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Timothy Carlson COHP 450 Ferris State University

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1 Timothy Carlson COHP 450 Ferris State University
PICO Presentation Timothy Carlson COHP 450 Ferris State University

2 Introduction Home Blood Pressure Monitoring (HBPM) vs. Compliance with Treatment PICO Question “Among patients with hypertension, does patient monitoring of blood pressure (BP) compared to no monitoring increase compliance with treatment?” Personal notes for voice over: The purpose of this presentation is to take a PICO statement and then analyze two articles related to home blood pressure monitoring programs. The PICO question will compare the results of patient self monitoring in regards to blood pressure and the effectiveness in compliance with treatment. The PICO question is as follows:

3 Search Results Key Words:
Home blood pressure monitoring, hypertension, patient education, self-management, monitoring, blood pressure, and patient compliance Search Engines: CINAHL, Cochrane Library, Sage Journals, Medline, Academic Search Complete, and PubMed Results of Search: 132 journals found searching “hypertension patient self-monitoring” Results - I narrowed it down to current articles within the last five years that would give me the most current information on the subject. This resulted in 132 articles that were peer reviewed journals from

4 Research Articles Study 1
Abdullah, A., & Othman, S. (2011). The influence of self-owned home blood pressure monitoring (HBPM) on primary care patients with hypertension: A qualitative study. BMC Family Practice, 12(143), 1-8. doi: doi: / Study 2 Crabtree, M.M., & Stuart-Shor, E. (2014) Implementing home blood pressure monitoring into usual care. The Journal for Nurse Practitioners, 10(9), doi: 

5 Rational for Articles Patient’s perception to barriers
Patient’s feel like they are a part of their treatment plan Understanding reasons for non-compliance with treatment Self-monitoring and the results with trying to decrease blood pressure Combination of qualitative and quantitative studies I chose the article in study 1 by Abdullah and Othman because it included an in-depth interview with two focus groups of 24 patients total and their experiences with home blood pressure monitoring (HBPM). The interviews explored the patients' practices and beliefs using home blood pressure monitoring as part of their hypertension management. These articles give great insight into the results from a patient monitored blood pressure regimen. The qualitative and quantitative studies are able to give the reader a look into compliance rates with treatment when patients self monitor their own blood pressure. I chose the study 2 article by Crabtree and Stuart-Shor Article because it used quantitative measures in regards to patients recruited and retained, number of clinic sessions attended, pre and post blood pressure readings, mean of BP, and percentage of improvement in BP. The study asked patients to measure their BP 3-4 times a week and bring results to a scheduled follow-up visit. The study also used qualitative methods with open-ended questions developed in surveys regarding patient assessment of self-care skills, satisfaction with HBPM, and provider satisfaction with HBPM.

6 Study 1 Evaluation of Findings
Theory: Grounded Theory Type of Study: Qualitative study Design: Case series In-depth interviews and focus groups Methods: In-depth interviews Two focus group discussions Theory- This refers to a set of systematic inductive methods for conducting qualitative research aimed toward theory development. Design- It is a collection of reports on the treatment of individual patients with the same condition. The study was carried out at an urban primary care clinic, located within the University Malaya Medical Centre. The populations sampled were primary care patients diagnosed with hypertension, who had experience owning and using home blood pressure monitors. Purposive sampling methods were used to recruit patients who self-initiated the use of HBPM. Patients were informed of the study by their healthcare providers and through posters. Those who were interested gave their contact numbers to a member of the research team. Patients were then invited to attend either an in-depth interview session or a focus group discussion, based on their availability. Method- Using the qualitative approach, the study hoped to understand the influences of HBPM on these patients. There were six in-depth interviews and two focus group discussions were conducted, taking into consideration the experiences of twenty-four primary care patients with hypertension. (Abdullah & Othman, 2011)

7 Study 2 Evaluation of Findings
Theory: Grounded Theory Type of Study: Qualitative and quantitative study. Design: Case series Patient recorded BP’s Method: In-depth interviews Analysis of recorded BP’s Project generated surveys (Crabtree & Stuart-Shor, 2014) Theory - This refers to a set of systematic inductive methods for conducting qualitative research aimed toward theory development. inductive: from empirical evidence to theories Type of study - A mixed method of qualitative and quantitative studies Design - Participants were given free blood pressure monitors, educated on the device and asked to record their BP 3-4 times a weeks and bring results to a follow up visit with HCP. The patient population came from active patients cared for at the health center. Inclusion criteria were adult, non-pregnant patients with BPs > 140/90 mm Hg; those with a history of hypertension; and those at risk for hypertension. The study participation was limited to 50. Participants were given free blood pressure monitors, educated on the device and asked to record their BP 3-4 times a weeks and bring results to a follow up visit with HCP. The provider and patient reviewed the recorded home BPs and discussed self-management skills and medication compliance, and then agreed upon a mutually identified action plan. Method- Deming’s Model for Improvement was used to guide the project. The model utilizes the phases of Plan, Do, Study, and Act in a rapid cycle format, which allows for changes in the protocol as feedback is gathered and facilitates the use of teamwork to make improvements.

