atrial fibrillation: a 15-year perspective (1992-2007)

    JAMA Int Med

    (2013)
  • Cited by (0)

    This study was partially supported by P01-HL047540 and P01-HL047540-19S1 (a Diversity Supplement awarded to Dr Keith Diaz) from the National Heart, Lung, and Blood Institute at the National Institutes of Health (NIH). The funding source had no role in the study design; collection, analysis, and interpretation of the data; writing of the report; and decision to submit the article for publication.

    Conflicts of interest: Dr Kent received salary support for Amgen Inc. Dr Viera has served on the Medical Advisory Board for Suntech Medical as well as a Hypertension Advisory Board for Daiichi Sankyo. Drs Kilgore and Muntner received institutional grants from Amgen Inc. Dr Muntner also served on an advisory board for Amgen Inc. There are no other potential conflicts of interest.

    View full text