Introduction
Methods
Goal
Sampling and recruitment
Data collection
Data analysis
Results
N = 27 | |
---|---|
Age in years | |
25–34 | 3 |
35–44 | 9 |
45–54 | 5 |
55–64 | 4 |
65–74 | 2 |
Missing a | 4 |
Sex | |
Male | 6 |
Female | 19 |
Missing a | 2 |
Race/Ethnicity | |
BIPOC | 7 |
White | 20 |
Hispanic | 0 |
Avg years practicing (range) | 16 (4–38) |
Avg years at KPWA (range) | 9 (1–35) |
Avg FTE | 0.9 |
Specialty | |
Family medicine | 25 |
General internal medicine | 2 |
Clinic blood pressure measurement
So, in clinic we always use the manual because I guess from my training that was considered the gold standard. (Clinic 6, PCP2)I would say a manual monitor [is more accurate]—at least this is what I'm taught, and this is kind of what I use in my practice—the manual monitor's the most effective. (Clinic 4, PCP20)
I have a preference to bring them into my clinic to have a manual blood pressure check by my MA, because I know they have them rest for five minutes before they check the blood pressure, make sure their arms aren't crossed and make sure the arm's rested and held at heart level when they're checking it, because those are sort of the norms we indicate to our MAs when they have a protocol to recheck it, if it's elevated beyond…140/90. If it's elevated beyond that, they usually recheck it in about five minutes and then notify us. (Clinic 4, PCP16)
Well, I think the only thing I hear patients complaining about is having to come in, if they weren't otherwise, needing to make the time, right? So, it's obviously extra work for people to come in through traffic, park and come in and then sit and wait for their blood pressure to be checked, so that would be one obvious barrier. (Clinic 1, PCP7)I think having patients come in for a frequent follow up, whether it's a doctor's visit or a blood pressure check visit, is not very patient centered because it's hard for people to come in. In my clinic, I work in a particular…clinic that's extremely non-patient-friendly for access. We have very poor parking…So it's just hard for people to come in. (Clinic 2, PCP19)Some patients live far away from clinics so coming to see us even without a copay is really a barrier because it's a 90-minute drive for them. (Clinic 4, PCP10)
I know there have been studies about the automatic cuff being more accurate than the humans. …I'm not sure, I haven’t had access to an automatic cuff since forever… Everything's manually, no automatic cuffs. So, I'd like to do that, I think that would be super helpful, but it's not an option. (Clinic 4, PCP12)
Home blood pressure measurement
I'm less comfortable with the kiosk and the home blood pressure reading…if someone's truly been resting or their position and things like that. And then oftentimes if someone brings in home readings, I don't know if their machine is calibrated or something like that, so it makes me a little more uncomfortable. (Clinic 1, PCP5)
I would be much more open to using the home numbers, but for whatever reason they have not been considered a legitimate use of the numbers. So, we'll keep getting reports saying people are out of control and [the EHR will do] automatic outreach and things like that... so it's really just from a practical standpoint, [we] can't use the home numbers because they do not translate into the [health care system’s] goal setting. That's why I use the clinic numbers …. There's a certain kind of tail wagging the dog … I recognize, but somebody emails their home numbers, and they are good, they're still going to show up on a report until they come in and get a blood pressure that looks good. (Clinic 1, PCP7)
But I do think being able to check your blood pressure at home is probably for most people the most convenient thing to do. (Clinic 3, PCP12)It's just easy. You don't have to leave the home to go anywhere, which I think is what people prefer, I would prefer that. Especially if you're older, which most of my patients with hypertension are, or a lot of them are. Transportation can be an issue. (Clinic 1, PCP5)That's the other thing about the home monitoring. I just feel that works so well for a lot of my patients to just check it at home and have them come in once and make sure the blood pressure cuff is accurate and then we can just titrate meds, do all this virtually. To me that just seems like much better. (Clinic 2, PCP9)
There is a subset who take a reading and they get anxious and then a minute later they take another reading and it's higher, another minute later they take another reading and it's higher, and they just work themselves up into a complete panic. So [there is a] slice of patients with hypertension and anxiety for whom I'd specifically say I do not recommend that you monitor your blood pressure at home, but that's the minority.” (Clinic 2, PCP13)But sometimes the patient is too much like anxious, they are pretty much checking the blood pressure 16 or 17 times per day, and I don't think that is good. …You don't want to get them in a panic…. (Clinic 6, PCP3)
Kiosk blood pressure measurement
The other one I really don't like is the kiosk ones, just because I find that people say, "I checked the blood pressure at the kiosk and it was high," but they were using it at the store, and they were walking around, and they weren't doing it properly. Or they're obese, and their arm size probably isn't a one-size-fit-all cuff. I think that is my least favorite. (Clinic 6, PCP3)
I do refer patients that don't have a cuff to go use those [kiosks]. I think they're another good tool to have. My only concern with them is that often it's hard for people to go sit down for five minutes before they do a blood pressure reading. If you're like at work, you're more in a get-in, get-out attitude. I have no real data to support that, but I tend to believe the readings that we were getting. I just always like to check if they've actually been seated for five minutes before they get their blood pressure checked.” (Clinic 2, PCP17)