8 Evaluation of Findings
Study 1 Findings: Identified five positive and two negative themes: Diet, exercise, awareness Doctor-patient relationship strengthened Enhanced family support Negatives: Self-doctoring and monitor accuracy Study 2 Findings: Feasible to implement HBPM to lower BP Significant reduction in blood pressure numbers (Abdullah & Othman, 2011) Study1: This study identified several influences of HBPM on patients’ management of hypertension. These influences could be divided into positive and negative influences, depending on their potential effect on blood pressure control. This study assessed the influence of HBPM on hypertensive patients who self-initiated its use. In-depth exploration of patients’ experiences and practices showed that self-initiation of HBPM is associated with both positive and negative implications. Positive influence on diet and exercise Increased awareness and interest in hypertension management Sense of reassurance in blood pressure monitoring Doctor-patient relationship strengthened Enhanced family support Negatives: Patients self-doctoring medication, diet, and exercise based on readings Patients questions accuracy of digital blood pressure monitors Study 2: The outcomes demonstrate it is feasible to implement HBPM into primary care in an underserved, high-risk population and blood pressure was improved. The proportion of patients at goal BP (< 140/90 mm Hg) improved from 30% vs 90%. Significant reductions were noted for systolic BP (-11.6) and diastolic BP (-8.8). 84% of participants reporting that it helped them understand and manage their BP, was easy to use, that taking readings at home and bringing results to their primary care provider enhanced their visits and it added value to their care. Eighty-four percent said they would continue to use the HBPM. (Crabtree & Stuart-Shor, 2014)

9 Ethical Considerations
Study 1: The ethical considerations are as follows: Informed consent and right to refuse Confidential information and honesty Give credit and support dignity of participants Do not fabricate, falsify, or plagiarize data The study adhered to all ethical considerations (Blessing & Forister, 2013) Study 2: Exempt by the institutional review board (IRB) The ethical considerations for study 1 are as follows: obtain informed consent, subjects right to refusal, protect confidential information, honesty in giving and disseminating information, give credit and recognition to others, do not fabricate, falsify, or plagiarize data, and support the dignity and values of participants. Study 2 was exempt from need for approval by the institutional review board (IRB) because it is consistent with quality improvement and standard practice procedures. Written informed consent was not required based on quality improvement and standard practice procedures. The ethical considerations still apply in this study.

10 Evidence Based Practice- Strength
Both Studies: Study can be revised with new information No specific interview questions Have a low level of evidence No generalizability Small study, no randomization, and no control group Overall low strength Interviews are not restricted to specific questions and can be guided/redirected by the researcher in real time. This can also cause bias based on the interviewer and alter participants responses. The research framework and direction of the study can be quickly revised as new information emerges. There is a Low level of evidence, unfiltered information that has not been critically appraised and there is no generalizability to reproduce in a larger population. The sample size is small, no randomization in either study, and no control group is used to compare treatment compliance and self-monitoring. Even though study one uses mixed methods which strengthens the study with possible limitations and biases cancelling each other out. The small study, no randomization, and no control group lower the strength of the study. The overall strength of the research studies is low and does not provide enough indication to be applied and utilized as evidence based practice. Figure 1. Pyramid (Quinnipac University, n.d.)

11 Evidence Based Practice- Quality
Both Studies: Pose an important question Contributes to knowledge base Provide information to replicate the study Research is peer reviewed Adhered to quality standards for reporting Study design is independent, balanced, and objective Both studies pose a significant, important question that is investigated empirically and contributes to the knowledge base of self-reporting blood pressure and treatment compliance. Information is provided to replicate the study with focus group topics, interview questions, and the patient the population that was recruited. The study design is independent, balanced, and objective to the research. The Research studies adhered to clear and complete standards for reporting their findings on home blood pressure monitoring in hypertensive patients. Even though the studies meet multiple standards of quality in research, the level of evidence is not critically appraised. (Blessing & Forister, 2013)

