The impact of the COVID-19 pandemic on cardiovascular care has been substantial. Following the pandemic declaration, approximately 41% of US adults delayed or avoided care . One of the silver linings from this pandemic has been the acceleration of innovations resulting in rapid implementation of new health care delivery models that reach patients outside of the clinic, including telehealth and increased utilization of SMBP, that would otherwise have taken years to incorporate into the workflow and improve access to care [14,15,16]. Nevertheless, one of the challenges of virtual care has been the decline in documented BP measurements and thus a decline in UDS reported BP control .
BP measurements are normally obtained by CHC clinical staff as part of routine vital signs taken during in-person encounters. In our study, in December 2019, the percent of patients with hypertension with an encounter but with no documented BP measurement in the past 12 months was minimal (0.5%). Before the pandemic, the CMS 165v8 eCQM was appropriate given the nature of the clinical encounter, endorsed timely and regular care of patients with hypertension, and was a logical gauge of BP control performance. As the pandemic progressed, we observed an inverse relationship between the increase in patients with no documented BP measurement and a decrease in BP control performance using CMS 165v8. In March 2021, reported BP control started trending upward. This may be associated with concurrent factors including the wider administration of the COVID-19 vaccine across the US, return to in-person encounters, and the wider implementation of SMBP across CHCs. By October 2021, BP control using CMS165v8 improved; however, it was still below pre-pandemic rates.
Data from a subset of patients with hypertension in three CHCs showed that BP measurements were documented on all patients with an in-person encounter, but only on 10% of those with a telehealth encounter. Although COVID-19 testing was made available at no cost at CHCs nationwide, in our study, services were limited to testing for COVID-19 and none of the patients seen through a COVID-19 testing encounter had a documented BP measurement. Although data from a national study indicate that BP control dropped from a 2019 average of 60.5 to 53.3% at the end of 2020 , our study suggests that telehealth and COVID-19 testing encounters likely increased the number of patients with hypertension lacking a BP measurement which might have led to lowering CHCs’ reported BP control rates. This lower performance might not be a true reflection of actual BP control in these CHCs but rather an unintended effect of the CMS 165v8 measure criteria during a period when patients increased use of virtual care options but where out-of-office measurement of blood pressure was and is still not widely practiced, accessible, or documentable in the EHR .
In our study, BP control based on CMS 165v8 decreased substantially in the non-SMBP implementing group relative to the SMBP-implementing group from December 2019 – March 2021. We did find that non-SMBP implementing CHCs had a higher percentage of patients with no documented BP measurement when compared to SMBP-implementing CHCs. Improvements in BP control after March 2021 were more likely a reflection of increased in-person encounters due to the availability of COVID-19 vaccines and other mitigation measures. However, over two years into the COVID-19 pandemic, lack of documented BP measurements in a substantial portion of adults with hypertension remains a challenge across CHCs, suggesting that efforts need to be made to ensure BP measurements can be documented during virtual encounters.
Achieving BP control requires multiple supportive evidence-based strategies, including SMBP. Before the pandemic, 43.5% of US adults with hypertension engaged in home BP monitoring but only 6.9% shared their BP measurements with their clinical provider using remote data transmission methods . Certain CHCs in this study belonged to an HCCN that had implemented SMBP among a limited number of its patients prior to March 2020. This implementation included the development of custom configurations to capture SMBP measurements in structured/reportable EHR fields, which facilitates documentation of BP measurement and corresponding hypertension management. CHCs have focused on the implementation of SMBP since 2017; with the support of HRSA’s National Hypertension Control Initiative, 500 additional CHCs nationwide received $90,000 to implement SMBP since January 2021.Footnote 2
Despite the growing evidence and endorsement of SMBP’s value in diagnosing and managing hypertension [18,19,20], potential cost savings , and potential in reducing hypertension-related care and outcome disparities , there are well-known patient and clinician barriers for implementation. One such barrier is limited insurance coverage. As of December 2021, only 34 state Medicaid programs provided some level of coverage for automatic upper arm devices and 26 provided some level of coverage for the separate cuffs . For CHCs, which receive reimbursement through Medicaid through prospective payment rates, monitors are not included, although in general, some CHCs had acquired a limited number of SMBP monitors before the pandemic through grant funding.
