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.

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.

SMS-facilitated home blood pressure monitoring: A qualitative analysis of resultant health behavior change

OBJECTIVE

Hypertension is largely asymptomatic and, as a result, patients often fail to sufficiently engage in medication adherence and other health behaviors to control their blood pressure (BP). This study explores the mechanisms by which MyBP, an automated SMS-facilitated home blood pressure monitoring (HBPM) program, helps facilitate healthy behavior changes.

METHODS

A thematic analysis of transcribed audio-recordings from semi-structured post-intervention interviews (n = 40) was conducted.

RESULTS

Three primary themes were identified as contributing most to patients' decision to initiate a behavior change: 1) increased hypertension literacy attributed to educational videos presented at enrollment, 2) increased day-to-day salience of blood pressure levels as a result of consistent HBPM, and 3) use of BP readings as feedback, with high readings triggering motivations to make behavior changes. These themes and most accompanying sub-themes correspond to constructs in the Health Belief Model and Social Cognitive Theory.

CONCLUSION

Patient-centered HBPM interventions such asMyBP appear to promote improvements in hypertension self-management via several mechanisms consistent with recognized models of behavior change.

PRACTICE IMPLICATIONS

SMS-supported HBPM, paired with video-based education, may provide a simple and scalable way of encouraging health behavior adherence in hypertensive patients.

Abstract P228: Text-Facilitated Home Blood Pressure Monitoring: A Qualitative Analysis of Health Behavior Change

Uncontrolled hypertension constitutes a major challenge for healthcare systems. Home blood pressure monitoring (HBPM) is widely recommended and may lower BP when combined with other supports. However, scalable and systematic HBPM interventions are lacking and the behavioral mechanism(s) through which BP is lowered remain poorly understood. Our team designed the MyBP program with video-based education and a fully automated, bi-directional texting to facilitate longitudinal HBPM. Exit interviews conducted after six-weeks of MyBP revealed that most participants made at least one healthy behavior change. The current study examines why participants made healthy behavior changes, and what specific components of the MyBP program facilitated those changes. Adults with hypertension were recruited from either an urban emergency department, a primary care office, or a hypertension referral center. The 40 enrolled participants were widely representative: age range 34-70, 23 women, 24 minority, 14 completed only high school, BP range 110-250/70-130 mm Hg, and prescribed BP medications range 0-5. A thematic analysis of transcribed exit interview audio-recordings identified three themes contributing to patients’ decision to initiate a behavior change: 1) improved hypertension literacy from viewing educational videos; 2) increased day-to-day salience of one’s BP as a result of consistent HBPM; and 3) use of BP readings as feedback on participants’ health behaviors, with high readings often triggering intrinsic motivations to make behavior changes. These themes and associated sub-themes were found to have analogous constructs in the Health Belief Model and Social Cognitive Theory. The presentation of educational materials at baseline, followed by regular BP self-monitoring, increased confidence and motivation to initiate changes in health behaviors. The receipt of bi-weekly reports then acted as feedback fueling participants’ motivation to maintain or add healthy behaviors. Facilitation of HBPM with automated texting, in conjunction with educational videos and regular feedback, appears to stimulate improvements in hypertension self-management via mechanisms consistent with recognized models of behavior change.

Development and Preliminary Feasibility of an Automated Hypertension Self-Management System

BACKGROUND

Uncontrolled hypertension constitutes a significant challenge throughout the world. Blood pressure measurement by patients is informative for both patients and providers but is rarely performed systematically, thereby reducing its utility. Mobile phones can be used to efficiently prompt individuals to measure blood pressure and automate data management while avoiding technology barriers to widespread adoption. Presented is the design and pilot test results of MyBP, an automated texting intervention to support blood pressure self-monitoring and patient self-management.

METHODS

Three sequential phases are described: (1) stakeholders' needs assessment, (2) preliminary design pilot (n = 10), and (3) a 6-week pilot of the redesigned comprehensive program with hypertensive patients (n = 43) recruited from 3 clinical sites (Emergency Department, Primary Care, Hypertension Center). Outcomes of interest included participant adherence, perceived importance of blood pressure monitoring, and healthy behavior change.

RESULTS

Median adherence to MyBP prompts over 6 weeks was 79% (72% emergency department, 84% primary care, and 96% hypertension center, H[2] = 5.56, P = .06). Adherence did not vary by age, sex, education, or baseline use of texting but was lowest among patients recruited from the emergency department (χ[2]2 = 6.66, P = .04). In the exit survey, MyBP was associated with increased importance of blood pressure self-monitoring and particularly motivated primary care and emergency department groups to improve dietary habits, increase daily physical activity, and focus on stress reduction. The majority of participants (88%) indicated interest in using the program for 6 months.