So, to me, store kiosk blood pressure cuffs are the same as home cuffs in the sense that I don't know how accurate they really are. I'm sure it's variable. But at the same time, I think it helps because if they're measuring high and I'm measuring an office high, I think it helps reinforce the people who aren't convinced that they really have high blood pressure, who think it's only high in the office. So, I do tell people to check outside the office and let me know what reading they're getting, but I'm not 100% confident in them. (Clinic 6, PCP1)
24-h Ambulatory blood pressure measurement
I would say it [the 24-hour monitor] is just a more robust set of data, so when you're doing ambulatory blood pressure monitoring, that's the gold standard. (Clinic 1, PCP7)I guess with the 24-hour monitoring, I do feel more confident telling a patient this really helps confirm your diagnosis being hypertensive and indicates that treatment would be helpful. (Clinic 3, PCP12)
Typically, in patients that do not currently carry a diagnosis, but I have an elevated reading, and are uncertain or unconvinced of whether they need medication. So, I'll use it as a tool to confirm diagnosis and establish a need for medication (Clinic 2, PCP13)
I guess with the 24-hour monitoring, I do feel more confident telling a patient this really helps confirm your diagnosis being hypertensive and indicates that treatment would be helpful. (Clinic 3, PCP12)So, I guess if they're just in the clinic and they're someone that's had consistent hypertension, I tend to rely more on the manual readings. If it's someone that's had really labile blood pressure, that's when I would usually use the 24-hour blood pressure monitoring. (Clinic 2, PCP 17)Well, I would like to be able to order a 24-hour home monitoring test whenever there's a lack of clarity behind diagnosis. It happens a lot where I notice that the blood pressure trend in the office has been high, and I suspect that it more likely than not is not simply a white coat hypertension issue and I would like them to start treatment of some kind. However, I have several patients, for whatever reason, that are very resistant to prescription medications and who would prefer to use so-called naturopathic remedies of various types. Or just flat out refuse medications. Or say look, doc, I don't agree. I think the blood pressures that you guys are getting here are inaccurate and I'll take it myself, with my home cuff or self-monitor I would likely say well, let's meet in the middle. Why don't we do a home monitoring test and really see what they are, with a reliable method of monitoring your home blood pressures that I as your doctor feel confident in. (Clinic 2, PCP 19)
I don't think I've ever ordered a 24-hour ambulatory blood pressure reading, just because the mechanism is not that readily available. That's pretty much it. Mostly in-clinic manual blood pressure readings is what we rely on. (Clinic 4, PCP24)I like the 24-hour monitor because I think it's a more realistic reading of what people are experiencing throughout the day, but I think it's a little bit of a hassle to get it set up for patients, the way that it's set up … it has to be a referral to nephrology and follow up with them, not available in primary care directly. (Clinic 2, PCP 17)
Patient engagement
So, the [patients] that get really into it will notice variations. So, then they will point that out. That's usually useful and helpful, especially if there are some that are on the higher side, because then that leads into showing people there is variation, it may be running higher at times when they don't realize it. (Clinic 3, PCP2)
If a patient measures blood pressure, no matter where, in the pharmacy, gas station, fire station, whatever, if a patient has a chance to measure their blood pressure, if they can write it down, I will count that. (Clinic 6, PCP2)I guess patient-centered means patients have different needs …. Some patients don't want to invest in a home blood pressure monitor, they are comfortable coming into clinic and having it checked from time to time or going to a kiosk ... (Clinic 3, PCP12)
Influence of the BP-CHECK trial
…we more routinely do that second blood pressure reading and we use the automated, we use the machine. And that came out of one of the discussions about the study and the unreliability of certain techniques and certainly the manual technique is less reliable. So, we have been more consistently using the automated cuff and especially for the second blood pressure reading… I find myself more reliably asking for home blood pressure readings outside of the clinic blood pressure readings as additional information. I have ordered a couple of 24-hour ambulatory measurements since then as well.Interviewer: … Is there anything that you can point to that's influenced that particular change?PCP: I think the awareness of the limitation or the unreliability of the single point measurements in clinic… especially with some of our older frail adults – basing treatment on a one-point measurement, they actually increase the risk of harm if that person really doesn't show hypertension outside of clinic. So really feeling certain about the diagnosis, that the study raised awareness of certainty of the diagnosis before initiating treatment. (Clinic 2, PCP5)I'm more willing to ask for and use outside readings. I've always been willing to use them, but I've also usually insisted patients still come into properly document for HEDIS [Healthcare Effectiveness Data and Information Set] purposes their results - I've got to admit I'm a little less concerned about that, and more concerned about let's make the right diagnosis and get you treated. Especially as we're trying to push the numbers down lower for good blood pressure control, I'm willing to accept more outside readings. I don't know if this ambulatory study influenced me in that decision - I suspect partly - just a willingness to be more open to use the outside readings, wherever we can get them. So that may be the only real change at this point. (Clinic 4, PCP6)