Dramatic improvements in blood pressure (BP) control were reported in a pilot study that switched patients to remote monitoring and had their care managed by nurse practitioners and pharmacists with the help of health coaches trained to use physician-developed algorithms for timely medication adjustments. A pharmacist reviewed and signed all new prescriptions.
Among the patients who stuck with the study protocol measuring blood pressure weekly, 91 percent achieved a target BP of less than 135/85 mm Hg in an average of seven weeks. The study’s overall BP control rate was achieved in 81 percent of patients, according to researchers at Brigham and Women's Hospital (BWH) in Boston who selected participants with a starting BP of 140/90 mm Hg and above. The study, “Development of an entirely remote, non-physician led hypertension management program,” was published in the journal Clinical Cardiology.
The program, now being offered to a vastly larger pool of patients, is designed to break through a persistent problem in hypertension management.
Connecting to at-home BP readings
Nationally, the blood pressure control rate hovers at about 50 percent. While home blood pressure monitoring is not uncommon, the study uses technology to send BP readings from the patient’s home to the office.
“Often the intervention stops there. BPs are sent, but not acted upon in any systematic way by providers,” said lead author Naomi D.L. Fisher, MD, an endocrinologist specializing in hypertension at BWH.
“What is unique about our program is putting all the pieces together in a cost-saving, effective way,” said Dr. Fisher. “Patients’ blood pressures are automatically, seamlessly transferred to the EMR. A software program analyzes them and calculates averages, then directs navigators to the next step in our clinical algorithm.”
Patients were provided with Bluetooth-enabled at-home BP monitoring devices. Software to capture and analyze the data was specially written for the study—which by itself was a substantial project.
The software was then used by a team of specially trained patient navigators to provide day-to-day management of the patient’s condition. These interactions with patients were also handled remotely. While the program has progressed, during the pilot, the nurse practitioner and pharmacist were responsible for the titrations, as well as training and overseeing navigators.
Navigators provide patient coaching
The patient navigators provided education and motivation to follow a set of lifestyle changes. However, central to the program was that navigators were also equipped with a treatment algorithm adapted by BWH hypertension specialists and based on established protocols.
Once alerted to a change in BP during weekly patient reporting, the nurse practitioner and pharmacist—who trained patient navigators in the process—obtained an algorithm-determined prescription adjustment. The pharmacist on the study team reviews and signs new prescriptions.
Such rapid modifications may not happen in traditional BP management. Physicians may be slow to make medication changes, for example, to give lifestyle changes a chance or because of patient promises to do better in that regard.
The study did result in some drug changes other than dosage, but the increased pill burden was modest overall. Overall success of the study occurred because of improved patient adherence, drug selections and timely titration, said the authors.
Non-physicians—pharmacists and a nurse practitioner—provided initial patient management, trained and later supervised the navigators. A physician disease specialist also provided top-level oversight for the program overall.
The navigators made strong connections with patients, and gave support and continuity, but did not execute the algorithm in the pilot. Through their contribution, the navigators contributed to the program’s positive patient response, which went beyond the reward of having improved BP readings.
“Many patients were grateful for the program,” said Dr. Fisher. “They appreciated the constant and personal attention from patient navigators, the education and coaching, and the rapid feedback.
“The ability to control blood pressure without having to come to the office is a huge incentive for many people,” she added. “In addition to eliminating the stress of travel and costs of parking, remote visits often save patients several hours per visit.”
About seven months after completion of the study, almost 100 patients contacted maintained signification reductions in their BP. This program, run by Brigham and Women’s Hospital Cardiovascular Innovation, is now being offered to members of locally based health plan Always Heath Partners. About 7,500 plan members are eligible for the hypertension control initiative, in parallel with a similar navigator-led program to control lipids.
The AMA has developed tools and resources using the latest evidence-based information to support physicians to help manage their patients’ high blood pressure. These resources are available to all physicians and health systems as part of Target: BP™, a national initiative co-led by the AMA and American Heart Association.
Target: BP offers annual, recurring gold-level recognition for all participating sites that achieve hypertension control rates of 70 percent or higher among their patient population of adults with hypertension, and participation level recognition for those sites that prioritize improving blood pressure control each year and submit data. In 2018, more than 800 organizations were recognized for their efforts focusing on blood pressure control within the populations they serve.
