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

总结 基于多项系统评价的证据，高血压指南强烈建议， 高血压患者在家中测量他们的血压（BP）作为改善BP控制的方法， 只要这种自测BP监测（SMBP）是在临床支持下进行的（即，支持SMBP）。 务实的试验表明，支持SMBP增加了药物滴定的机会， BP药物治疗方案的强度和依从性，并最终改善BP控制。然而，很少有卫生系统 正在系统地实施支持性SMBP，不到20%的高血压患者常规实施 在家中测量血压，导致将循证建议转化为 实践造成这一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提高患者和提供者的接受率。 在与纽约长老会（NYP）的领导人合作，我们开发了一个护士支持的SMBP 干预措施， 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HTN控制反馈 .我们接着提出了一个理论- 驱动过程（行为改变轮），以选择旨在提高采用率的实施战略 支持SMBP。我们将远程监测确定为一项关键的实施战略。然后我们进行了试点测试 在一家诊所的干预和实施策略，并发现适度的吸收和有希望的趋势，在BP 控制，但仍有必要改进执行战略。很少有研究评估 在初级保健中，特别是在低收入环境中，系统地实施支助性SMBP。 我们现在建议应用以人为本的设计来完善我们的实施策略，然后实施 并评估整个初级保健网络（12个诊所）的支持性SMBP干预措施， 社会经济多样化的患者（27，600例HTN患者，35%的血压不受控制）。我们将评估 通过进行平行组群集随机试验，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）实施远程监护启用，护士- 支持SMBP干预。主要临床有效性结局将是实施前至实施后 在12个月的日历期间，患者最后一次收缩压的临床平均值的变化。的影响 将通过测量患者和提供者对支持性SMBP的吸收来评估实施策略 并通过与患者和提供者面谈来评估关键的实施结果（可接受性、忠诚度）。到 信息传播、卫生系统干预措施的成本效益和卫生保健总成本 前景也将得到评估。如果成功，我们的项目将提供一个广泛实施的路线图， SMBP，并将加速从诊所到家庭的高血压管理模式的变化。

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.