CONCLUSIONS

Automated mobile-phone-based blood pressure self-monitoring using MyBP is feasible, acceptable, and scalable, and may improve self-management and support clinical care.

Comorbidity and survival of hepatocellular carcinoma patients at a VA medical canter

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Background: To determine whether comorbidity indices predict survival in hepatocellular carcinoma (HCC) pts. Methods: In an IRB approved protocol, we reviewed the records of pts with tissue diagnosis of HCC seen at a VA Medical Center between 1/1/1999 to 12/31/2008. Comorbidity was assessed with four comorbidity indices, the Charlson Comorbidity Index (CMI), the Kaplan- Feinstein Index (KFI), the Cumulative Illness Rating Scale (CIRS), and VA Comorbidity Scale (VACS). Demographics, ECOG PS, stage, alpha-fetoprotein (AFP) at diagnosis, hepatitis B (HBV) and C (HCV) status, alcohol use, and iron overload were also reviewed. Cox survival regression analysis was performed. Results: There were 44 pts. All pts were men. The median (M) age at diagnosis was 60.5 years (range 35–86). The overall M survival was 230 days (4–2784). There were Stage I 12 (27%) pts, Stage II 7 (16%) pts, Stage III 14 (32%) pts, and Stage IV 11 (25%) pts. The M ECOG PS was 1.0 (0–4), stage 3 (1–4), CMI 5.75 (1–16), CIRS15 3.0 (1–5), CIRS16 6.0 (1–14), CIRS17 2.0 (0.83–5.0), CIRS18 0 (0–2), CIRS19 0 (0–1), KFI 3.0 (1–3), VACS 6.0 (2–9), and AFP 56.35 (1.1–379567). HBV was positive in 10 pts (23%), HCV 26 (59%) pts, alcohol use 37 (84%) pts, and iron overload 11 (25%) pts. In univariate survival analysis, stage (p<.038), ECOG PS (p<.001), AFP (p<.009), presence of iron overload (p<.006), and CMI (p<.019) were significant in predicting survival. However, age, HBV, HCV, alcohol use, CIRS15, CIRS16, CIRS17, CIRS18, KFI, and VACS were not significant for survival. In multivariate survival analyses that included stage and a comorbidity index, the CMI approaches significance (p<.077). Conclusions: In this sample, the CMI was a predictor for survival in pts with HCC. Further analysis in a larger sample is needed to provide a more definitive conclusion. This was supported by the New Jersey Commission for Cancer Research 09–1133-CCR-EO.

No significant financial relationships to disclose.

Comorbidity and survival in advanced non-small cell lung cancer (NSCLC) veteran patients

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Background: Prognostic value of comorbidity at diagnosis has received increasing attention. We studied whether the Charlson Comorbidity Index (CMI), Cumulative Illness Rating Scale (CIRS), Kaplan Feinstein Index (KFI), and/or VA Comorbidity Scale (VA) independently predicted survival for NSCLC patients Methods: In an IRB approved protocol, the charts of 101 patients with Stage IIIA, IIIB or IV Non small cell lung cancer seen from 2004 through 2006 at a VA medical center were reviewed of whom 94 have already died. Comorbidity scores ECOG performance status (PS), stage, number of treatments, serum LDH, and albumin levels were obtained or coded from medical records. Survival analyses were performed using proportional hazards models. Results: Median (M) patient age was 69 years (range 51–88), the M ECOG PS was 1 (range 0–4); 13 (13%) had stage IIIA, 27 (26%) IIB and 62 (61%) IV. The M number of treatments was 1 (range 0–6). Histologies were adenocarcinoma in 48 (48%) pts, squamous cell in 37 (37%) pts, and other 17 (15%) pts. The M survival was 207 days (range 4–1785 days). The Median (and ranges) were: 4.2 (1.2–12.8) for CMI, 3 (0–6) for CIRS15, 5(0–11) for CIRS16, 1.8 (0–4) for CIRS17, 0(0–1) for CIRS18, 2 (0–3) for KFI, and 4 (0–8) for VA. The M albumin was 3.7 (range 1.9–5.3) and LDH 201 (range 104–1036). In univariate survival analyses, the stage (p<0.001), ECOG PS (p<0.001), albumin (p<0.003), and the CIRS 17 (p <0.052) were predictive of survival; when, however, bisected by median values, the VA scale (p<0.027), ECOG PS (p<0.052) and albumin (p<.0017) were significantly related to survival but age, LDH, CMI, KFI and subscales of the CIRS (CIRS 16, CIRS 17, CIRS18) were not related to survival. In multivariate proportional hazards analyses that included stage and a comorbidity index, the CIRS16 (p<.032) was an independent predictor of survival; the combinations of stage (p<0.008), ECOG PS (p<.004), stage (p<.006) and albumin (p<.002) were independent predictors of survival. Conclusions: In this small sample, current comorbidity indices did not add to determinations of survival of veterans with advanced NSCLC. Further research is needed in a larger sample. Supported in part by the New Jersey Commission for Cancer Research 09–1133-CCR-EO and VA HSRD IIR 02–103.

