This study assessed the status of home BP monitor ownership and regular HBPM behaviour among Chinese adults with hypertension. The results showed that nearly half of the participants had a home BP monitor, but this varied across different provinces. More than one-quarter of participants reported weekly HBPM. The HBPM regimens specified in hypertension guidelines are seldom achieved in actual practice. Only a small group of participants actively discussed their HBPM readings with their doctors. Healthcare professionals’ advice was the strongest factor contributing to home BP monitor ownership and weekly HBPM.
Use of HBPM has progressively increased over the last two decades. Initially, around 20% of patients with hypertension in developed countries used HBPM [18, 19], with current rates reported as 31%–75% in studies across different countries [15-18]. A large difference was also found across different areas of China; with performing HBPM at least once a week reported by 52% in Zhejiang, 36.9% in Chengdu [20] and 42.8% in Beijing [21]. The present study showed that HBPM was performed by around 47.8% of patients with hypertension in Beijing, 19.8% in Jiangsu and 14.7% in Shandong. The majority of previous studies showed a higher prevalence of HBPM among urban residents; however, rural residents comprised half of our sample, and we found a low proportion of rural participants had a home BP monitor.
Various factors may affect an individual purchasing a home BP monitor and using HBPM. Previous studies among general patients with hypertension (primary care or community settings) have shown inconsistent results. Some studies reported that patients with a higher education level, higher income, male sex and a younger age were more likely to adopt HBPM [2,15,22,23], whereas other studies found higher HBPM use in older adults [16,23,24]. In this study, no difference in HBPM was found between males and females, and older participants were more likely to use HBPM. Similarly, HBPM use has been associated with healthcare providers’ advice on HBPM [12,16,24]. A study among patients with chronic kidney disease revealed the most common reason for not using HBPM was lack of advice by a physician (43.4%) [25]. Another study showed that 35.2% of patients were advised to perform HBPM by their doctor, with this proportion being 29.7% in Canada [16], about 50% in Japan [26] and the UK [27] compared with 62.1% in our study. Those results suggested that healthcare professionals should promote HBPM use, especially among patients with hypertension who are younger, newly diagnosed with hypertension and live in rural areas.
Previous studies defined regular HBPM as a respondent’s self-report of monitoring their own BP at home, and performing this at least weekly [16,23]. According to relevant hypertension guidelines [13,14], we defined regular HBPM more clearly and completely. Performing HBPM regularly (duplicate measurements in the morning and evening for 7 days) is seldom achieved in current practice; about 4.4% of participants in our study had achieved optimal HBPM regimens. Uptake of both morning and evening measurement was low, especially in those with controlled office BP. According to the US National Health and Nutrition Examination Survey 2009–2010, patients with uncontrolled BP engaged in weekly or more frequent HBPM, whereas patients who achieved the ideal control standard engaged in monthly HBPM [28].
HBPM use remains low and poor adherence to hypertension guidelines may be attributable to barriers at the patient, clinician, and healthcare system levels [11]: 1) patients lack adequate knowledge about the optimal regimen for HBPM [20,24,29]; 2) presence of barriers to conducting morning and evening measurement for patients [11]; 3) lack of encouragement from healthcare providers or more detailed direction for HBPM not being provided to patients [25]; and 4) HBPM readings seldom being documented by clinicians [30]. Healthcare systems should further enhance the successful implementation of HBPM, supported by plans to encourage healthcare professionals and provide patients with HBPM regimens, such as selection of appropriate BP measurement devices, measurement conditions and self-measurement skills and protocols.
Clinicians seldom use HBPM instead of office measurements for treatment adjustment. A Canadian study noted that only 19% of primary physicians used HBPM readings to guide therapy [30], although about 30% of patients shared their HBPM results with their health professional [16,30]. In the present study, 31.9% of participants were asked their HBPM results by their doctors, and only 16.0% proactively shared their readings with their doctors. With the development of BP telemonitoring technology and equipment, Internet-based remote monitoring and home management of BP is expected to further improve the application of HBPM readings [31].
Optimal BP control at home was obtained among participants with controlled office BP, but optimal morning BP control was significantly lower than other time BP control. Previous studies showed 50%–60% of patients with controlled office BP had an elevated morning BP [32,33]. Our findings are consistent with previous publications involving similar populations in that 47.4% did not achieve the target for morning BP control. Morning BP is now recognised to be superior to office BP in predicting cardiovascular risk, Therefore, hypertension guidelines highlight the assessment of morning BP [34].
Several limitations of this study should be noted. First, given that the sample size was not large, the results may not be representative of all urban and rural areas in Shandong, Jiangsu and Beijing. Second, we did not investigate patients’ knowledge of HBPM and common reasons for not using HBPM, and therefore cannot validate assumptions regarding such reasons. Third, there was no consideration of advice from healthcare providers to investigate their efficacy; even if there was standard plan for HBPM in the guideline, guideline adherence was not evaluated. Fourth, the rate of home BP control was not representative because the results were not based on the uniform measuring standard and were from a small group of patients. In addition, we did not confirm whether participants measured their home BP using appropriate BP monitoring (validated or not, appropriate cuff size) and a proper measurement technique. These details might have lead to measurement errors. Reporting bias also existed because home BP monitors did not have a log-memory function.