Author: Barry Stultz
Clinicians at University of Utah Health have completed a study demonstrating how guideline-quality office blood pressure measurements and home blood pressure monitoring - often viewed as cumbersome and time-consuming - can be effectively implemented into the workflow of a busy primary care practice. The results published online in Journal of the American Board of Family Medicine on May 8.
With last November’s new blood pressure guidelines lowering the numbers for diagnosing hypertension to 130/80 mmHg, it is expected that millions more Americans will be classified with the condition, a major risk factor for heart attack and stroke. The change highlights a need for improving blood pressure measurements, which are notoriously variable depending on hardware accuracy and on how, when, and where measurements are taken.
Research has shown that patients should have blood pressure measured by an automated blood pressure (AOBP) device while the patient calmly sits alone in the exam room, and if elevated, followed by additional monitoring out of the doctor’s office. But the recommendations alter the typical clinical workflow and rely on patient involvement that can be unpredictable.
“We wanted to know, how feasible is it to do this in clinical practice?,” said U of U Health internist John Doane, MD, first author of a study led by his colleague Barry Stults, MD. “We knew we would have to develop ways to bridge the chasm between research and the real-world.”
To do so, the clinic implemented a program to train staff and patients, and invested in validated loaner blood pressure monitors for patients to take home. Patients found to have hypertension in the office were asked to take their blood pressure at home and report the average of twice daily measurements for five days by phone or online through their electronic health records.
Like any culture change, it wasn’t easy. “One of the issues we found out quickly is that it takes training. And any staff turnover can add a kink to the program,” said Doane. Not only that, but both patients and staff had to be reminded about proper technique or re-trained on a regular basis. Otherwise, for example, some patients fell into bad habits such as performing other tasks while the automated machine took measurements.
Despite hiccups, the approach worked. The team gauged effectiveness of guideline-quality measurements in their clinic by following 183 patients with elevated in-office blood pressure for 13 months.
They found that approximately one-third had “white-coat hypertension,” where blood pressure is elevated in a medical setting but not at home. Among patients who were not on blood pressure medication at the time of enrollment, 54 percent (45 patients) were diagnosed as new cases of hypertension through home monitoring. Of enrollees who were already on anti-hypertensive medication, 54 percent (53 patients) were diagnosed with uncontrolled hypertension.
The results showed that at-home monitoring could be used to diagnose and control hypertension at rates consistent with previous studies, validating the effort. In addition, staff reported that implementing automated office monitoring added less than 15 minutes to their daily schedule, and the majority had a positive view of the program.
“Everyone knows this is a tricky thing to do,” said co-author and U of U Health internist Molly Conroy, MD. “But overall it worked and we were able to make this happen in our clinic without dedicated research staff, time, or space.”
Home monitoring is not for everyone. Ten percent of enrollees failed to send in their initial home measurement, and 22 percent did not provide follow-up measurements despite elevated blood pressure at home. In addition, 26 percent reported that they did not plan on continuing at-home measurements after the study ended.
“Improving this may be difficult but will be worth it. The downstream benefits of reducing the risk of heart attack and stroke are what’s best for our patients,” said Doane. Larger follow-up studies will be needed to determine how well the approach works in other clinical contexts and with different patient populations.