Based on the 2011 SMBP CER and our discussion with stakeholders, we identified 16 potential research areas, five of which were ranked as high priority areas of future research. The first four of these high-priority topics pertain to interrelated evidence gaps, such as the lack of longer term studies which show persistence of BP control or clinical benefit from SMBP, uncertainty regarding the populations likely to benefit from SMBP, the lack of standardization in prescription of SMBP, and uncertainty regarding the most effective modality of additional support. The fifth topic relates to the inability to assess the cost-effectiveness of SMBP, due to the deficiencies in evidence identified in the first four future research needs gaps.
The recommendations for priority topics for future research were generated based on a stakeholder-driven nomination and review process. We followed a recently developed taxonomy that was designed to aid researchers in the identification, recruitment and engagement of stakeholders. Our stakeholder panel represented a broad range of perspectives, across all major stakeholder categories identified in this taxonomy. We were able to obtain input from all panel members, and the final ranking showed a clear separation of the top priorities.
Nevertheless, the process was not without limitations. The total number of stakeholders recruited was restricted, thus limiting representation. Also, despite formal planning, the selection of stakeholders, solicitation of contributions, facilitation of discussion, and synthesis of suggestions remain, to some degree, idiosyncratic. There are as of yet no accepted standard methods by which to assess the validity of procedures to synthesize diverse stakeholder viewpoints. We believe that future methods work may be necessary to establish a formal process for validation, certification, or peer review of FRN rankings.
One additional cross-cutting methodological issue merits discussion, namely the challenge of translating BP readings obtained at home, in the clinic, or by ambulatory BP monitoring. This issue was identified as a limitation of the evidence base in the CER, and was also brought up by the stakeholder panel, but did not fall within the scope of the SMBP CER. This problem is relevant to the whole field of hypertension, including diagnosis, management and research, and is not specific to management of hypertension with SMBP.
Generally, SMBP is used in addition to BP monitoring in the health care setting, with readings from ambulatory BP monitoring also available in some patients. Thus, for an accurate assessment of BP, home, clinic, and ambulatory BP measurements must all be integrated in some comprehensive manner. The SMBP CER reported a wide variation across studies in the targets set for home and clinic BP. The need to standardize the integration of BP readings across different settings and modalities, therefore, constitutes an important challenge. Standardization may not be achievable with a constant conversion factor, as different BP patterns, including diurnal variation, must also be considered.
As this question was outside of the scope of the SMBP CER, an updated systematic review of available literature (across the spectrum of hypertension diagnosis and management) is the first step to better understand the existing evidence base. Addressing this gap would require review of observational data comparing concordance of BP levels obtained by SMBP, clinic BP, and ambulatory BP monitoring—possibly aggregated in different ways—as well as the study of risk relationships between BP readings with consideration of different BP patterns and clinical outcomes. In addition, comparative studies may be needed to compare the effectiveness of managing BP according to different approaches to integrate BP readings. Once it is possible to convert between home BP, clinic BP, and ambulatory BP readings, BP can be assessed comprehensively across different settings, and consistent targets can be set.
Agency for Healthcare Research and Quality (US), Rockville (MD)
Uhlig K, Patel K, Concannon TW, et al. Self-Measured Blood Pressure: Future Research Needs: Identification of Future Research Needs From Comparative Effectiveness Review No. 45 [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Aug. (Future Research Needs Papers, No. 16.) Discussion.