Discussion
arrhythmias, hypertension, anxiety
ARRHYTHMIAS, HYPERTENSION, PCP, HBP
Interviews with PCPs who had experience with ABPM through the BP-CHECK randomized trial revealed that overall, they preferred clinic-based BP measurement for hypertension diagnosis, especially manual BP measurement. PCPs viewed measurement in clinics as accurate because it is performed by a trained professional who can ensure optimal patient rest and body positioning. For HBPM, PCPs worried about patients’ ability to follow best practices regarding rest and body positioning, the accuracy of the monitors they have at home, and whether repeated measurements would cause patient anxiety. These results suggest that PCPs’ confidence in clinic-based BPs and concerns about HBP may be misplaced given that the main findings of the BP-CHECK study found HBPM for diagnostic testing was more accurate than clinic-based BP follow-up measurements. However, in the BP-CHECK study, patients received free validated home BP monitors and were trained to use them [PCPs were also concerned that there was no acceptable way to document HBPM readings in the EHR for HEDIS purposes at the time of the interviews. (HEDIS rules have since changed to allow quality measurements to include manual and electronic entry of BP measurements taken at home.) Also, subsequent to the COVID-19 pandemic, the Center for Medicare and Medicaid Services approved use of home BP measurements for reporting quality metrics. Pursuant to this change, our health care system is testing several strategies for collecting BPs from home, including a BP telemonitoring program with BP measurements directly transferred to the EHR or patients hand-entering their home BP readings into secure email sent via the patient's shared EHR.For kiosk-based measurements, PCPs were concerned about maintenance of the BP machines, whether testing in a public setting created stress, and patients’ ability to follow recommended resting time and positioning prior to taking measurements. PCPs also noted that kiosk results tended to be high, which aligns with the results of the main study that found kiosks but not clinic or HBPM methods tended to give higher readings than ABPM [While interviewees acknowledged that ABPM is a very accurate method for measuring BP for diagnostic purposes, they correctly perceived that it was not readily available. ABPM devices are expensive and require specialized software and staff who are trained to do ABPM testing and retrieve the data. However, ABPM could be made more easily available, similar to devices that track arrhythmias that can be set up within primary clinics or mailed to patients directly. We know of only one study that is testing strategies for improving access to ABPM and home BP hypertension diagnostic testing and the results are not yet available [Our findings are consistent with and expand on prior studies that explored PCP beliefs and preferences about out-of-clinic BP measurement. One key finding from the literature comes from a systematic review of qualitative studies on patients and physicians. The studies were conducted in the U.K. (6 studies), Sweden (1), Malaysia (1), Canada (1) and the U.S. (2) and were about self-measurement of BP for management of hypertension. For hypertension management (not diagnosis), the review found that physicians: 1) recognized that that home monitoring often gave lower measurements than clinic and that created a dilemma about which BP measurements to use, 2) were concerned that HBPM would increase anxiety for patients, and 3) reported that variability in BP introduced by HBPM increased treatment uncertainty. A survey of general practitioners in the U.K. found that only a minority recognized that threshold values for diagnosis using HBPM were lower than those for clinic measurement [Our study also has a unique focus on diagnosis rather than management: Diagnosis has important implications for if and how individuals understand and begin management for their hypertension. Our findings reinforce Fletcher et al.’s themes regarding the concerns that PCPs have with self-monitored BP, including difficulties interpreting variable BP readings and reconciling them against clinic measurements as well as perhaps unfounded worries that HBPM causes patients to become overly anxious about their BP [Our findings provide additional insight into the reliance and trust that PCPs place in clinic BP measure. PCPs in these interviews articulated a preference for in clinic BP measurement for diagnosis, which was reinforced by a parallel survey our team conducted that found that 64.7% of PCPs and 88.9% of registered nurses and MAs endorsed clinic BP as the most accurate measurement method [Our study has many implications for practice. First, our findings highlight the need for education of both PCPs and patients about how to interpret BP values obtained by different methods using established threshold values for abnormal BP that are available for each BP measurement method. Our findings also show the importance for PCPs and patients of understanding the variability in BP and therefore the benefits of multiple readings. Indeed, PCPs appeared to lack understanding about what to do with variable readings and desire to treat BP as a more static vital sign. Our findings also show the need to find ways to demonstrate the accuracy of HBPM and increase PCP confidence in this measurement method. In addition to the need to address PCP knowledge and attitudes toward BP measurement and diagnosis, our results also show the need to address systems barriers for use of HBPM and ABPM, for example by finding secure, user-friendly mechanisms to integrate HBPM results into EHRs, ensuring that these results are acceptable for HEDIS or other quality metrics, and making ABPM more readily available to PCPs. Another policy and systems challenge that health care delivery is facing in the U.S. is that clinics and health plans are not allowed to provide patients with free home BP monitors, because they are considered to be inducements, and would violate anti-kickback laws. They can, however, loan patients home BP monitors, but getting the monitors back and cleaning them for the next patients presents additional barriers. Resources for training patients to use home BP monitors properly also might not be easily available. Overall, both increased education for PCPs regarding how best to screen for and diagnose hypertension in primary care settings and changes to clinical workflow and infrastructure are needed to improve the rate of hypertension diagnosis and treatment in the U.S.Limitations to our study include that it was conducted in a single large, integrated healthcare system with diverse practice patterns, patients, and providers from 12 clinics. Also, the sample size,while considered robust for qualitative methods, may not have captured all possible PCP perspectives. The PCPs who participated in our study were all physicians and their results may not represent the attitudes and practice patterns of non-physicians who provide primary care within our healthcare system. As part of the study, all interviewees ere offered an educational session on BP measurement and diagnosis conducted by the study leader and had more exposure to ABPM than other PCPs not involved in the trial. We expect that PCPs who were most innovative and interested in research would volunteer to participate in the interviews; therefore, we believe this selection bias may skew our results toward PCPs who are more open to considering new methods for measuring BP and diagnosing hypertension. Finally, the results regarding patient centeredness come from the PCPs rather than patients. Our patient data will be reported in a separate manuscript.