JMIR Publications

ABSTRACT

Background:

Hypertension control is critical to reducing cardiovascular morbidity and mortality, as well as being a key quality measure and indicator for value-based care. Multipronged interventions have been successful in public health (e.g., tobacco control), but have infrequently been intentionally used in quality improvement efforts. Furthermore, quality improvement across diverse clinic settings (academic, employer-based, community) has rarely been examined.

Objective:

The objective of this qualitative implementation science evaluation of a layered hypertension intervention was to identify lessons learned and recommendations to support sustainability and scale of hypertension control.

Methods:

We evaluated efforts to improve blood pressure control in n=6 total clinics - 2 academic, 1 employer-based, and 3 community clinics. Intervention components included: 1) implementing an electronic medical record advisory support, 2) an ambulatory office blood pressure measurement (AOBP), and 3) pre and post visit hypertension-focused care coordination delivered by medical assistants. During half-day site visits (2019-2020), we conducted 28 semi-structured interviews with clinicians (physicians and advance practice providers, n=9), medical assistants (n=11), clinic management (n=6), and other team members (n=2). We examined the following implementation outcomes for individual intervention components: feasibility within clinical workflow, acceptability to clinical teams, and facilitators and barriers to sustainability/maintenance. We also assessed themes across intervention component and clinic setting for emerging best practices for implementation.

Results:

Participants reflected that the EMR advisory component was: 1) acceptable with some feasibility concerns; 2) implemented with significant variation; and 3) sustainable in part due to perception that adoption provided MA training in new skills. AOBP acceptability and feasibility was also challenged by variation in usage and lack of confidence in the technology. These concerns resulted in major sustainability challenges for this component. Participants reflected that the patient care coordination component was: 1) acceptable with some modifications; 2) offered the potential for high fidelity and standardization (e.g., a single patient coordinator could theoretically support multiple clinics in a remote coordinator position); and 3) sustainable with risks related to turnover and competing priorities. Emerging best practices for implementation across clinic settings included emphasizing process, identifying champions, deliberately balancing improvement work against other priorities, and aligning incentives and rewards. Process success focused on creating multiple cues to take two blood pressure readings (e.g. visual reminders in patient rooms, verbal reminders at meetings, written e-mail reminders, etc.). BP champions (i.e., highly-engaged clinic managers and some clinicians) also supported implementation, adoption, and maintenance by motivating teams and supporting continuous learning environments. In terms of competing priorities, there was a recognition that this kind of long-term, multi-layered intervention needs to be balanced against the volume of work overall in the clinic. Lastly, alignment with internal and external rewards is needed, particularly in a value-based care context; one example of this related to benchmarks set as part of contracts with the academic health center for employer-based clinics.

Conclusions:

Next steps and further directions point towards strengthening implementation strategies, and innovating on technology and reimbursement. Specifically, the current billing/remote patient monitoring codes to support this work are cumbersome. A more efficient tracking-to-billing process is needed. Also, facilitation of EMR simplification (e.g., simplifying SmartSets; designating intuitive areas to house additional home monitoring data) will be key to tracking and success of multi-layered population health initiatives such as this one in the future.