Transcript Document
Improving Diagnosis and Management of Hypertension: Implementation of Ambulatory Blood Pressure Monitoring in Primary Care* A teaching hospital of Harvard Medical School Scot B. Sternberg, MS; Kristine Sullivan, RN; Catherine Ivkovic, RN; Tarsha A. Soares,RN; Jennifer Beach, MD Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Problem: Hypertension is a major risk factor for myocardial infarction, stroke and renal failure. Lowering blood pressure to target ranges prevents cardiovascular events and decreases mortality¹. Ambulatory Blood Pressure Monitoring (ABPM) which records blood pressure measures during a 24 hour cycle provides a better indicator of actual BP and predictor of cardiovascular outcomes. BIDMC’s HealthCare Associates (HCA) is a large academic adult primary care practice for almost 42,000 patients of whom approximately 30% have hypertension. New Draft recommendations from the U. S. Preventive Services Task Force recommends considering ABPM to confirm all new diagnoses of hypertension prior to initiating drug therapy (Grade A recommendation) Access to ABPM has historically been limited to a few specialty practices. Aim/Goal: Implement a multidisciplinary ABPM clinic at HCA. Improve diagnosis and management of hypertension. Description of the Intervention, including context Reviewed literature on ABPM and discussed with specialists using ABPM in BIDMC and externally. Lead physician became certified as a hypertension specialist and received training in ABPM interpretation. Purchased equipment and trained nursing staff on utilization. Developed and fine-tuned referral process, patient education materials and activity log. In collaboration with IS, developed process to integrate results and interpretation within webOMR. Nurses educate patients on process of monitoring and logging activities. ¹James PA, et al. Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA Dec 18, 2014. ²Piper MA, et al. Screening for High Blood Pressure in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 121. AHRQ Publication No. 13-05194-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014. The Results/Progress to Date: Results/Findings to date: ABPM Referral Indication: Apparent drug resistant hypertension ABPM Referral Indication: White coat hypertension 23.5% 27.6% Sustained hypertension Controlled hypertension White Coat Hypertension Orthostatic Hypotension 65.5% 6.9% Sustained hypertension • 65.5% confirmed as sustained hypertension. Recommendations included increasing medication regimen, assessing for secondary causes, increasing lifestyle modifications and assessing adherence. • 27.6% diagnosed as controlled hypertension. Recommended maintaining current treatment plan. • 6.9% diagnosed as hypotensive. Recommended reducing medication regimen. 76.5% • 23.5% ABPM diagnosed as sustained hypertension. Recommendations include add medication, increase dose or assess for secondary causes Key Lessons Learned BP measures during a 24-hour cycle provides valuable information for clinicians seeking to improve diagnosis and treatment of hypertension. ABPM can assist providers in accurate diagnosis of hypertension and optimizing management of hypertension as well as identify those needing assessment for secondary causes. Next Steps Formalize referral process for ABPM within HCA including Hypertension Management consults. Pending USPTF recommendations for use of ABPM¹, develop plan for further expansion of service. *This work was supported by the Linde Fellowship in Primary Care Leadership . Special thanks to Jayne Carvelli-Sheehan, RN, VP Ambulatory/Emergency Services and System Integration, for support of this project and purchase of the Ambulatory Blood Pressure Monitors. For More Information, Contact Jennifer L. Beach, MD: [email protected]