White Coat Hypertension/White Coat Syndrome (WCH) describes a situational condition in which some patients display higher blood pressure at their doctor’s office than at home[1]. This post focuses on the costs and potential cost savings from improved blood pressure profiling and hypertension diagnoses. This is important for two reasons, (1) healthcare costs continue to climb and (2) because, in contrast to nearly every other industry, healthcare analysts and policymakers frequently blame technology for rising healthcare costs[2],[3].
Some patients experience increases in blood pressure during doctor visits. In about 20% of cases, the increases led to unwarranted and costly hypertension diagnoses dubbed White Coat Hypertension.
Our first challenge was to find a workable WCH definition[4] and estimates of its prevalence. Studies varied widely (15–30%[5]), so we settled on 20%, or 23.2 million hypertensives (116 million hypertensives x 0.2). We developed the excess cost estimates based on prescription drugs alone, without considering additional costs from doctor visits, blood work, and other tests. We based our estimated total costs on average excess prescription costs published in the Journal of the American Heart Association (JAHA), which concluded that “Annual prescription medication expenditure was $2,371 for individuals with hypertension versus only $814 for those without hypertension.” Thus, the additional prescription costs per patient were set at $1,557 ($2,371 - 814)[6]. Therefore:
Total excess prescription costs = 23,200,000 x $1,557 = ~$36 billion per year!
Masked hypertension (MH) is a related condition that, by contrast, describes patients that “have normal blood pressure readings at the doctor’s office but then experience increases in blood pressure at other times of the day or in different settings[7].” We reviewed the literature but did not include cost estimates because reliable data was not available. Still, MH is worth mentioning because of shared causal and clinical factors. Specifically, diagnosing WCH and MH is made difficult by the influences of clinical personnel, instruments, and settings. The practical solution for overcoming these biases is ambulatory blood pressure measurements (ABPM), which I’ve previously discussed and was also highlighted by de la Sierra, Vinyoles, et al[8].
Unfortunately, legacy ambulatory profiling technologies rely on pressure cuffs that remind patients they are being monitored each time the cuff inflates and deflates. The procedure can be uncomfortable and painful when repeated ninety-six times over 24 hours, as required by protocol. Patients report being awakened during the night when readings are taken, which compromises the system's ability to capture resting blood pressure. Thus, legacy cuff-based ABPM does not isolate patients from process effects known to influence their blood pressure. Finally, legacy ABPM profiles only capture and trend blood pressure and pulse rate, which limits their diagnostic value, particularly with patients with persistent hypertension. Missing are the underlying drivers of blood pressure, tissue, and organ perfusion, i.e., systemic vascular resistance and mean arterial pressure[9].
The cuffless revolution
Unlike their cuff-based legacy predecessors, Biobeat’s ABPM solutions are based on the only FDA-listed cuffless, wearable blood pressure sensors that measure and trend blood pressure, heart rate, systemic vascular resistance, and mean arterial pressure. Patients have experientially reported forgetting that they are wearing the device. Readings are imperceptible to wearers, which eliminates measurement effects responsible for white coat syndrome. The resulting blood pressure profiles break down blood pressure and other factors by time periods (day, evening, and night) to give clinicians unprecedented insights into each patient’s blood pressure, as partially shown in the image below.
Partial Cuffless ABPM report showing plots of cardiac output, systemic vascular resistance and blood pressure by time-of-day.
Summary
Unlike legacy technologies, Biobeat's cuffless ABPM allows doctors to profile their patients' blood pressure, quantify and trend the underlying drivers of hypertension, quickly develop patient-specific treatment strategies, and validate treatment efficacy. The small sensors are comfortable to wear, and readings are imperceptible, which effectively eliminates process effects and known causes of white coat syndrome. Our investigations suggest that in this instance, inexpensive innovative technologies can save more than thirty billion dollars in unwarranted healthcare costs while improving the diagnosis, treatment, and management of hypertension.
References
[1] White Coat Syndrome, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23989-white-coat-syndrome, accessed September 22, 2022 [2] Ozzie Paez, Healthcare Economics, July 27, 2021, https://www.oprhealth.com/post/healthcare-economics [3] Ozzie Paez, Harvard’s Healthcare Economics, August 26, 2021, https://www.oprhealth.com/post/harvard-s-healthcare-economics [4] de la Sierra A, Vinyoles E, Banegas JR, Segura J, Gorostidi M, de la Cruz JJ, Ruilope LM. Prevalence and clinical characteristics of white-coat hypertension based on different definition criteria in untreated and treated patients. J Hypertens. 2017 Dec;35(12):2388-2394. doi: 10.1097/HJH.0000000000001493. PMID: 28723880. [5] Stanley S. Franklin, Lutgarde Thijs, Tine W. Hansen, Eoin O’Brien and Jan A. Staessen, White-Coat Hypertension - New Insights From Recent Studies, Hypertension, Vol. 62, No. 6, https://www.ahajournals.org/doi/full/10.1161/hypertensionaha.113.01275 [6] Elizabeth B. Kirkland, Marc Heincelman, Kinfe G. Bishu, Samuel O. Schumann, Andrew Schreiner, R. Neal Axon, Patrick D. Mauldin and William P. Moran, Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003–2014, JAHA, June 5, 2018, Vol 7, Issue 11, https://www.ahajournals.org/doi/10.1161/JAHA.118.008731 [7] White-Coat Hypertensions and Masked Hypertension, Cedars Sinai, https://www.cedars-sinai.org/health-library/diseases-and-conditions/w/white-coat-hypertension-and-masked-hypertension.html, accessed September 22, 2022. [8] Op. Cit., de la Sierra, Vinyoles, et al. [9] Ozzie Paez, Defeating Hypertension, OPRHealth, September 9, 2022, https://www.oprhealth.com/post/defeating-hypertension