Approximately one in five patients with elevated office blood pressure (BP) has normal BP when measured out of the office using ambulatory BP monitoring (ABPM). This condition, known as white-coat hypertension, confers minimal increased cardiovascular risk and does not require antihypertensive treatment. Failure to detect white-coat hypertension places patients at risk for adverse effects from BP medications and unnecessarily increases healthcare costs. Accordingly, the U.S. Preventive Services Task Force (USPSTF) recently published a draft update of their hypertension screening guideline in which they recommended that patients with elevated office BP undergo ABPM prior to being diagnosed with and treated for hypertension. Despite the strong, consistent evidence in support of this guideline, ABPM is infrequently used in the U.S. The goal of this proposal is to develop and test an intervention that will increase uptake of the USPSTF hypertension screening guidelines in diverse primary care settings. We will first conduct pre-implementation focus groups with primary care patients and providers from a large ambulatory care network that serves a vulnerable patient population to increase the understanding of the barriers and facilitators to implementing this USPSTF guideline. We will next refine an implementation strategy comprised of 1) educational activities that increase knowledge of the guidelines; 2) a computerized clinical decision support tool that facilitates ordering of ABPM when indicated by the guideline; and 3) a culturally-adapted, easily accessible ABPM service. We will then conduct a 2-year cluster randomized clinical trial in which we randomize 8 primary care clinics in the network to either 1) the multifaceted guideline implementation intervention or 2) a wait-list control group. At the end of the trial, we will assess the effectiveness of the intervention at increasing the proportion of indicated patients who complete ABPM. We will also conduct post-implementation focus groups of patients and providers to assess whether the intervention can be sustained within the ambulatory care network and should be disseminated to other practice settings.

Public Health Relevance

Approximately one in five patients with elevated office blood pressure (BP) has a normal BP when measurements are taken out of the office. This condition, known as white-coat hypertension, confers minimal risk and does not require treatment. Accordingly, the U.S. Preventive Services Task Force (USPSTF) recently updated their guidelines to recommend patients undergo ambulatory BP monitoring (ABPM) prior to being diagnosed with hypertension. Presently, ABPM is rarely used for this purpose in the U.S. The goal of this research is to develop and test an implementation strategy that will increase uptake of this guideline into primary care.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Project (R01)
Project #
5R01HS024262-04
Application #
9552106
Study Section
Healthcare Effectiveness and Outcomes Research (HEOR)
Program Officer
Mabry-Hernandez, Iris Renee
Project Start
2015-09-01
Project End
2020-08-31
Budget Start
2018-09-01
Budget End
2019-08-31
Support Year
4
Fiscal Year
2018
Total Cost
Indirect Cost
Name
Columbia University (N.Y.)
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
621889815
City
New York
State
NY
Country
United States
Zip Code
10032
Carter, Eileen J; Moise, Nathalie; Alcántara, Carmela et al. (2018) Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study. Am J Hypertens 31:919-927
Anstey, D Edmund; Muntner, Paul; Bello, Natalie A et al. (2018) Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both? Hypertension 72:1200-1207
Muldoon, Matthew F; Kronish, Ian M; Shimbo, Daichi (2018) Of Signal and Noise: Overcoming Challenges in Blood Pressure Measurement to Optimize Hypertension Care. Circ Cardiovasc Qual Outcomes 11:e004543
Kronish, Ian M; Kent, Shia; Moise, Nathalie et al. (2017) Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens 11:573-580
Tajeu, Gabriel S; Kent, Shia T; Kronish, Ian M et al. (2016) Trends in Antihypertensive Medication Discontinuation and Low Adherence Among Medicare Beneficiaries Initiating Treatment From 2007 to 2012. Hypertension 68:565-75