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.