Advertisement

Improving primary care follow-up for gynecologic patients with hypertension: an implementation science pilot study

      Objective

      Hypertension is the leading modifiable risk factor for cardiovascular disease (CVD), the leading cause of death in women.
      • Farley T.A.
      • Dalal M.A.
      • Mostashari F.
      • Frieden T.R.
      Deaths preventable in the U.S. by improvements in use of clinical preventive services.
      Timely referral to primary care from specialty clinics for hypertension occurs infrequently, even among gynecologists.
      • Schmittdiel J.
      • Selby J.V.
      • Swain B.
      • et al.
      Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics.
      BP Connect, a staff protocol for specialty clinics, doubled the odds of timely primary care follow-up for rheumatology patients with hypertension (42% after BP Connect implementation vs 29% before BP Connect implementation).
      • Bartels C.M.
      • Ramly E.
      • Johnson H.M.
      • et al.
      Connecting rheumatology patients to primary care for high blood pressure: specialty clinic protocol improves follow-up and population blood pressures.
      Here, we sought to evaluate the feasibility and impact of implementing BP Connect in gynecology clinics.

      Study Design

      In 2 academic gynecology clinics, the BP Connect intervention trained medical assistants and nurses to “check” (remeasure) blood pressure (BP) of ≥140/90, “advise” patients of links between hypertension and CVD, and “connect” patients with confirmed high BP for timely primary care follow-up. The implementation included (1) tailored staff engagement focus groups, (2) staff education defining hypertension (≥140/90) and CVD risk, (3) electronic health record alerts prompting staff to remeasure elevated BPs and order timely follow-up (≤4 weeks) for confirmed high BP, (4) staff feedback (monthly audits), and (5) patient education and tools (brochure and BP log).
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.
      The BP Connect implementation toolkit can be accessed at http://www.hipxchange.org/BPConnect.
      • Bartels C.M.
      • Ramly E.
      • Panyard D.
      • et al.
      BP Connect: improving follow-up after high blood pressures.
      Descriptive analyses compared the rates of BP remeasurement and the offers for and fulfillment of timely primary care follow-up in the 6 months before (August 2020 to February 2021) and after (February 2021 to August 2021) BP Connect implementation. Multivariable logistic regression, controlling for age, insurance, hypertension, and CVD, evaluated impacts on BP remeasurement and timely primary care follow-up.

      Results

      BP was elevated in 676 preimplementation and 708 postimplementation visits. The Table describes the sociodemographics and relevant comorbidity of the patient visits. The only statistically significant difference between the pre- and postimplementation visit cohorts was a higher proportion insured by Medicaid before implementation (16% vs 11%, P = .004). The rate of BP remeasurement increased from 19% before implementation to 76% after implementation (P<.001). Staff provided patient education in 83% of postimplementation visits where patients had confirmed high BP and offered a referral for primary care follow-up in 60% of instances. Overall, the rate of timely primary care follow-up for high BP increased from 28% before implementation to 48% after implementation (P<.001) despite implementation during the COVID-19 pandemic. BP Connect implementation resulted in a 12-fold increase in BP remeasurement among patients with high BP in unadjusted (odds ratio [OR], 12.6; 95% confidence interval [CI], 9.6–16.6; P<.001) and adjusted (OR, 12.9; 95% CI, 9.7–17.1; P<.001) models. Timely primary care follow-up for hypertension doubled after BP Connect implementation (adjusted OR, 2.2; 95% CI, 1.5–3.1; P<.001).
      TableSample characteristics and outcomes of patient visits with high BP before and after BP Connect implementation
      CharacteristicBefore implementation (n=676)After implementation (n=708)P value
      Age (y), mean (SD)63.29 (14.94)64.48 (14.84).136
      Primary care provider in the health system358 (53.0)395 (55.8).316
      Self-reported race
       African American or Black28 (4.1)42 (5.9).15
       Other40 (5.9)31 (4.4)
       White608 (89.9)635 (89.7)
      Self-reported ethnicity: Hispanic or Latinx24 (3.6)13 (1.8).07
      Primary language: English664 (98.2)692 (97.7).653
      Marital status.092
       Married or with partner422 (62.6)403 (57.3)
       Separated, divorced, or widowed135 (20.0)172 (24.5)
       Single117 (17.4)128 (18.2)
      Medicaid insured110 (16.3)77 (10.9).004
      Tobacco use.449
       Never402 (59.6)411 (58.1)
       Former214 (31.7)244 (34.5)
       Current59 (8.7)53 (7.5)
      BMI (kg/m2), mean (SD)31.00 (8.36)30.24 (8.16).089
      BMI categories (kg/m2).125
       Underweight (<18.5)5 (0.7)6 (0.9)
       Normal weight (18.5–24.9)164 (24.3)179 (25.5)
       Overweight (25.0–29.9)199 (29.5)240 (34.2)
       Obese (≥30)307 (45.5)276 (39.4)
      Hypertension403 (59.6)458 (64.7).059
      Cardiovascular disease150 (22.2)172 (24.3).388
      Emergency department visits in the last year, mean (SD)5.39 (4.79)4.92 (4.96).071
      Primary care provider visits in the last year, mean (SD)1.47 (2.18)1.45 (2.20).885
      Outcomes
       Remeasurement129/676 (19.1)541/708 (76.4)<.001
       Confirmed high BP404/541 (74.7)
       Education provided334/404 (82.7)
       Follow-up referral offer241/404 (59.7)
       Timely primary care follow-up for patients with in-system primary care100/358 (27.9)113/238 (47.4)<.001
      Data are presented as number (percentage) or number/total number (percentage), unless otherwise specified.
      BMI, body mass index; BP, blood pressure; SD, standard deviation.
      Williams. Primary care follow-up improvement for gynecologic patients with hypertension. Am J Obstet Gynecol 2022.

      Conclusion

      BP Connect implementation was feasible in academic gynecology clinics and doubled the likelihood of patients with high BP having timely primary care follow-up without creating an undue burden on specialty clinics. The impact of BP Connect in gynecology clinics on timely primary care follow-up was almost identical to that seen in the rheumatology clinics where the intervention was initially developed and tested. Subsequent work will examine its impact on hypertension and CVD in more diverse populations and explore its impact when implemented at postpartum visits.

      References

        • Farley T.A.
        • Dalal M.A.
        • Mostashari F.
        • Frieden T.R.
        Deaths preventable in the U.S. by improvements in use of clinical preventive services.
        Am J Prev Med. 2010; 38: 600-609
        • Schmittdiel J.
        • Selby J.V.
        • Swain B.
        • et al.
        Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics.
        Hypertension. 2011; 57: 717-722
        • Bartels C.M.
        • Ramly E.
        • Johnson H.M.
        • et al.
        Connecting rheumatology patients to primary care for high blood pressure: specialty clinic protocol improves follow-up and population blood pressures.
        Arthritis Care Res (Hoboken). 2019; 71: 461-470
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.
        J Am Coll Cardiol. 2018; 71: e127-e248
        • Bartels C.M.
        • Ramly E.
        • Panyard D.
        • et al.
        BP Connect: improving follow-up after high blood pressures.
        HIPxChange. 2020; (Available at:)
        https://www.hipxchange.org/BPConnect
        Date accessed: March 23, 2021