Integrating Home Blood Pressure
Monitoring into Primary Care
Practice: A Pilot Study
Barbara Holloway, RN, BSN, CDE
Elizabeth Ciemins, PhD, MPH, MA
March 12, 2016
About Us
Quality care is delivered by approximately 4,000 employees,
including more than 400 physicians and advanced practitioners
offering more than 50 specialties.
•
Community governed, not-for-profit
•
304 licensed-bed acute care hospital
•
Level II Emergency & Trauma Center
•
90 bed long-term care facility
•
43 county service area - 127,801 square miles
•
12 regional partnerships
Study Objective
• To improve the monitoring, management,
and control of hypertension by:
– identifying high risk patients with the
diagnosis of hypertension;
– engaging patients in discussion and education
about their disease;
– promoting self monitoring using an automated
wireless blood pressure measurement device;
– expanding the use of the EHR to manage
disease
Specific Aims
• Aim 1: Identify patients with newly diagnosed or
uncontrolled hypertension, engage patients in
disease management education, and to supply
patients with an electronic, wireless oscillometric
monitor for home blood pressure measurements.
• Aim 2: Retrieve the automatic blood pressure
reading values from the device manufacturer’s
data base, and alert the patient’s primary care
provider of any out of range values.
Methods
•
•
•
•
•
Recruit 37 patients
Provide education and home monitors
Follow patients for 4-7 months
Assess blood pressure change over time
Monitor provider behavior through chart
review
• Survey patients on ease of use, perceived
effect on outcomes, engagement, and
perceived quality and accuracy of device
Recruitment and Workflow
• Recruitment sources for 37 participants:
–
–
–
–
–
24 primary care provider
1 Billings Clinic newsletter
6 Employee Board notification
5 calls to patients with HTN with scheduled office visit
1 physician self-referred
• RN navigator interviewed and educated
prospective participants and issued monitors
• Reviewed Withings site once per week and
noted the high, low and median values
Recruitment and Workflow (cont.)
• Readings sent to nurse practitioner (NP)
• NP determined if PCP should be notified
• NP provided f/u appointment date if
applicable
• RN navigator fielded questions from
participants, called to remind to take BPs
more often if appropriate, or provided
technical assistance or education
Demographics (n=37)
Measure
Age (years)
BMI (kg/m2)
Length in Study (months)
Female
White
Hypertension Diagnosis
Diabetes Diagnosis
Chronic Kidney Disease Diagnosis
mean
55.4
32.3
4.8
n
18
35
32
5
3
range
28-78
20-45
0.4 - 6.7
%
49
95
86
14
8
Provider Plan
Hypertension Medication Action
Started or added medication
Increased dose
Decreased dose
Discontinued medication
Lifestyle Change Action
n (%)
13 (35)
8 (22)
3 (8)
7 (19)
n (%)
Instructed participant to return for nurse re-check
DASH or other diet plan?
16 (43)
Recommended weight loss, exercise or other lifestyle changes
25 (68)
Referrals
Specialist for HTM management
Dietitian, Educator, or other care provider
25 (68)
n (%)
1 (3)
2 (5)
Blood Pressure Control
Baseline
Controlled BP
51%
Definition of Controlled Blood Pressure:
• < 140/90
• < 150/90, if age 60+
Study
Completion
68%
DIFFERENCES IN BLOOD PRESSURE BY GENDER
GENDER
FEMALE
n = 18
MALE
n = 19
TOTAL
n = 37
SYSTOLIC
BEGINNING
SYSTOLIC
ENDING
SYSTOLIC
DIFFERENCE
137.2
132.5
-4.7
143.2
139.1
-4.1
140.3
135.9
-4.4
DIFFERENCES IN BLOOD PRESSURE BY AGE
AGE GROUP
30 - 49 YO
n = 12
50 - 69 YO
n = 15
70+ YO
n = 10
SYSTOLIC
BEGINNING
SYSTOLIC
ENDING
SYSTOLIC
DIFFERENCE
140.8
136.1
-4.3
140.4
134.5
-3.9
139.3
137.7
-4.1
Patient Survey
Perceived Ease of Use
PRE
POST
Confidence in Ability to Use or Having Used the Device Correctly
4.54
4.53
Device Will Be, or Was, Easy for Patient to Use
4.37
3.91
The Instructions I Received on How to Use the Device Were Comprehensive
4.56
4.59
I Learned How to Use the Device
4.51
4.38
Connecting the Device to the Phone Will Be, or Was, Easy for Me to Do
4.41
4.09
Device Will, or Did, Improve Patient's Ability to Monitor and Control Blood Pressure
Use of the Device Will Enhance, or Is Enhancing, the Ability of My Provider and me to
Improve my Blood Pressure Control
I Will, or Did, See Improvements in My Blood Pressure Through Using the Device
4.46
4.28
4.65
4.22*
3.92
3.94
I Will, or Am, Monitoring Blood Pressure More Often with the Device
4.65
3.88*
Perceived Effect on Outcomes
1 = Strongly Disagree, 5 = Strongly Agree
Patient Survey (cont.)
