Automated Messaging Program to Facilitate Systematic Home Blood Pressure Monitoring: Qualitative Analysis of Provider Interviews

BACKGROUND

Hypertension is a leading cause of cardiovascular and kidney disease in the United States, yet blood pressure (BP) control at a population level is poor and worsening. Systematic home BP monitoring (HBPM) programs can lower BP, but programs supporting HBPM are not routinely used. The MyBP program deploys automated bidirectional text messaging for HBPM and disease self-management support.

OBJECTIVE

We aim to produce a qualitative analysis of input from providers and staff regarding implementation of an innovative HBPM program in primary care practices.

METHODS

Semistructured interviews (average length 31 minutes) were conducted with physicians (n=11), nurses, and medical assistants (n=6) from primary care settings. The interview assessed multiple constructs in the Consolidated Framework for Implementation Research domains of intervention characteristics, outer setting, inner setting, and characteristics of individuals. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes, followed by mapping to the updated Consolidated Framework for Implementation Research constructs.

RESULTS

Health care providers reported that MyBP has good ease of use and was likely to engage patients in managing their high BP. They also felt that it would directly support systematic BP monitoring and habit formation in the convenience of the patient's home. This could increase health literacy and generate concrete feedback to raise the day-to-day salience of BP control. Providers expressed concern that the cost of BP devices remains an encumbrance. Some patients were felt to have overriding social or emotional barriers, or lack the needed technical skills to interact with the program, use good measurement technique, and input readings accurately. With respect to effects on their medical practice, providers felt MyBP would improve the accuracy and frequency of HBPM data, and thereby improve diagnosis and treatment management. The program may positively affect the patient-provider relationship by increasing rapport and bidirectional accountability. Providers appreciated receiving aggregated HBPM data to increase their own efficiency but also expressed concern about timely routing of incoming HBPM reports, lack of true integration with the electronic health record, and the need for a dedicated and trained staff member.

CONCLUSIONS

In this qualitative analysis, health care providers perceived strong relative advantages of using MyBP to support patients. The identified barriers suggest the need for corrective implementation strategies to support providers in adopting the program into routine primary care practice, such as integration into the workflow and provider education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03650166; https://tinyurl.com/bduwn6r4.

In vitro microvascular engineering approaches and strategies for interstitial tissue integration

The increasing gap between clinical demand for tissue or organ transplants and the availability of donated tissue highlights the emerging opportunities for lab-grown or synthetically engineered tissue. While the field of tissue engineering has existed for nearly half a century, its clinical translation remains unrealised, in part, due to a limited ability to engineer sufficient vascular supply into fabricated tissue, which is necessary to enable nutrient and waste exchange, prevent cellular necrosis, and support tissue proliferation. Techniques to develop anatomically relevant, functional vascular networks in vitro have made significant progress in the last decade, however, the challenge now remains as to how best incorporate these throughout dense parenchymal tissue-like structures to address diffusion-limited development and allow for the fabrication of large-scale vascularised tissue. This review explores advances made in the laboratory engineering of vasculature structures and summarises recent attempts to integrate vascular networks together with sophisticated in vitro avascular tissue and organ-like structures. STATEMENT OF SIGNIFICANCE: The ability to grow full scale, functional tissue and organs in vitro is primarily limited by an inability to adequately diffuse oxygen and nutrients throughout developing cellularised structures, which generally results from the absence of perfusable vessel networks. Techniques to engineering both perfusable vascular networks and avascular miniaturised organ-like structures have recently increased in complexity, sophistication, and physiological relevance. However, integrating these two essential elements into a single functioning vascularised tissue structure represents a significant spatial and temporal engineering challenge which is yet to be surmounted. Here, we explore a range of vessel morphogenic phenomena essential for tissue-vascular co-development, as well as evaluate a range of recent noteworthy approaches for generating vascularised tissue products in vitro.

Abstract P121: Automated Messaging Program To Facilitate Systematic Home Blood Pressure Monitoring: A Qualitative Analysis Of Provider Interviews

Introduction: Hypertension is a leading cause of morbidity worldwide. Home blood pressure monitoring (HBPM) has been shown to lower blood pressure (BP) if paired with co-interventions but such programs are not routinely used in clinical care. MyBP is an automated bi-directional text messaging HBPM program that assists lowering of BP, but how to best implement within clinical care remains unknown. Therefore, in this study, we sought stakeholder input from care providers.

