Abstract
BACKGROUND: EMBRACE was a practice-level cluster randomized trial of a multicomponent implementation strategy for increasing out-of-office blood pressure (BP) monitoring during hypertension screening. Key components included linking practices to ambulatory BP monitoring (ABPM), deploying electronic health record (EHR) tools to prompt and facilitate test ordering, and delivering educational presentations and reminder emails. OBJECTIVE: Understand why the implementation strategy modestly increased ABPM but not home BP monitoring (HBPM) versus usual care. DESIGN, SETTING, AND PARTICIPANTS: Clinicians from intervention and control practices were surveyed 1 year after implementation to compare attitudes toward out-of-office BP monitoring and recall of implementation strategies. A subsample was interviewed to gain a deeper understanding of survey results. KEY RESULTS: Of 142 eligible clinicians, 89 (63%) completed surveys (53 from intervention practices, 36 from control practices; 49% trainees). There was a pattern of clinicians from intervention practices having more favorable attitudes toward out-of-office BP monitoring generally (remember to order out-of-office BP testing) and ABPM specifically (aware of ABPM availability, know how to order/interpret ABPM, perceive ABPM to be affordable), but not HBPM. The implementation strategies most commonly recalled by intervention clinicians were the accessible ABPM testing service (recalled by 59%) and reminder emails (recalled by 48%). Only 38% and 24% of intervention clinicians recalled EHR tools for ABPM and HBPM, respectively. Key themes that emerged during interviews to explain modestly more favorable attitudes toward ABPM and no difference for HBPM included persistent logistical challenges with ABPM referrals when unavailable locally, low awareness of EHR tools to facilitate ABPM and HBPM ordering, and limited availability of nurses to offload HBPM training from clinicians. CONCLUSIONS: Locally available ABPM testing, better designed EHR tools to prompt and facilitate test ordering, and increased nurse availability for HBPM teaching may be needed to substantially increase out-of-office BP monitoring as part of hypertension screening. TRIAL REGISTRATION: NCT03480217; http://clinicaltrials.gov/show/NCT03480217.