White-coat hypertension was diagnosed in 17 of 35 patients who completed out-of-office blood pressure monitoring.
There is a need for more intensive implementation strategies that address adherence to out-of-office blood pressure monitoring before a hypertension diagnosis, according to the results of a study (NCT03480217) published in JAMA Network Open.
Currently, there are few primary care patients who complete the out-of-office blood pressure monitoring recommended by current guidelines, even before a hypertension diagnosis, according to the study authors. The study aimed to evaluate the efficacy of behavioral theory-informed and multifaceted implementation strategies for ambulatory blood pressure monitoring for individuals who were newly diagnosed with hypertension.
The study included 1186 patients from a primary care network of 8 practices—including 4 intervention practices with 99 physicians and 4 control practices with 55 physicians—with 857 patients included in the intervention group and 329 in the control group. . The group had a mean age of 54 years, 68% were female, 48% Spanish speaking, 10% were Black, and 31% were Hispanic.
All patients had at least 1 visit with elevated office blood pressure, but no prior diagnosis of hypertension during the pre-implementation period from October 2016 and 2017, or between April 2018 and March 2019, which was the post-implementation period. Investigators analyzed the data from February 2023 to July 2023.
Patients who received usual care were placed in the control group whereas the intervention group was administered a multifaceted implementation strategy that used accessible ambulatory blood pressure monitoring. Electronic health records were used to order tests. The study authors also included physician education, reminders, and feedback for the out-of-office blood pressure monitoring. There was a nurse for home blood pressure monitoring and patients were given informational handouts.
The primary outcome of the study was patient completion of the out-of-office blood pressure monitoring within the 6 months of eligibility, with a secondary outcome of physicians ordering out-of-office blood pressure monitoring.
For those in the intervention group, the percentage of those who completed out-of-office blood pressure monitoring increased from 0.6% to 5.7% between the pre-implementation and post-implementation periods. Additionally, among those in the control group, the percentage of visits that led to out-of-office blood pressure monitoring decreased from 5.4% to 4.3% between the periods. Investigators found the same results in the analyses adjusted for both patient age and sex.
Furthermore, the study authors reported that the ratio of relative risks for out-of-office blood pressure monitoring in the post-implementation compared to the pre-implementation periods for the intervention and control groups was 10.5, with a ratio of 2.2 for out-of-office blood pressure monitoring. In the intervention group, ordering the blood pressure monitoring changed from 15 of 529 visits to 36 of 454 visits, while the control group only changed from 13 of 149 visits to 19 of 207 visits.
When the blood pressure monitoring was not ordered by the physician, investigators found that the predominant action was “wait-and-see” until the next visit. Specifically, the study authors reported that during the post-implementation periods of the intervention group, no action was taken in 391 of 418 remaining visits, after exclusion of visits where blood pressure monitoring was ordered. Hypertension was diagnosed in 23 visits, according to the study results. There was a similar pattern observed in the control group.
Investigators also found that ambulatory blood pressure monitoring was successful for 17 of 22 patients. For home blood pressure monitoring, the percentage who completed it increased from 3 of 15 pre-implementation to 9 of 14 post-implementation in the intervention group. Investigators reported that it decreased from 8 of 13 to 9 of 19 in the control group.
Further, white-coat hypertension was diagnosed in 17 of 35 patients who completed out-of-office blood pressure monitoring. They could not compare the differences in white-coat hypertension diagnosis between the intervention and control groups due to the limited number of those who completed the out-of-office blood pressure monitoring.
Kronish IM, Phillips E, Alcántara C, Carter E, et al. A multifaceted implementation strategy to increase out-of-office blood pressure monitoring: the EMBRACE cluster randomized clinical trial. JAMA Netw Open. 2023;6(9):e2334646. doi:10.1001/jamanetworkopen.2023.34646