Methods: We conducted semi-structured interviews (average recorded duration 28 minutes) with physicians, nurses, and medical assistants from primary care settings, most of whom had participated in a feasibility trial of MyBP. The interview was designed around constructs from the Consolidated Framework for Implementation Research. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes.

Results: Subjects were physicians (n = 11) and nurses/medical assistants (n = 6). Care providers felt that patients benefitted from MyBP’s positive influence on BP measurement adherence, psychological factors (such as health literacy and patient empowerment), and perceived patient usability of the program. They reported that the program data aided in clinical diagnosis and management of HTN with a practical user interface for providers. Barriers to implementation included lack of integration into the electronic medical record and difficulty in training office staff in its use.

Conclusion: In this qualitative analysis of care provider stakeholders, MyBP was seen as a pragmatic and effective way to empower patients in BP self-management and tangibly aid providers. Future research will need to focus on strategies to overcome implementation barriers to facilitate integration in to the clinical and digital environment.

Comparison of simple measures of insulin sensitivity in young girls with premature adrenarche: the fasting glucose to insulin ratio may be a simple and useful measure

Insulin resistance is a strong predictor of the development of type 2 diabetes mellitus and cardiovascular disease. Girls with premature adrenarche (PA) or obesity may be at an increased risk for the development of insulin resistance. Recently, in prepubertal girls with PA, a fasting glucose to insulin ratio (FGIR) of less than 7 was found to be predictive of insulin resistance as determined by the frequently sampled iv glucose tolerance test. We sought to compare the FGIR with 2 insulin sensitivity measures, SiM (an adjusted mean measure of insulin sensitivity based on fasting and 2 h post glucose load insulin sensitivity measures) and the composite whole body insulin sensitivity index, ISI(comp), both derived from the 2-h oral glucose tolerance test in 2 groups of children at risk: girls with PA and obese girls. We studied 25 prepubertal girls with PA and/or obesity and further classified them as insulin resistant (IR) or insulin sensitive (IS) based on the FGIR. Four simple measures of insulin sensitivity [FGIR, quantitative insulin sensitivity check index (QUICKI), fasting insulin resistance index, and fasting insulin] were compared with SiM and ISI(comp). Additionally, we characterized the subjects in terms of risk factors associated with insulin resistance according to their insulin resistance status based on the FGIR. In our subjects the strongest correlations overall appeared to be between FGIR and SiM, FGIR and ISI(comp), QUICKI and SiM, and QUICKI and ISI(comp) [correlations (r) ranged from 0.81--0.84]. Furthermore, the IR group had higher body mass index and body mass index z-scores and triglyceride levels than the IS group and were over 3 times more likely to have triglycerides greater than the 95th percentile compared with national norms. We conclude that the FGIR and QUICKI are highly correlated with oral glucose tolerance test measures of insulin sensitivity. An FGIR less than 7 in young girls with PA or obesity may be helpful in the early identification of children at risk for complications of insulin resistance.

Adherence of clinical isolates of Saccharomyces cerevisiae to buccal epithelial cells

A number of isolates of Saccharomyces cerevisiae have been associated with disease in immunocompromised individuals. Such isolates display a variety of characteristics that enable colonization and persistence in the host. The aim of the work presented here was to establish whether clinical isolates of S. cerevisiae were capable of adhering to epithelial tissue. Adherence to host tissue has been shown to be crucial to the virulence of the pathogenic yeast Candida albicans, and identification of this ability in S. cerevisiae might indicate a role for adherence in tissue colonization by this emerging pathogen. Clinical S. cerevisiae isolates were found to be capable of adhering to exfoliated buccal epithelial cells (BECs) but to a lesser degree than C. albicans. In contrast to the situation evident with C. albicans, the adherence of S. cerevisiae isolates to BECs was not influenced by the carbon source in which the yeast was grown. Treatment of S. cerevisiae with trypsin or proteinase K resulted in a significant reduction in adherence ability while adherence was unaffected by treatment of cells with mannosidase, thus indicating a possible role for proteins rather than mannoproteins in the adherence of S. cerevisiae to BECs.

Fibroblastic tumor of the abducens nerve. Case report

Tumors of the cranial nerves are uncommon, and are usually schwannomas or neurofibromas. The authors describe a case of a fibroblastic tumor involving the sixth cranial nerve. Based upon electron microscopy and immunohistochemistry, the tumor was not of nerve-sheath origin, but was comprised of fibroblasts. Clinical, radiographic, and pathological material are presented, and the literature is discussed. This represents the third case report of a tumor of the abducens nerve, and the first report of a fibroma of a cranial or peripheral nerve.