Success With a Home BP Monitoring Program in Colorado
Success With a Home BP Monitoring Program in Colorado
A CARE was a quality improvement intervention that used HBPM to improve blood pressure control. A chart audit of randomly selected patients with HTN was conducted to compare blood pressure control among A CARE participants with nonparticipants. The evaluation protocol and chart audit instrument were approved by the Colorado Multiple Institutional Review Board at the University of Colorado Anschutz Medical Campus.
Twenty-six practices implemented the A CARE program. Practices were members of the Shared Networks of Colorado Practices and Partnerships (SNOCAP), a statewide affiliation of practice-based research networks. Practices were primarily in rural or underserved urban areas. Nonpregnant adults aged 18 years and older were eligible. Since this was a quality improvement program, patients and practices were not randomized. Providers selected participants based on patient needs, although they were encouraged to enroll patients with elevated office blood pressure readings, established HTN, or other cardiovascular disease risk factors.
Staff and providers at participating practices attended a continuing medical education program that included training in HTN control, the importance of HBPM, and home blood pressure measurement technique. Before starting the program, participating patients were asked to watch a training video that reviewed both HBPM technique and the system for reporting HBPM results to their provider. Trained practice staff evaluated patient HBPM cuff use while the patient was in the office and answered patients' questions. Enrolled patients received a copy of the video for review at home and a patient education booklet that reinforced the information presented in the video.
Participating patients were given a home blood pressure monitor. The home blood pressure monitors used in A CARE (Prevention [Mark of Fitness] models WS-80 and DS 1902; Nissei/Japan Precision Instruments, Inc., Gunma, Japan) were validated for accuracy by the German Hypertension Society using standard international criteria. The DS 1902 monitor was validated with a one-size cuff that fits arm sizes of 9 to 17 inches (22 to 43 cm), which is equivalent to the standard regular and large adult cuff sizes used in offices. Patients with arm size >16.5 inches (office extra-large or thigh cuff) received the WS-80 wrist cuff. Training for patients emphasized the importance of arm position when using this cuff, especially for patients who received the wrist cuff. Participants were asked to measure their blood pressure once a day, varying the time of day of measurement. The monitors automatically recorded each reading and included a feature that could average up to 30 blood pressure readings. Patients enrolled by registering with the A CARE reporting system. Registration information included demographic information, cuff type, and diagnosis of diabetes.
Participants were asked to report once a month their average home blood pressure and the number of readings taken using the A CARE secure website, interactive telephony, or mail-based reporting systems. Monthly reminders to report HBPM results were sent via E-mail or telephone. Patients received immediate feedback about whether their reported average home BP was at goal, how the blood pressure compared with the previous report, and a graph of all reports over time. Information was stored in the secure, Health Insurance Portability and Accountability Act–compliant A CARE reporting system database. For most patients, the home blood pressure goal was an average of <135/85 mmHg. For patients with self-reported diabetes, the home blood pressure goal was <130/80 mmHg. These goals were based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, which was the standard of care at the time of the program. Providers received a weekly faxed report that included the average home blood pressures for their patients who had reported during the past 7 days and a list of patients in the practice who were enrolled in the program but had not reported in the past 90 days.
For this quality improvement, quasi-experimental program, a before-and-after methodology was used to evaluate the effect of HBPM on blood pressure control. Two data sources were used for this evaluation: (1) chart audit of office blood pressure measurements and (2) home blood pressure reports.
A retrospective chart audit was conducted to collect office blood pressure data at 20 clinics that had participated in A CARE for at least 1 year. Eligibility criteria included being an adult aged 18 years or older, a diagnosis of HTN (as indicated by a billing code 401.x), at least 1 office visit in the year preceding the clinic's A CARE start date, and diagnosis of HTN at an office visit the year before the clinic state date. Patients in the A CARE program must have been enrolled for at least 4 months before the audit. A total of 20 randomly selected A CARE patients and 20 nonparticipating patients were audited in each clinic, for a total of 40 charts. In clinics with fewer than 20 patients enrolled in A CARE, all participant charts were audited. Equal numbers were audited in each group to maximize power. A minimum of 200 controls were included to provide a stable estimate.
