Implementing Remote Patient Monitoring to Improve Hypertension Control in a Primary Care Network

实施远程患者监测以改善初级保健网络中的高血压控制

• 批准号: 10428468
• 负责人: Ian Matthew Kronish
• 金额: $ 71.6万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-06-15 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10428468
• 关键词: Address; Adherence; African American; Age; Ambulatory Care; American Medical Association; Blood; Blood Pressure; Blood Pressure Monitors; COVID-19 pandemic; Calendar; Caring; Centers for Disease Control and Prevention (U.S.); Chronic Disease; Chronic Obstructive Pulmonary Disease; Clinic; Clinic Visits; Clinical; Clinical effectiveness; Cluster randomized trial; Code; Consolidated Framework for Implementation Research; Cost Analysis; Data; Early Intervention; Economics; Effectiveness of Interventions; Feedback; Fostering; Goals; Guidelines; Health Care Costs; Health system; Healthcare Systems; Heart; Heart failure; Hispanic; Hispanic Populations; Home; Hybrids; Hypertension; Intervention; Interview; Knowledge; Low income; Lung; Marketing; Measurement; Measures; Medicaid; Modeling; Monitor; New York; New York City; Nurses; Outcome; Patient Care; Patient Monitoring; Patients; Persons; Pharmaceutical Preparations; Presbyterian Church; Primary Health Care; Process; Provider; Public Health; Quality-Adjusted Life Years; Randomized; Reach Effectiveness Adoption Implementation and Maintenance; Reading; Regimen; System; Team Nursing; Telemedicine; Titrations; Training; Translations; Uncertainty; United States; Use Effectiveness; Waiting Lists; Work; base; behavior change wheel; blood pressure control; blood pressure elevation; blood pressure medication; budget impact; cost; cost effective; cost effectiveness; design; effectiveness implementation design; effectiveness outcome; evidence based guidelines; human centered design; hypertension control; hypertensive; implementation evaluation; implementation outcomes; implementation strategy; improved; innovation; models and simulation; patient population; pilot test; post implementation; pragmatic trial; programs; remote patient monitoring; socioeconomics; systematic review; telemonitoring; theories; treatment as usual; trend; trial design; uptake

SUMMARY Based on evidence from multiple systematic reviews, hypertension guidelines strongly recommend that hypertensive patients measure their blood pressure (BP) at home as an approach to improving BP control so long as this self-measured BP monitoring (SMBP) is conducted with clinical support (i.e., Supported SMBP). Pragmatic trials demonstrate that Supported SMBP increases opportunities for medication titrations, increases BP medication regimen intensity and adherence, and ultimately, improves BP control. Yet, few health systems are systematically implementing Supported SMBP, and less than 20% of hypertensive patients routinely measure their BP at home, resulting in a gap in the translation of evidence-based recommendations into practice. This gap is driven by lack of knowledge regarding how best to implement Supported SMBP to maximize uptake by patients and providers at an acceptable health system cost. In partnership with leaders at New York-Presbyterian (NYP), we developed a nurse-supported SMBP intervention in which a centralized team of nurses is responsible for engaging patients in SMBP, monitoring SMBP data, and providing feedback on HTN control to patients and providers . We next followed a theory- driven process (the Behavior Change Wheel) to select an implementation strategy aimed at increasing uptake of Supported SMBP. We identified telemonitoring as a key implementation strategy. We then pilot tested this intervention and implementation strategy at one clinic and found moderate uptake and promising trends in BP control, but there was still a need to improve the implementation strategy. Few if any studies have assessed the systematic implementation of Supported SMBP in primary care, particularly in low-income settings. We now propose to apply human-centered design to refine our implementation strategy, and then implement and evaluate the Supported SMBP intervention across a primary care network (12 clinics) that provides care to socioeconomically diverse patients (27,600 HTN patients, 35% with uncontrolled BP). We will evaluate the program by conducting a parallel-group cluster randomized trial in which clinics will be randomly assigned to early (intervention) versus delayed (wait-list control) implementation of the telemonitoring-enabled, nurse- supported SMBP intervention. The primary clinical effectiveness outcome will be pre-to-post implementation change in the clinic mean of patients' last systolic BP during a 12-month calendar period. The impact of the implementation strategy will be assessed by measuring uptake of Supported SMBP by patients and providers and by interviewing patients and providers to assess key implementation outcomes (acceptability, fidelity). To inform dissemination, the cost-effectiveness of the intervention from a health system and total healthcare cost perspective will also be assessed. If successful, our project will provide a roadmap for widely implementing SMBP, and will accelerate a change in the paradigm of hypertension management from the clinic to the home.

摘要 基于来自多个系统评价的证据，高血压指南强烈建议 高血压患者在家中测量血压以改善血压控制 只要这种自我测量的血压监测(SMBP)是在临床支持下进行的(即，支持的SMBP)。 实用试验表明，支持的SMBP增加了药物滴定的机会，增加了 BP用药方案的强度和依从性，并最终改善血压控制。然而，很少有卫生系统 正在系统地实施支持性SMBP，只有不到20%的高血压患者常规 在家里测量他们的血压，导致在将循证建议转化为 练习一下。造成这种差距的原因是缺乏关于如何最好地实施受支持的SMBP的知识 以可接受的卫生系统成本最大限度地为患者和提供者所接受。 与纽约长老会(NYP)的领导人合作，我们开发了一种由护士支持的SMBP 在哪些方面进行干预 一个集中的护士团队负责让患者参与SMBP，监测 SMBP数据，并向患者和提供者提供有关HTN控制的反馈 。接下来我们遵循了一个理论-- 驱动流程(行为改变轮)以选择旨在提高采用率的实施策略 支持的SMBP的。我们将远程监测确定为一项关键的实施战略。然后我们进行了试飞 一家诊所的干预和实施策略，发现BP适度摄取和前景看好的趋势 在控制方面取得了一些进展，但仍有必要改进执行战略。几乎没有研究评估过 在初级保健中，特别是在低收入环境中，系统地实施得到支助的SMBP。 我们现在建议应用以人为中心的设计来细化我们的实施策略，然后实施 并评估在初级保健网络(12家诊所)中支持的SMBP干预措施，该网络为 社会经济多样化的患者(27,600名HTN患者，35%的患者血压未得到控制)。我们将评估 计划通过进行平行组整群随机试验，在该试验中，诊所将被随机分配 早期(干预)与延迟(等待名单控制)实施启用远程监护的护士- 支持SMBP干预。主要的临床效果结果将是实施前到实施后 患者在12个月历期内最后一次收缩血压的临床平均值的变化。经济衰退带来的影响 将通过测量患者和提供者对支持的SMBP的摄取量来评估实施战略 并通过采访患者和提供者来评估关键的实施结果(可接受性、保真度)。至 信息传播、卫生系统干预的成本效益和医疗保健总成本 还将对前景进行评估。如果成功，我们的项目将为广泛实施提供路线图 SMBP，并将加速高血压管理范式从诊所向家庭的转变。