Effect on Patient Engagement
I Will, or Do, Feel More Confident in My Provider's Ability to Help Me Control My
Blood Pressure Once Using the Monitor
Use of the Device Will, or Did, Improve Communications with My Provider Regarding
My Blood Pressure
I Will, or Do, Feel More Comfortable in My Ability to Improve My Health Through
Using the Device
The Device Will, or Did, Improve My Motivation to Try to Control My Blood Pressure
PRE
POST
4.43
4.00*
4.62
4.13*
4.24
4.25
4.54
4.28
4.14
4.25
4.54
4.50
4.08
4.13
4.46
4.49
4.25
4.56
Perceived Quality and Accuracy of Product
Blood Pressure Results Obtained Through the Device Will Be, or Were, About What
Was Expected
The Device Will, or Does, Give Me Clear Feedback on My Blood Pressure Level
I Expect to, or Do, Recommend the Device to People Who Are Trying to Monitor Their
Blood Pressure Level
Use of the Device Will Not, or Did Not, Intrude On or Disrupt My Personal Life
The Blood Pressure Results Obtained Through the Device Will Be, or Were, Clear
1 = Strongly Disagree, 5 = Strongly Agree
COMMENTS BY AGE GROUP
30 - 40 s
n= 12
50 - 60 s n=15
70 - 80 s
n=10
"It helped different providers to finally
Liked it, learned about the affect of Takes phone in to MD - states MD
collaborate about the wide variations in
exercise and some foods on BP now interested in talking about my
my readings. I'm in better control" readings - kept
BP and management - kept
kept
Stated she loved monitor sporadic use - kept
Loves it, working with MD, no
problems - kept
Thought it very beneficial and
wants to keep the monitor - kept
Used in collaboration with PCP, led to a
med change. - kept
Liked it - kept
Used in collaboration with PCP, led to a
med change. Lost weight and noticed
the effect on her BP. - kept
Called MD to get a med changed
works well, helpful - kept
- kept
Trouble when got a new android
until site was updated. - kept
Loves the monitor, found PCP not
real responsive to her information
and questions regarding BP
management, - changing PCP kept
On button is too small for large
hands otherwise likes it. Credits
study with saving his life - kept
Loves the monitor, Working well,
no problems. - Kept
Used in collaboration with PCP.
"Managed my meds this way". - kept
COMMENTS BY AGE GROUP (cont.)
30 - 40 s
n= 12
50 - 60 s n=15
70 - 80 s
n=10
Had to resync with phone every
Once in awhile had trouble getting a time. BP readings did not show Hated it, "too time consuming, had to be
reading – ‘Could have been
up in phone. Turned monitor in too careful not to move" Glad to get rid of
positioned wrong”. - kept
early
it.
States it read too high all the time - Large muscular arms, unable to
preferred old monitor with large cuff. get it to work on him
Never could figure out how to use it.
We found no problem, turned it in Travels a lot , too bulky to take,
early
or not good Wi-Fi (Mexico).
“Need to improve the battery
connection system.” On button
hard to push - kept
"Errors too often." Battery runs down very
fast.
"Too fussy". Likes old monitor better.
"Too complicated". Had trouble navigating
the app on his phone.
Participant Comments
Dislikes
Likes
• Asked to keep the meter
and continue to work with
PCP (n=25)
• Learned what effect
exercise, food, or stress has
on BP
• Reported PCP more
responsive to discussing
HTN and problem-solve
with them
•
•
•
•
Did not trust readings
Trouble with app or Bluetooth
C/O pain with readings
Trouble with reading errors or
monitor stopping often
• Green light had to be manually
turned off
• Batteries did not hold charge
• Button too small for large
hands.
Success Story #1
• 68 yo female
• Could not convince PCP about her widely
fluctuating BP values (108/60 – 184/87)
• Took her phone in to office visit with the
Withings graph
• Convinced PCP to order a specialist
consultation and problem-solve with
patient
Success Story #2
• 59 yo male
• Surprised by extreme readings on intake
• Sent home with monitor & told to check
several more times and call PCP if high
readings continued
• Found that his medication bottle had
been filled with a statin at the pharmacy
• Corrections made and he is very happy
with the monitor.
Summary
• Home monitoring has the potential to improve
HTN management among patients with
uncontrolled or newly diagnosed HTN
• Technology needs to be easy to use and
operate, and integrated into local EHR
• Home monitoring has the potential to improve
provider-patient engagement in HTN
management
Questions?
Barbara Holloway: [email protected]