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

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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.