HYPERTENSION IN THE TIME OF COVID: PIVOTING TO AN ASYNCHRONOUS QI INTERVENTION FOR HOME BLOOD PRESSURE MONITORING

ABSTRACT

BACKGROUND: Hypertension (HTN) affects 29% of US adults, however in-office blood pressure (BP) readings are often inaccurate leading to clinical inertia. Repeating BP within 6 weeks leads to quicker control but patients and primary care practices have limited resources for frequent visits. Home blood pressure monitoring (HBPM) is accurate and convenient. In reviewing HTN burden at a suburban Maryland primary care practice, we found 19% of patients had an encounter BP >140/90, and a sample chart review estimated half were advised to self-monitor but lacked standardized follow up. We aimed to implement a quality improvement program to increase HBPM among our patients. METHODS: We engaged stakeholders (practice leadership, frontline staff) and content experts (HTN, patient engagement) to develop educational materials on HBPM and reporting results via the patient portal. We planned in office implementation, identifying patients with elevated BP during encounters and utilizing nurses to provide counseling. However, with COVID-19, we pivoted to asynchronous outreach and home delivery of BP cuffs. We developed messaging, delivered via the patient portal, for patients with uncontrolled HTN, controlled HTN, and elevated BP readings without HTN. Eligible patients, covered by a single insurance that provides reimbursement for BP cuffs, had HTN on their problem list and/or a BP >140/90 during an encounter between Jan-Oct 2020. For interested patients, we placed BP cuff orders and sent the educational materials. RESULTS: We identified 243 eligible patients who received outreach about HBPM;4 did not have patient portal access and received letters with no responses. Of the remaining 239 patients, 77% (N=183) read the electronic message and 43% (N=103) responded. Among responders, 81% (N=83) requested a cuff and 14% (N=14) reported having an up-to-date device. Among patients with a cuff, 18% (N=17) reported a BP reading to their primary care physician, with systolic and diastolic readings on average 11 and 6 mmHg lower, respectively, than the most recent in-office measurement. Initial review found some patients did not receive a cuff after the order resulting from delayed order processing and patients not scheduling delivery. CONCLUSIONS: Patients with elevated BP readings or HTN responded to messaging through the patient portal and were interested in receiving BP cuffs for HBPM. However, many patients did not report BP values after a device was ordered. Next steps include addressing barriers to delivery of the cuffs and incorporating follow up visits, including with our clinical pharmacist, to encourage reporting of HBPM. We will use lessons learned from this pilot to plan outreach and encourage self-monitoring during the COVID-19 era.