Use Of Blood Pressure Monitoring Research Articles

Feasibility and Methodology of a Pilot Free Blood Pressure Monitoring and Follow-Up Program at Two Free Clinics.

Hypertension affects approximately 1 in 2 adults in the US. Home blood pressure (BP) monitoring programs are effective in the diagnosis and management of hypertension. Free clinics serve as an integral safety net for millions of uninsured and economically disadvantaged patients in the US. The feasibility and effects of a free home BP monitoring and follow-up program in a free clinic setting is not well characterized. This was a prospective study of the implementation of a pilot BP monitoring and follow-up program between March 2021 and August 2023 at 2 free clinics in the San Francisco Bay Area. A total of 78 hypertensive patients were enrolled in the program and given a free BP monitor. We surveyed via telephone the change in systolic and diastolic BPs and BP monitor use and comfort at 3 weeks. Volunteers in clinic roles involved in the BP monitoring program were surveyed to assess their time spent and perceptions of the program. Of the 78 patients, 37 provided responses to the 3-week survey. A total of 36 of 37 (97%) patients reported using their BP monitor. A total of 35 patients reported using it at least once a week (95%), with the majority reporting at least four uses a week (68%). A total of 36 patients (97%) planned on continuing to use their BP monitor. At 3 weeks, the mean systolic and diastolic BP changed by -6.40 mmHg (95% CI, -10.8 to -2.01 mmHg; P = .00577) and -2.72 mmHg (95% CI, -5.62 to 0.188 mmHg; P = .0657), respectively. The time commitment for this program ranged from 130 ± 51 min for program leaders to 16 ± 14 min per week for patient-facing roles. All volunteer roles (patient-facing, phone follow-up, program leaders) expressed that they had a clear understanding of their responsibilities in the program (median 4 on Likert scale, IQR 3-5). Home BP monitoring and follow-up is feasible to implement in free clinics, resulting in high rates of patient engagement among respondents. Our findings suggest that home BP monitoring and follow-up programs may be beneficial in vulnerable patient populations.

Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack

Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. ClinicalTrials.gov Identifier: NCT01763203.

Capsule Commentary on Margolis et al., A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why did it Work?

M argolis et al. 1 conducted a comparative effectiveness research trial to assess whether blood pressure (BP) telemonitoring improved systolic BP over a 6-month period compared to standard care. Using a two-group cluster randomized trial design (eight sites served as controls and eight as intervention arms), the intervention group received home BP telemonitoring with the aid of a pharmacist, who called patients periodically to ensure they were checking their BP regularly. The authors hypothesized that greater medication intensification, greater adherence to medication and healthy lifestyle behaviors, and effective patient–pharmacist relationship—consisting of educational counseling sessions about hypertension and the health benefits of adherence and positive lifestyles changes—would yield improved BP, mediated by either: 1) home BP monitor use; 2) number of BP medication classes; 3) patient-reported adherence to BP medications; 4) physical activity; 5) salt intake; 6) alcohol use; or 7) weight change. Findings indicate that home BP telemonitoring and medication intensification, over the 12-month duration of the study, accounted for 42 % of the intervention effect. Despite the innovativeness of this approach, the lack of clarity as to how adding an educational component to the pharmacist's role can be translated into a scalable intervention calls into question the study’s feasibility. In fact, the authors made no mention of why pharmacists were most suited to deliver this behavioral intervention, nor did they identify a theoretical grounding as to how education and frequent home BP monitoring led to greater BP control. Additionally, the authors did not control for two significant clinical confounders, participants with obstructive sleep apnea and participants with resistant hypertension requiring a medication regimen beyond intensification. Despite these limitations, the current findings are consistent with previous studies which suggest that task-shifting is a viable method of improving BP management. Future work should investigate the effectiveness of this treatment model with patients who have sleep apnea or resistant hypertension.

A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work?

It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others. We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6months in a trial to improve hypertension control. The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228). Four hundred three of 450 trial participants completing the 6-month follow-up visit were included. Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits. Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight. The difference in change in systolic BP was 11.3mmHg. The multivariable mediation model explained 47% (5.3mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24%) and increased home BP monitor use (19%). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group. Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.

Patient engagement strategies used for hypertension and their influence on self-management attributes

Several effective methods to facilitate patient self-management of hypertension are available in primary care. These include direct support from community pharmacists and general practice, and the use of home blood pressure (BP) monitoring. The aim of this study is to establish the prevalence of use of key strategies and to determine their independent relationship with patient self-management attributes. A survey of patients with treated hypertension was undertaken in 27 community pharmacies. This established recent use of BP monitoring and advice from health professionals. Patient awareness of BP and targets, appropriateness of BP targets and adherence to anti-hypertensive medications were assessed as indicative self-management outcomes. Predictors of outcomes were determined using binary logistic regression. Overall, 215 surveys were returned. Two-thirds of patients were aged >65 years, and 45% had conditions warranting tighter BP control (<130/80 mmHg). Almost all patients reported monitoring of their BP in the previous year and 63% could report their most recent BP reading. Just 36% reported knowing a target BP, and 78% of reported targets were within guidelines recommendations. One-fifth (22%) monitored their own BP, and 15% reported non-adherence to medication. Doctors provided the large majority of professional advice. Self-monitoring or documentation of BP readings was independently associated with increased likelihood of BP and target BP being known. Regular monitoring of BP does not automatically translate to professional advice. Increased uptake of patient self-monitoring should be promoted as a means of enabling self-management.

Validation of the SAA-102 home blood pressure monitor according to the protocols of the European Society of Hypertension, the Association for the Advancement of Medical Instrumentation and the British Society of Hypertension

To determine the accuracy of a new oscillometric home blood pressure (BP) monitor for arm BP measurement, the SAA-102, developed by the Sensacare Company. Evaluation of the SAA-102 was performed using validation protocols of the European Society of Hypertension (ESH), the Association for the Advancement of Medical Instrumentation (AAMI), and the British Hypertension Society (BHS). The SAA-102 monitor was assessed on 33 participants according to ESH requirements, which are based on four zones of accuracy differing from the mercury standard by 5, 10, 15 mmHg or more. Then the oscillometric monitor was tested on 85 participants according to AAMI criteria which require a mean device-observers discrepancy within 5+/-8 mmHg. Finally, the electronic device was evaluated on 93 participants according to BHS requirements, which are based on five phases: before-use calibration, in-use assessment, after-use calibration, static device validation and report of the results. The SAA-102 passed all phases of the ESH international protocol for both systolic and diastolic blood pressure (SBP and DBP). The SAA-102 passed also AAMI criteria for SBP and DBP. The mean discrepancy between the SAA-102 and observers was 0.1+/-4.6 and -2.7+/-5.2 mmHg, for SBP and DBP, respectively. According to BHS protocol, the oscillometric monitor achieved final grading of A/A for SBP and DBP, respectively. These data show that the SAA-102 device satisfies ESH, AAMI, and BHS protocols for both SBP and DBP and may be recommended for everyday use for BP monitoring at home and in clinical practice.