12 Evidence Based Practice- Credibility
Study 1: Dr. Sajaratulnisah Othman - Medical doctor in primary care medicine Dr. Adina Abdullah - Medical doctor in family and primary care medicine Study 2: Marjorie M. Crabtree, DNP, ANP-BC, FNP-BC, is a nurse practitioner Eileen Stuart-Shor, PhD, is an assistant professor at the University of Massachusetts (University of Malaya, 2014) Study 1- Both authors are professionals in their respected fields and are credible and reliable sources of information. Dr. Sajaratulnisah Othman- Medical doctor in primary care medicine. Dr. Adina Abdullah-Medical doctor in family and primary care medicine. The two are on staff of the Department of Primary Care Medicine, University of Malaya. Study 2- Marjorie M. Crabtree, DNP, ANP-BC, FNP-BC, is a nurse practitioner at the Harbor Health Hyannis Community Center in Hyannis, MA. Eileen Stuart-Shor, PhD, is an assistant professor at the University of Massachusetts. Both authors are professionals in their respected fields and are credible and reliable sources of information. Both studies have the potential to contribute to EBP, but lack a strong body of evidence, low participation rate, no randomization, and no control group to compare the results with. (Crabtree & Stuart-Shor, 2014)

13 Relevant to Practice Communicated at an individual, policy, and professional levels Could improve patient outcomes Involves the patient in their care Makes the patient aware of their treatment progress Potential to change individual practice Lack of generalizability An evidence-based HBPM could improve patient outcomes The findings can be communicated to individuals to make them aware of blood pressure readings and more active in their care. The results can be communicated to policy makers to try and influence third-party payers to reimburse the cost of HBPM. At a professional level it can give awareness to health care providers, nurses, and medical staff about the importance of including the patient in their care and making them feel a part of the treatment plan. The studies can influence nurses to teach patients how to take their own blood pressure on a consistent basis and provide this information to their health care provider. The studies have the potential to be implemented in the treatment plan for hypertensive patients. There is evidence to support the more active patients are in their care the more likely they are to be compliant with treatment plans. There is no generalizability in the study. The data is only collected from a few individuals, so the findings on home blood pressure monitoring and treatment compliance cannot be generalized to a larger population. The findings could however be transferable to another setting. An evidence-based HBPM could improve patient outcomes related to controlling hypertension thus derailing future chronic health conditions.

14 How are they Relevant Potential Barriers on utilization of findings:
Low level of evidence Resources: Funding to supply patients with monitors Policy: Insurance approval and reimbursement Value: Cost vs. Benefit Non-participation Additional PICO questions: There is a low level of evidence and the studies would require a randomized controlled trial to be considered for implementation into evidence based practice. The lack of funding and insurance approval to supply patients with their own blood pressure monitors is a potential barrier to implementation. Does the cost of the HBPM program outweigh the potential benefits in the eyes of insurance carriers when giving approval to participants. Home blood pressure monitoring may be beneficial, but barriers exist in participation with patient forgetfulness in taking their blood pressure, forgetting to report results to their health care provider, and missed follow-up appoints with their health care provider. Additional PICO questions include: In hypertensive patients, does an insurance discount, compared to no insurance discount, improve patients participation in a home blood pressure monitoring program? In home blood pressure monitoring patients, does motivational education, compared to basic blood pressure monitoring education, improve patient compliance rates with treatment? In hypertensive patients, does the implementation of a home blood pressure monitoring program, compared to no blood pressure program, decrease patient blood pressure numbers?

15 Conclusion Requires further studies to validate
Credible Sources vs. Weak Study Beneficial on an individual and professional level Could lead to patient self-doctoring practices Can keep patients involved in their care Home Blood pressure monitoring requires further studies of a higher level of evidence to be considered for practice change and as an evidence based practice. The articles are by reputable professionals in their respected fields, but the low level of evidence in the studies, small population, and lack of randomized control trials hinders the implementation into practice. Lack of sufficient evidence in studies limits the implementation to an individual and professional level. Self-monitoring can have positive effects, but could lead to patients self-doctoring their medication based on results. The study shows that if patients are involved in their care and treated as a team member, then they are more likely to continue with a prescribed treatment.

16 References Abdullah, A., & Othman, S. (2011). The influence of self-owned home blood pressure monitoring (HBPM) on primary care patients with hypertension: A qualitative study. BMC Family Practice, 12(143), 1-8. doi: doi: / Blessing, J.D., & Forister, J.D. (2013). Introduction to research and medical literature for health professionals (3rd ed.). Burlington, MA: Jones & Bartlett Learning Crabtree, M.M., & Stuart-Shor, E. (2014). Implementing home blood pressure monitoring into usual care. The Journal for Nurse Practitioners, 10(9), doi:  j.nurpra Quinnipac University.(n.d.). Pyramid [Photograph]. Retrieved from d= University of Malaya. (2014). Faculty of medicine. Retrieved from Primary_Care_Medicine&subpilihan=Research


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