Download Implementation of Ambulatory Blood Pressure Monitoring in Primary

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]