PROJECT SUMMARY / ABSTRACT
This AHRQ R18 proposal focuses on evaluating patient-level and clinic-level strategies to increase
implementation of self-measured blood pressure (SMBP) monitoring programs with clinical support;
specifically, we focus on identifying approaches to increase SMBP monitoring in safety net settings where
many low-income and/or culturally diverse populations who experience worse hypertension control and
outcomes receive clinical care. SMBP monitoring is an evidence-based, guideline-recommended practice that
is most effective when combined with clinical support. However, SMBP monitoring with clinical support has had
limited adoption in many safety net clinical settings due to multi-level barriers. To accelerate adoption of SMBP
monitoring with clinical support in safety net settings, we propose to conduct this project in an integrated, urban
safety net healthcare system that provides ambulatory care for >50,000 patients.
In Aim 1, we will co-design patient-level and clinic-level implementation strategies to increase SMBP
monitoring supported by clinical teams. We will conduct three rounds of design sessions in focus groups with
English, Spanish, and Chinese-speaking patients with hypertension and clinical care team members (e.g.,
clinicians, pharmacists, nurses). We will design: (1) two patient-level strategies (a low-intensity strategy of
providing cellular-enabled BP monitors and training on its use vs. a high-intensity strategy that adds reminders,
training on transmitting BP data to the clinical team, and approaches to engage caregivers/peer in SMBP
monitoring activities); and (2) one clinic-level strategy (training of clinical champions and design of electronic
health record [EHR] implementation tools). In Aim 2, we will conduct a hybrid type 2 effectiveness-
implementation trial and evaluate effectiveness and implementation outcomes. A total of 330 patients will be
enrolled for 12 months and randomized to high-intensity vs the low-intensity patient-facing implementation
strategy; six primary care clinics will receive the clinic-level implementation strategy in a stepped wedge
design. For the patient-level strategy, the primary effectiveness outcome will be change in systolic BP at 12
months and primary implementation outcome will be the number of home BP values measures over the 12-
month period. For our clinic-level implementation strategy, the primary effectiveness outcome will be change in
clinic-wide BP control and primary implementation outcome will be the frequency of documenting patient-
collected BP values. Our secondary outcomes include other clinical outcomes, patient-reported outcomes, and
other implementation outcomes, collected from surveys, observations, interviews, and EHR data. In Aim 3, we
will conduct a cost-analysis of our implementation strategies and intervention with a focus on understanding
the costs of implementing an SMBP monitoring program when supported by our implementation strategies.
Data will be collected through surveys, interviews, observations, and review of EHR data.
