key: cord-1018839-2cfklffr
authors: Thakker, Ravi A.; Chatila, Khaled F.; Sonstein, Lindsay K.; Hommel, Erin
title: Telemedicine and hypertension management: Impact of COVID-19 on an institutional quality initiative
date: 2022-04-21
journal: Am J Med Sci
DOI: 10.1016/j.amjms.2022.04.017
sha: e87ae6b867fd40c672e9a1cd7f9cb20c1d58f8ac
doc_id: 1018839
cord_uid: 2cfklffr

nan

Hypertension is among the most devastating diseases with the greatest potential for treatment and reversibility. Recent worldwide estimates of age-standardized prevalence of hypertension have been appreciated to be 34% in men and 32% in women aged 30-79 years. 1 Hypertension is also a well-known risk factor for the development of coronary heart disease, which has been implicated as the leading cause of death in the United States. 2 With the emergence of the COVID-19 pandemic, a large portion of healthcare was transitioned to telemedicine which allowed access for patients to continue managing their chronic illnesses from the comfort and safety of their homes. 3 Prior to the start of the COVID-19 pandemic, our institution sought to improve outpatient metrics for hypertension in patients presenting to Internal Medicine Primary Care clinics through a quality improvement (QI) project. The aim of our QI initiative was to increase the percentage of patients between 18-85 years of age with known hypertension to have a goal blood pressure (BP) of <140/90 mmHg in greater than 68% of the four Internal Medicine Primary Care clinics at our institution. During the QI period, the COVID-19 pandemic occurred resulting in the transition of majority of care to telemedicine.

Our QI initiative spanned from January 2020 through December 2020. Metrics were obtained through populated data used for evaluation of quality metrics by our institution. Exemption was provided by the institutional review board. From January 2020 through February 2020 patient visits were face-to-face with BP readings obtained upon initial presentation by trained medical assistants and nursing staff. Elevated readings were re-obtained by the medical staff during the clinical encounter to ensure accuracy. Home BP logs and antihypertensive medications were Internal Medicine Clinics reaching goal BP from June to December 2020 was 55% [ Figure 1 ].

The impact of the COVID-19 pandemic on the management of this important group of patients was apparent. Despite just having two months of face-to-face visits prior to transitioning to telemedicine visits, our patients surpassed our aim of 68% meeting goal BP criteria. There was a sudden decline once telemedicine was implemented with a slow rise of patients starting to meet goal BP during the transition period from telemedicine to face-to-face, but still less than prior. The drop in patients meeting goal BP during the initial phase of transition from face-to-4 face visits to telemedicine can be appreciated by the absence of in person BP readings, since not all patients were reporting their daily readings to their primary care physician. Most concerning was the steady but slow rise in clinics meeting goal BP after transitioning back to face-to-face visits. Medication adjustments continued to be made according to the uniform protocol established at the start of our QI initiative prior to transitioning to telemedicine which may have contributed to this rise. This slow rise if appreciated at the individual level is concerning for patients having an elevated BP. Although, some studies have demonstrated that telemedicine has a beneficial role in hypertension management, many were single center with large population studies currently lacking. 4 From our experience, as well as, from recommendations of expert consensus, 5 an implementation strategy to address continued BP management in a telemedicine setting is through frequent ambulatory monitoring and physician update either through electronic medical record (EMR) messaging or telephone communication with clinic staff. Subsequently, with frequent telemedicine monitoring, medication dosages can be adjusted if a standard protocol is set among all clinics. Most important, is empowering and training patients in accurately measuring their BP on a routine basis prior to any event that results in the absence of in-person events. This can be done either through community-based health care initiatives, as well as, during routine semi-annual or annual visits that would have occurred prior to transitioning to telemedicine. Home BP machines could have also been calibrated during these visits. Lastly, given the social toll the pandemic had, it is understandable that proper physical activity and dietary compliance was a challenge. One way to have addressed this during telemedicine visits, is to have provided ways for patients to do at home exercises, especially given the abundance of fitness electronic 5 applications. 6 Dietary compliance could have been addressed by providing simple healthy recipes that follow the Dietary Approaches to Stop Hypertension (DASH) diet. 7 Telemedicine overall has had a positive impact by providing safe means of managing diseases. 8 Unfortunately, in hypertensive patients, the time it took to recover from transitioning back from telemedicine medicine encounters to face-to-face visits was appreciated by the steady rise yet overall low average of clinics reaching goal BP. Both patient and provider education should be implemented to ensure consistent management of this critical group of patients in various clinical settings. Percentages are demonstrated on the y-axis.

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