Although SMBP is an evidence-based strategy that, when used in conjunction with co-interventions, including medication titration, therapeutic lifestyle changes, and education and counseling, leads to clinically significant BP reduction in patients with hypertension, there is still much to be done to effect widespread implementation, particularly around data transmission [19, 23,24,25]. Most EHRs cannot automatically process out-of-office BP data, in part due to the lack of standards-based interfaces between home BP devices and EHRs and because of the lack of structured data fields in which to store the data. Currently, average BP is not required by the most recent version (3) of the United States Core Data for Interoperability , which means EHR vendors are not required to include average BP in their EHR software as a standard data field. Moreover, virtual health platforms relying on smartphones, computers, and high-speed internet may not be equally available to all patients and communities, and therefore, patients without access to or who are not literate in using the technology needed for SMBP may not benefit from this strategy.
It is also important to note that the SMBP model does not fully align with the eCQM model, which is based on assessing a single BP measurement from the most recent visit. SMBP guidelines typically ask patients to take multiple readings per day over 3–7 days and average the results, so asking the patient to take their BP again during a telehealth visit to comply with CMS 165v8 specifications may feel repetitive and not as meaningful. Further, the CMS 165v8 measure only allows for BP measurement data to be electronically transmitted from SMBP devices directly to the care team for numerator compliance; patient-reported data are not accepted . This limitation precludes patients seen through telehealth encounters without the ability to show their device memory via video; it also may preclude patients without access to a Bluetooth home BP device and fast internet that enables them to share their BP measurements electronically with their health care providers. The next iteration of the UDS Controlling High Blood Pressure measure criteria to be implemented in 2023 is expected to align with the National Committee on Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by > 90% of US community health centers to measure performance on different dimensions of care and service, which accepts patient-reported BP measurements. Nonetheless, the issue of where to document out-of-office BP measurements in the EHR will still be a barrier, as will the incongruency of the eCQM approach of using a single BP measurement to gauge BP control vs. SMBP, which uses an average of BP readings over time to assess BP control.
There is an opportunity to use technology to redefine BP control by developing standards to facilitate remote data exchange between patients and health care providers and enable clinical decision making. Additionally, EHR vital signs interfaces should be improved to prompt for and allow the capture of out-of-office BP measurements and averages during a patient encounter. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage, and increase affordability . Further, an essential component to SMBP implementation involves education and training for health care providers (e.g., billing for SMBP services using current procedural terminology codes, reimbursing for SMBP training and data management), and patients (e.g., improving digital health literacy, appropriate device selection, fitting and usage, behavioral health changes). Finally, the telehealth policies that enabled broader and flexible telehealth coverage during the Public Health Emergency, especially around the originating site and audio/telephone only visits , could be made permanent.
Our study should be interpreted in the context of several limitations. First, this study was conducted during the pandemic and based on a convenience sample not generalizable to all CHCs. Our findings are mainly derived from CHCs that had existing efforts on improving BP control within their population, and therefore, should not be considered reflective of the full CHC population. Because the main purpose was to show the broad differences between groups that included people with documented BP and those that did not, we elected not to test all the differences statistically. Formal statistical testing was not conducted for two reasons. First, data were not available in a form that allowed for estimation of correlated error across multiple measurements within-patient. So, statistical tests would have violated the assumption of independence, and led to biased conclusions. Second, the sample sizes in both groups (10’s of thousands) would have yielded spuriously high significance (p < 0.001) for even tiny differences without conveying clinical relevance.
An additional limitation is that data were quickly extracted in the midst of the pandemic and were only available as aggregates of three HCCNs whose health centers were participating in the NACHC Million Hearts® project, thus not allowing for more granular analyses. For this reason, one non-SMBP implementing CHC was analyzed as part of the SMBP implementing group, which might have underestimated the BP control rate in this group. We also did not determine the number or characteristics of patients with no encounters during the study period, nor the characteristics of patients with BP measurements and whether they differed from those who had an encounter but no documented BP. Lastly, the sample size used for the determination of encounter type was small.