The community Montefiore Einstein serves has some of the highest rates of hypertension in New York City. Identifying and monitoring people is critical. But there is a challenge to doing that if patients aren’t making regular visits to the doctor. And even if they are, taking a patient’s blood pressure once or twice a year does not give a clear and accurate account of what is happening every day. This can lead to adverse outcomes such as heart attacks, strokes, and kidney failure.
Clinicians and researchers at Montefiore Einstein want to preempt that. They started a Quality Improvement Initiative: Remote Patient Monitoring Program for Hypertension (RPM-HTN) that seeks to improve blood pressure control, which affects more than 100,000 of Montefiore’s patients, and to test the viability of remote monitoring for the disease.
“Although hypertension has a huge impact on health, we can do better on the control side,” says Sharon Rikin, M.D., assistant professor in the department of medicine (general internal medicine), who is a co-leader of the program along with Allison Stark, M.D., assistant professor in the department of medicine (geriatrics) and department of family and social medicine.
Less than half of Montefiore’s patients have their blood pressure controlled, which is where remote patient monitoring comes in.
Says Rikin, “Remote patient monitoring has been talked about but there had not been a lot of momentum around implementing it for several reasons: it’s a new technology, costly, and requires greater resources, including having clinical staff to analyze and respond to a slew of data and teach patients how to self-measure.”
It was COVID that accelerated the remote monitoring movement. The growth of institutions adopting remote monitoring has exploded as a result.
Instead of just getting a one-off blood pressure measurement in the office, patients in the RPM-HTN program measure their blood pressure every day – sometimes several times a day. They are given a blood pressure device that is cellular enabled, which allows for patients who do not have WiFi or a smartphone to participate. The device pings the nearest cell tower and gives clinicians the reading. They are planning to sync it with Montefiore’s electronic health record so there will be a seamless integration between home and clinic.
Patients learn about the program through their primary care physicians. A grant from the National Hypertension Control Initiative (a partnership with the Department of Health and Human Services, Health Resources and Services Administration, and Office of Minority Health) enables Montefiore Einstein to conduct outreach specifically to uninsured patients.
A year into the program, nearly 300 patients have participated, which involves having their blood pressure monitored for approximately three months. Those whose blood pressure is under control for one month can be discharged. Some patients like it so much, they want to stay on even when their blood pressure is in the normal range (<140/90 for people without risk factors; <130/80 for people with risk factors). For patients who have resistant hypertension after three months, they can be referred to hypertension specialists.
Among patients participating in the program at 12 weeks, 30% maintained an average weekly blood pressure of <140/90.
Montefiore plans to expand the program to all of its primary care sites over the next year.
There are multidisciplinary teams involved, including three full time nurses who review the blood pressure measurements on a bi-weekly basis with patients (those with very high readings will be contacted within 24 hours). They counsel patients about medication adherence, lifestyle modifications, and ensure that patients understand how to take their medications. The team includes clinical pharmacists who meet with patients to make medication adjustments.
“We see the day-to-day trends in blood pressure readings, which is very compelling because when we spot abnormalities, we can do something about it in real time. This is especially helpful for patients whose only health concern is hypertension and who would not be seen all that frequently. We can intervene before their hypertension turns into something more serious,” says Rikin.
There is a subset of complex patients in the program with chronic kidney disease, who are followed by Molly Fisher, D.O., assistant professor in the department of medicine (nephrology) and Tanya Johns, M.D., associate professor in the department of medicine (nephrology). “These patients are at the highest risk for adverse outcomes related to their hypertension,” says Fisher. “Many of them have had hypertension for more than a decade and are already on multidrug regimens, but their blood pressure is still uncontrolled,” Fisher adds.
Nine months into the nephrology program, nearly 80 patients have participated. Despite many having resistant hypertension at the time of enrollment, the program has been a success with 65% achieving a monthly average blood pressure of <140/90 and 35% achieving a monthly average blood pressure of <130/80 after participating for 12 weeks.
“Hypertension is a chronic medical condition that can and should be managed outside of the office,” Fisher says. “The multidisciplinary approach of this program provides the necessary tools that allow patients and providers to partner together to achieve blood pressure control.”
Posted on: Friday, April 29, 2022