To further evaluate the effect of HBPM on clinic blood pressure control, the change in home blood pressure levels and the proportion of participants at target were assessed using the A CARE HPBM database. Initial blood pressure reports were compared with the most recent report for all patients who had reported at least twice.
The main outcomes of chart audit and HBPM data analyses were mean change in blood pressure and change in the proportion of patients at target blood pressure.
The chart audit analysis compared blood pressure at the final visit before the clinic started the program compared with blood pressure at the final visit at the end of the project. HBPM analysis compared the initial home blood pressure report to the most recent report for all patients who had reported at least twice. Target office blood pressure is defined as ≤140 and ≤90. For diabetes, the target is ≤130 and ≤80. Target home blood pressure is ≤135/85 mmHg. For diabetes, the target home blood pressure level is ≤130/80 mmHg.
Descriptive statistics were computed to describe baseline patient and practice characteristics. Patient and practice characteristics were used as covariates in the analyses if they were associated with the outcome in bivariate analyses (at P < .20) or if they were determined to be clinically important. χ and t tests were used to determine whether there were differences between HBPM participants and nonparticipants. General linear mixed-effects models (SAS Proc Mixed; SAS Institute, Inc., Cary, NC), adjusted for clustering of patients within practices using a practice random effect, were used to compare change in systolic and diastolic blood pressure for participants and nonparticipants. For the dichotomous outcome of blood pressure at target before and after the intervention, generalized linear mixed models (SAS Proc GLIMMIX; SAS Institute, Inc.) were used. All hypothesis tests were 2-sided with α = 0.05 or P values reported. Statistical analysis was conducted using SAS software version 9.4 (SAS Institute, Inc.).
Methods
A CARE was a quality improvement intervention that used HBPM to improve blood pressure control. A chart audit of randomly selected patients with HTN was conducted to compare blood pressure control among A CARE participants with nonparticipants. The evaluation protocol and chart audit instrument were approved by the Colorado Multiple Institutional Review Board at the University of Colorado Anschutz Medical Campus.
Implementation
Twenty-six practices implemented the A CARE program. Practices were members of the Shared Networks of Colorado Practices and Partnerships (SNOCAP), a statewide affiliation of practice-based research networks. Practices were primarily in rural or underserved urban areas. Nonpregnant adults aged 18 years and older were eligible. Since this was a quality improvement program, patients and practices were not randomized. Providers selected participants based on patient needs, although they were encouraged to enroll patients with elevated office blood pressure readings, established HTN, or other cardiovascular disease risk factors.
Practice and Patient Training
Staff and providers at participating practices attended a continuing medical education program that included training in HTN control, the importance of HBPM, and home blood pressure measurement technique. Before starting the program, participating patients were asked to watch a training video that reviewed both HBPM technique and the system for reporting HBPM results to their provider. Trained practice staff evaluated patient HBPM cuff use while the patient was in the office and answered patients' questions. Enrolled patients received a copy of the video for review at home and a patient education booklet that reinforced the information presented in the video.
Home Blood Pressure Monitoring
Participating patients were given a home blood pressure monitor. The home blood pressure monitors used in A CARE (Prevention [Mark of Fitness] models WS-80 and DS 1902; Nissei/Japan Precision Instruments, Inc., Gunma, Japan) were validated for accuracy by the German Hypertension Society using standard international criteria. The DS 1902 monitor was validated with a one-size cuff that fits arm sizes of 9 to 17 inches (22 to 43 cm), which is equivalent to the standard regular and large adult cuff sizes used in offices. Patients with arm size >16.5 inches (office extra-large or thigh cuff) received the WS-80 wrist cuff. Training for patients emphasized the importance of arm position when using this cuff, especially for patients who received the wrist cuff. Participants were asked to measure their blood pressure once a day, varying the time of day of measurement. The monitors automatically recorded each reading and included a feature that could average up to 30 blood pressure readings. Patients enrolled by registering with the A CARE reporting system. Registration information included demographic information, cuff type, and diagnosis of diabetes.
