Adding Ancillaries: Ambulatory blood pressure monitoring

Do some of your patients have "white-coat" hypertension? No matter how you try to put them at ease, in-office blood pressure measurements are nerve-wracking experiences for them.

"I used to tell patients like that to buy a blood pressure machine," says internist Brian S. Israel of Tarrytown, NY, "but some would get so obsessed with taking their blood pressure that using the machine became a source of anxiety in itself, and their blood pressure would go up."

To get better readings for this type of patient, Israel leased an ambulatory blood pressure monitor. "I can get patients' blood pressure when they're not stressed by being in my office or responsible for taking it themselves. It really helps you discern whether a patient has white-coat hypertension or the real thing. I can also see if their blood pressure dips when they're asleep, which is really useful."

Reimbursement for ABPM might be problematic, though. Here's what to consider before offering it in your practice.

Equipment

There are three ways to add ambulatory blood pressure monitoring to your practice: purchase the monitor outright, lease it with a buyout payment after 12 months, or rent the device for a specified time period. Under each of these arrangements, you plug the monitor into your computer via a serial port to download the readings. You can read the report onscreen or print it out.

Sal Volpe bought his SunTech Medical Oscar 2 ABPM with AccuWin Pro software because he thought it would be a good investment and he didn't expect the technology to change significantly over the next five years. Brian Israel leased a Tiba 24-hour ambulatory blood pressure monitor after he saw one at the American College of Physicians' 2005 annual meeting. Tiba also has a rental plan.

An inexpensive monitor could pay for itself in a year if you order two studies a month (based on Medicare reimbursement levels). If you don't want to buy the device outright, you'll need to do three a month to cover lease payments on the Tiba model; two to three studies a month will pay the rental fee.

The minimum computer requirements for the Tiba 24-hour ABPM are a Windows-based operating system with 20 MB of hard drive space, a CD drive, and an available serial or USB port. For the Oscar 2, the PC requirements are a Pentium-based processor or higher, a SVGA display, a 9 pin serial COM port or USB port, 32 MB RAM or higher, and a Windows 98 or later operating system. Other systems may have different specifications.

Space

The monitors are compact. The Oscar 2 is about 12 x 7 x 3 centimeters and weighs 284 grams while the Tiba monitor weighs 290 grams. They come with a cuff. (Some models come with multiple cuffs: the Tiba model comes with three sizes of cuff: regular adult, large, and child; the Oscar 2 comes with two Orbit cuffs.) You'll need room for a pouch, a strap, batteries, and patient diaries.

According to the doctors we spoke with, a file drawer or cabinet is all that's needed to store the monitors and associated paraphernalia. You or a qualified staffer can fit the monitor to a patient in a standard examination room. The device can also be removed in an exam room, or the patient can remove it himself and return it to your office.

Staff/training

Typically, medical assistants or nurses attach the monitors. Sal Volpe's staff learned the process for the Oscar 2 monitor simply by reading the instructions that came with it. Tiba representatives offer complimentary training over the phone to physicians and staff.