Operationalizing Home Blood Pressure Monitoring for Dialysis Patients: An Effectiveness-Implementation Hybrid Study

Rationale & Objective: Blood pressure (BP) control in dialysis patients is often inadequate, partly owing to a lack of standardized home BP monitoring. We aimed to implement and evaluate a remote BP monitoring (RBPM) program for incenter hemodialysis (HD) patients. Study Design: An effectiveness-implementation hybrid study conducted as a quality improvement program. Setting & Participants: We screened 79 patients with kidney failure receiving thrice-weekly incenter HD at a US academic medical center between February and September 2022. Exposure: Initiation of an RBPM program integrated into the electronic medical record. Outcomes: The primary outcome was patient use of home BP monitoring. Secondary outcomes included changes in BP, number of antihypertensive medications, and target weight. Analytical Approach: We compared 30-day average pre-HD BP, home BP measured 1 day after midweek HD, number of BP medications, and target weight before and after RBPM initiation using paired t test or Wilcoxon rank sum test. In addition, mixed-effects models were used to assess changes over time. Results: Among the 79 patients screened, 48 referred to RBPM, 30 started monitoring, and 27 completed the 3-month follow-up. The mean predialysis systolic BP before RBPM initiation was 145 (standard deviation, 20) mm Hg. During month 1, home systolic BP postmidweek HD was lower than pre-HD measurement by 14 mm Hg (P = 0.005). The median number of BP medication decreased from 2.5-2.0 in month 3 (P = 0.005). Median monthly home BP measurements decreased from 17 during month 1 to 6 during month 3 (P < 0.001). In month 3, 67% (18/27) of participants were actively monitoring their BP, with only 13 (48%) measuring BP postmidweek HD. Limitations: A single-center, observational study without a standardized protocol for medication management. Conclusions: Our RPBM program confirmed significant discrepancies between home and pre-HD BP measurements, underscoring its potential use. However, the observed decline in patient engagement highlights the challenge of maintaining long-term adherence. Plain-language Summary: Blood pressure (BP) is often difficult to control in patients receiving dialysis, and BP readings taken at the dialysis clinic may not show the full picture. We wanted to see if using a home BP monitoring program, in which patients measure their own BP and the readings are sent to their doctors electronically, could be a practical and useful tool in a real-world setting. We provided bluetooth-enabled home BP monitors to patients receiving incenter hemodialysis at our hospital. We trained them how to use the devices and asked them to measure their BP twice daily for 3 months. We then looked at how many patients used the monitors, how their home BP readings could be compared with their clinic readings, and whether their BP medications or other treatments changed. We learned that home BP readings were often significantly lower than the BP measured right before a dialysis session. This suggests that home monitoring can give doctors a more accurate understanding of a patient's true BP. Based on this new information, doctors were able to slightly reduce the number of BP medications for some patients. However, we also found that over the 3-month period, patients used the monitors less and less, highlighting that keeping patients engaged with daily monitoring was a major challenge. This study not only shows that home BP monitoring has great potential in improving how we manage high BP in dialysis patients but also has revealed that just giving patients a device is not enough. To make these programs successful, we need to find better ways to support patients and keep them motivated to track their health over the long term.