Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York.
Division of General Internal Medicine, Weill Cornell Medicine, New York, New York.
JAMA Netw Open. 2023 Sep 5;6(9):e2334646. doi: 10.1001/jamanetworkopen.2023.34646.
Few primary care patients complete guideline-recommended out-of-office blood pressure (BP) monitoring prior to having hypertension diagnosed.
To evaluate the effectiveness of a behavioral theory-informed, multifaceted implementation strategy on out-of-office BP monitoring (ambulatory BP monitoring [ABPM] or home BP monitoring [HBPM]) among patients with new hypertension.
DESIGN, SETTING, AND PARTICIPANTS: This 2-group, pre-post cluster randomized trial was conducted within a primary care network of 8 practices (4 intervention practices with 99 clinicians; 4 control practices with 55 clinicians) and 1186 patients (857 intervention; 329 control) with at least 1 visit with elevated office BP and no prior hypertension diagnosis between October 2016 and September 2017 (preimplementation period) or between April 2018 and March 2019 (postimplementation period). Data were analyzed from February to July 2023.
Usual care (control group) or a multifaceted implementation strategy consisting of an accessible ABPM service; electronic health record (EHR) tools to facilitate test ordering; clinician education, reminders, and feedback relevant to out-of-office BP monitoring; nurse training on HBPM; and patient information handouts.
The primary outcome was patient completion of out-of-office BP monitoring within 6 months of an eligible visit. Secondary outcomes included clinician ordering of out-of-office BP monitoring. Blinded assessors extracted outcomes from the EHR.
A total of 1186 patients (857 intervention; 329 control) were included, with a mean (SD) age of 54 (16) years; 808 (68%) were female, and 549 (48%) were Spanish speaking; among those with race and ethnicity documented, 123 (10%) were Black or African American, and 368 (31%) were Hispanic. Among intervention practices, the percentage of visits resulting in completed out-of-office BP monitoring increased from 0.6% (0% ABPM; 0.6% HBPM) to 5.7% (3.7% ABPM; 2.0% HBPM) between the preimplementation and postimplementation periods (P = .009). Among control practices, the percentage of visits resulting in completed out-of-office BP monitoring changed from 5.4% (0% ABPM; 5.4% HBPM) to 4.3% (0% ABPM; 4.3% HBPM) during the corresponding period (P = .94). The ratio of relative risks (RRs) of out-of-office BP monitoring in the postimplementation vs preimplementation periods for intervention vs control practices was 10.5 (95% CI, 1.9-58.0; P = .01). The ratio of RRs of out-of-office BP monitoring being ordered was 2.2 (95% CI, 0.8-6.3; P = .12).
This study found that a theory-informed implementation strategy that included access to ABPM modestly increased out-of-office BP monitoring among patients with elevated office BP but no hypertension diagnosis.
ClinicalTrials.gov Identifier: NCT03480217.
在被诊断为高血压之前，很少有初级保健患者完成推荐的门诊外血压（BP）监测。
评估一种基于行为理论的、多方面的实施策略对新诊断为高血压的患者进行门诊外 BP 监测（动态血压监测[ABPM]或家庭血压监测[HBPM]）的效果。
设计、地点和参与者：这是一项 2 组、前后群组随机试验，在一个初级保健网络的 8 个实践中进行（4 个干预实践有 99 名临床医生；4 个对照实践有 55 名临床医生）和 1186 名患者（857 名干预；329 名对照），他们至少有一次就诊时发现血压升高且没有之前的高血压诊断，时间在 2016 年 10 月至 2017 年 9 月（实施前）或 2018 年 4 月至 2019 年 3 月（实施后）。数据于 2023 年 2 月至 7 月进行分析。
常规护理（对照组）或由以下组成的多方面实施策略：可访问的 ABPM 服务；促进测试订购的电子健康记录（EHR）工具；与门诊外 BP 监测相关的临床医生教育、提醒和反馈；护士进行 HBPM 培训；以及患者信息传单。
主要结果是在合格就诊后 6 个月内患者完成门诊外 BP 监测的情况。次要结果包括临床医生对门诊外 BP 监测的订购情况。盲法评估人员从 EHR 中提取结果。
共纳入 1186 名患者（857 名干预；329 名对照），平均（SD）年龄为 54（16）岁；808 名（68%）为女性，549 名（48%）为西班牙语；在有记录种族和民族的患者中，123 名（10%）为黑人或非裔美国人，368 名（31%）为西班牙裔。在干预实践中，在实施前后期间，导致完成门诊外 BP 监测的就诊比例从 0.6%（0% ABPM；0.6% HBPM）增加到 5.7%（3.7% ABPM；2.0% HBPM）（P = .009）。在对照实践中，在相应期间，导致完成门诊外 BP 监测的就诊比例从 5.4%（0% ABPM；5.4% HBPM）变化到 4.3%（0% ABPM；4.3% HBPM）（P = .94）。实施后与实施前相比，干预与对照实践之间门诊外 BP 监测的相对风险（RR）比值为 10.5（95%CI，1.9-58.0；P = .01）。门诊外 BP 监测被订购的 RR 比值为 2.2（95%CI，0.8-6.3；P = .12）。
这项研究发现，一种基于理论的实施策略，包括获得 ABPM，适度增加了门诊外 BP 监测在有升高的门诊 BP 但无高血压诊断的患者中的应用。
ClinicalTrials.gov 标识符：NCT03480217。
