Improving Patient Adherence for Home Blood Pressure Management: A Quality Improvement Project
Executive Summary
Executive Summary
Background and Significance: Nearly half of adults in the United States are being treated for hypertension (HTN), defined as a systolic blood pressure (BP) greater than 130 mmHg or a diastolic BP greater than 80 mmHg. HTN is a prominent modifiable risk factor for cardiovascular, renal, and cerebral diseases (Egan et al., 2018). Self-monitored blood pressure (SMBP) reduces HTN related deaths and disability while empowering patients through increasing autonomy, self-efficacy, and lifestyle modification. Small primary care clinics often serve patients with lower incomes who may not have the resources or personal technology to support smart BP monitoring and many patients prefer the tactile route of paper recording. Therefore, implementing digital remote tracking of SMBP is not feasible for many clinics. Identifying different tools to increase patient engagement with BP measurement and record-keeping is critical to decreasing uncontrolled HTN rates.
Problem Statement: The project clinic in Lynnwood, Washington sought methods to encourage patients to record and report back their SMBP. Nurse practitioners at the project clinic report that less than 25% of patients return with the requested two-week BP recordings to their follow-up appointment. SMBP reported back to providers establish a broader picture of medication efficacy, adherence, and patient engagement to base medication changes. Establishing an economical and tactile method for patients to use SMBP and increase adherence to reporting results, supports practitioners in providing accurate and time-effective BP management.
Purpose Statement: This DNP project aimed to assess patients with HTN performing home SMBP and whether a paper take-home recording log would increase patient adherence to returning BP records at follow-up appointments. The process improvement aimed to improve patient adherence to SMBP.
Methods: This project was implemented at the project clinic in Lynnwood, Washington. All male and female patients ≥ 18 years old diagnosed with HTN, essential HTN or uncontrolled HTN were included in this study. A packet was distributed to each qualifying patient seen by an NP between January 2022 and April 2022 (Appendix A, B, C). The packet featured three documents, a cover letter, recording log, and questionnaire. The questionnaire consisted of patient demographics and questions on BP monitoring behavior: six five-point Likert scale and one yes or no question. Demographic data was framed as a fill-in-the-blank at the top of the questionnaire page. Patients were then asked to return their recording logs and questionnaires via post mail, scan into EMR, or physically return to the clinic. The NPs collected the packets as they were returned, removing any identifiable patient information before distributing back to the project lead.
Results/Outcomes: A total of 95 patients were given the packets, and three of them returned their BP recording logs and questionnaire. The total response rate was 3.2%. Participating patient demographics consisted of 44 to 70 years old, with a mean age of 59.6. All three participants were males and identified as Caucasian. All three participants completed the entire questionnaire (five Likert scale questions and one yes or no question). Results varied with questions regarding frequency of checking BP, forgetting to check BP, and if the intervention helped them remember to check their BP. Conversely, all participants agreed they do not find it difficult to check their BP, that they found the tool helpful in tracking BP, and that if they do not notice their high BP they may skip checking it.
The poor return rate (3/95, 3%) indicates that these results are not transferrable to practice guidelines. The project significantly highlighted the low participation in returning BP recordings. Therefore, it is key for the clinic to implement a change to increase patient adherence and education on SMBP. Such as workflow changes to address the poor return rates, gathering formal data analysis on BP return rates, and enhancing the remote device monitoring system to utilizing home BP monitoring with their EMR.
Sustainability: Due the minimal number of participants and low return rate it is difficult to determine the efficacy of the BP recording logs. The results of the study were few, with positive patient response to the usefulness of the BP recording log. If the clinic site deems the paper recording log a valuable tool to implement into their practice, and commits to consistent distribution, the clinic may find positive patient responses. Furthermore, the clinic should conduct a program evaluation regarding their patient population specific barriers to home BP monitoring before electing to implement this project.
Implications: Without home BP recording logs or remote device monitoring, practitioners must rely on only in office BP to make medication changes. Without a complete assessment of a patients’ BP, medication management is solely based on office BP possibly resulting in inadequate medication adjustments. HTN increasing a patient’s risk for cardiovascular and renal disease complications. Patient engagement in their own healthcare monitoring and management appears to be low based on the project results. However, further investigation is necessary for deeper understanding of patient adherence and the barriers to poor adherence.
References:
Egan, B. M., Sutherland, S. E., Rakotz, M., Yang, J., Hanlin, R., Davis, R. A., & Wozniak, G. (2018). Improving hypertension control in primary care with the measure accurately, act rapidly, and partner with patients protocol. Hypertension, 72(6), 1320–1327. https://doi.org/10.1161/hypertensionaha.118.11558