Reporting
Participants were asked to report once a month their average home blood pressure and the number of readings taken using the A CARE secure website, interactive telephony, or mail-based reporting systems. Monthly reminders to report HBPM results were sent via E-mail or telephone. Patients received immediate feedback about whether their reported average home BP was at goal, how the blood pressure compared with the previous report, and a graph of all reports over time. Information was stored in the secure, Health Insurance Portability and Accountability Act–compliant A CARE reporting system database. For most patients, the home blood pressure goal was an average of <135/85 mmHg. For patients with self-reported diabetes, the home blood pressure goal was <130/80 mmHg. These goals were based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, which was the standard of care at the time of the program. Providers received a weekly faxed report that included the average home blood pressures for their patients who had reported during the past 7 days and a list of patients in the practice who were enrolled in the program but had not reported in the past 90 days.
Evaluation
For this quality improvement, quasi-experimental program, a before-and-after methodology was used to evaluate the effect of HBPM on blood pressure control. Two data sources were used for this evaluation: (1) chart audit of office blood pressure measurements and (2) home blood pressure reports.
A retrospective chart audit was conducted to collect office blood pressure data at 20 clinics that had participated in A CARE for at least 1 year. Eligibility criteria included being an adult aged 18 years or older, a diagnosis of HTN (as indicated by a billing code 401.x), at least 1 office visit in the year preceding the clinic's A CARE start date, and diagnosis of HTN at an office visit the year before the clinic state date. Patients in the A CARE program must have been enrolled for at least 4 months before the audit. A total of 20 randomly selected A CARE patients and 20 nonparticipating patients were audited in each clinic, for a total of 40 charts. In clinics with fewer than 20 patients enrolled in A CARE, all participant charts were audited. Equal numbers were audited in each group to maximize power. A minimum of 200 controls were included to provide a stable estimate.
To further evaluate the effect of HBPM on clinic blood pressure control, the change in home blood pressure levels and the proportion of participants at target were assessed using the A CARE HPBM database. Initial blood pressure reports were compared with the most recent report for all patients who had reported at least twice.
The main outcomes of chart audit and HBPM data analyses were mean change in blood pressure and change in the proportion of patients at target blood pressure.
The chart audit analysis compared blood pressure at the final visit before the clinic started the program compared with blood pressure at the final visit at the end of the project. HBPM analysis compared the initial home blood pressure report to the most recent report for all patients who had reported at least twice. Target office blood pressure is defined as ≤140 and ≤90. For diabetes, the target is ≤130 and ≤80. Target home blood pressure is ≤135/85 mmHg. For diabetes, the target home blood pressure level is ≤130/80 mmHg.
Statistical Analysis
Descriptive statistics were computed to describe baseline patient and practice characteristics. Patient and practice characteristics were used as covariates in the analyses if they were associated with the outcome in bivariate analyses (at P < .20) or if they were determined to be clinically important. χ and t tests were used to determine whether there were differences between HBPM participants and nonparticipants. General linear mixed-effects models (SAS Proc Mixed; SAS Institute, Inc., Cary, NC), adjusted for clustering of patients within practices using a practice random effect, were used to compare change in systolic and diastolic blood pressure for participants and nonparticipants. For the dichotomous outcome of blood pressure at target before and after the intervention, generalized linear mixed models (SAS Proc GLIMMIX; SAS Institute, Inc.) were used. All hypothesis tests were 2-sided with α = 0.05 or P values reported. Statistical analysis was conducted using SAS software version 9.4 (SAS Institute, Inc.).
