Celebrating Clinic Teams Who Roll Up Their Sleeves Every Day Measuring Blood Pressure
I knew just the victory I wanted to celebrate after listening to Intermountain’s Dr. Taki May call out the need for celebrating small victories in healthcare to combat clinician burnout. The victory was achieved by one of our clinic teams at Activate Healthcare that tirelessly works every day to achieve our mission to help patients take charge of their health and help organizations take charge of their health care costs.
They partner with patients so that over time, patients develop the knowledge, skills and confidence required to pursue care that is needed and supported by evidence. I wish there was an “easy button” to make that happen, but no such button exists and this will only be achieved through many small victories. One speaker at a recent Bridge to Pop Health conference I attended in Boston stated it this way—paraphrasing what I heard: “There are no more discoveries like penicillin coming down the pike....realizing major gains in population health now requires that we roll up our sleeves and do the hard work associated with collaborating with others and engaging patients.”
The victory our team achieved exemplifies the type of “roll up your sleeves” effort that will result in great gains over time. They took the gritty steps involved in making it as easy as possible for patients to record accurate blood pressure readings at home.
Measuring blood pressure out of the office
One recommendation made in the recent 2017 ACC/AHA guideline on high blood pressure that was salient yet challenging to implement was this: “Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.”
Is the hassle involved with incorporating out-of-office blood pressure measurements into clinical decision making warranted? I think so. Though accurate measurement of blood pressure (described in the guideline) in a primary care office is possible, following the recommended protocol to obtain an accurate blood pressure may sometimes be incompatible with normal office flow. (For example—how often is blood pressure measured in patients who are relaxed and sitting in a chair for > 5 minutes, have avoided exercise or caffeine in last 30 minutes, have an empty bladder, with uncrossed legs and no one talking, and have sleeves rolled up if needed—all of which can increase blood pressure by an appreciable amount...see page 8 of this primer about how to engage patients in self-measurement). To me it is not surprising that the guideline’s authors suggest that office blood pressure measurement “errors are common and can result in a misleading estimation of an individual’s true level of BP.”
Reliance on error-prone blood pressure measurements to make diagnoses and titrate medications creates two risks: 1) patients whose blood pressures are high in the office but normal at home (so-called white coat hypertension) are treated when it may not be indicated; and 2) patients whose blood pressures are normal in the office but high at home (so-called masked hypertension) are not treated.
Celebrating a victory
Demonstrating their commitment to making it as easy as possible for patients to pursue needed care (and avoid unneeded care), one clinic team rolled up their sleeves, purchased 10 blood pressure monitors for home use, each with a regular and large size cuff. Blood pressure cuffs are dispensed with measurement instructions, blood pressure log sheets, along with a lending agreement. So far, treatment decisions (or decisions not to treat) have been enhanced in approximately 45% of the patients who recorded home bp measurements. The team indicated that "patients absolutely understand why it is important to have BP monitored at home and they are generally happy to monitor BP at home."
Some patients have chosen to communicate home blood pressure readings to our clinicians electronically through Twine Health, allowing rapid medication adjustment in between office visits. The program has made this whole process easier for patients, increasing adherence to home blood pressure monitoring resulting in better data being used for clinical decision making. This is a great victory that is engaging our patients in taking charge of their health.
Our journey continues to achieve our mission, but it is a privilege to celebrate this small victory with you today!