Increasing the Uptake of the USPSTF Hypertension Screening Guidelines in Primary Care.

 描述（由申请人提供）：约五分之一的诊室血压（BP）升高患者在诊室外使用动态血压监测（ABPM）测量时BP正常。这种情况，被称为白大衣高血压，赋予最小的心血管风险增加，不需要抗高血压治疗。未能检测到白大衣高血压使患者面临BP药物不良反应的风险，并不必要地增加了医疗费用。因此，美国预防服务工作组（USPSTF）最近发布了高血压筛查指南的更新草案，其中他们建议办公室血压升高的患者在诊断和治疗高血压之前进行ABPM。尽管有强有力的、一致的证据支持该指南，但ABPM在美国很少使用。该提案的目标是开发和测试一种干预措施，以增加USPSTF高血压筛查指南在不同初级保健环境中的应用。我们将首先与初级保健患者和提供者进行实施前焦点小组，这些患者和提供者来自为弱势患者群体提供服务的大型门诊护理网络，以增加对实施USPSTF指南的障碍和促进因素的了解。我们接下来将完善实施策略，包括1）增加指南知识的教育活动; 2）计算机化临床决策支持工具，便于在指南指示时订购ABPM; 3）适应文化的、易于获得的ABPM服务。然后，我们将进行一项为期2年的群集随机临床试验，在该试验中，我们将网络中的8个初级保健诊所随机分配到1）多方面指南实施干预或2）等待名单对照组。在试验结束时，我们将评估干预措施在增加完成ABPM的适应症患者比例方面的有效性。我们还将开展实施后的患者和提供者焦点小组，以评估干预措施是否可以在门诊护理网络内持续，并应传播到其他实践环境。

 DESCRIPTION (provided by applicant): Approximately one in five patients with elevated office blood pressure (BP) has normal BP when measured out of the office using ambulatory BP monitoring (ABPM). This condition, known as white-coat hypertension, confers minimal increased cardiovascular risk and does not require antihypertensive treatment. Failure to detect white-coat hypertension places patients at risk for adverse effects from BP medications and unnecessarily increases healthcare costs. Accordingly, the U.S. Preventive Services Task Force (USPSTF) recently published a draft update of their hypertension screening guideline in which they recommended that patients with elevated office BP undergo ABPM prior to being diagnosed with and treated for hypertension. Despite the strong, consistent evidence in support of this guideline, ABPM is infrequently used in the U.S. The goal of this proposal is to develop and test an intervention that will increase uptake of the USPSTF hypertension screening guidelines in diverse primary care settings. We will first conduct pre-implementation focus groups with primary care patients and providers from a large ambulatory care network that serves a vulnerable patient population to increase the understanding of the barriers and facilitators to implementing this USPSTF guideline. We will next refine an implementation strategy comprised of 1) educational activities that increase knowledge of the guidelines; 2) a computerized clinical decision support tool that facilitates ordering of ABPM when indicated by the guideline; and 3) a culturally-adapted, easily accessible ABPM service. We will then conduct a 2-year cluster randomized clinical trial in which we randomize 8 primary care clinics in the network to either 1) the multifaceted guideline implementation intervention or 2) a wait-list control group. At the end of the trial, we will assess the effectiveness of the intervention at increasing the proportion of indicated patients who complete ABPM. We will also conduct post-implementation focus groups of patients and providers to assess whether the intervention can be sustained within the ambulatory care network and should be disseminated to other practice settings.