No significant financial relationships to disclose.

Evaluation of glycosylation and malonylation patterns in flavonoid glycosides during LC/MS/MS metabolite profiling

Flavonoid conjugates constitute several classes of plant phenolic secondary metabolites including many isomeric compounds differing in the hydroxylation pattern and substitution of their rings with different groups such as alkyls, acyls or sugars. These compounds occur in plant tissues mainly as glycosides and in many cases it is necessary to have reliable and detailed information concerning the structure of these natural products. Our results were obtained using leaf extracts of Arabidopsis thaliana and Lupinus angustifolius in which different glycosides of flavones, flavonols and isoflavones are present. Analysis of collision-induced dissociation (CID)/MS/MS spectra of protonated [M + H](+), sodiated [M + Na](+) or deprotonated [M - H](-) molecules recorded during HPLC runs may bring needed information in this respect. However, registration of mass spectra of [M + Na](+) ions with a good efficiency is possible only after post-column addition of a sodium acetate solution to the LC column eluate. The retention of sodium cation on the saccharidic parts of the molecule is observed after the CID fragmentation. In many cases, the location of this cation on the glycan attached to C-3 hydroxyl group of flavonol led to assignment of its structure. Additionally, the determination of the structure of the aglycone and of the sequence of the glycan part was made possible through the CID data obtained from the [M + H](+) and [M - H](-) ions. CID spectra show a different order of sugar elimination from hydroxyl groups at C-3 and C-7 in flavonol glycosides isolated from A. thaliana leaves and give sufficient information to discriminate flavonoid O-diglycosides from flavonoid di-O-glycosides.

Natural sunlight NO(3)(-)/NO(2)(-)-induced photo-degradation of phenylurea herbicides in water

The nitrate-induced photodegradation of phenylureas in water was demonstrated to occur efficiently using natural sunlight irradiation. The kinetics of disappearance was found to be dependent on the inducer and substrate concentrations, the phenylurea structure and the origin and composition of the aqueous matrix including the presence of nitrite. The measured effects under sunlight were of the same order of those measured previously in the lab using our solar light simulated system. However, by-product distribution might differ substantially particularly considering the nitration pathway.

Photo-induced degradation of diuron in aqueous solution by nitrites and nitrates: kinetics and pathways

The photo-induced degradation of diuron (3-(3,4-dichlorophenyl)-1,1-dimethylurea) in aqueous solution under simulated solar irradiation has been investigated in the presence of NO3-/NO2- ions. The degradation rates were compared by varying environmental parameters including substrate and inducer concentrations, oxygen content and pH. The photoproducts were identified by extensive LC-ESI-MS and LC-ESI-MS-MS studies after SPE preconcentration on prepacked cartridges. In both NO3- and NO2- conditions, oxidation of the N-(CH3)2 terminus group is the main process leading to the N-monodemethylated (NHCH3), N-formyl (N(CH3)CHO) and the uncommon and unstable carbinolamine (N(CH3)CH2OH) by-products. Cl/OH substituted and nitrated phenylureas are formed minorily. Degradation pathways involving OH* and NO2* (or dimer) radicals as reactive species are proposed.

Profiling of flavonoid conjugates in Lupinus albus and Lupinus angustifolius responding to biotic and abiotic stimuli

Qualitative and quantitative composition of flavonoid and isoflavonoid glycosides as well as free aglycones in lupin seedlings (roots and aerial parts) grown under different light conditions or responding to infection with Pleiochaeta setosa, a fungus causing brown leaf spot, were monitored by liquid chromatography with UV and/or mass spectrometric detection. Both physical and biotic factors affected flavonoid and isoflavonoid levels in lupin tissues. Fungal infection evoked significant increase in the amounts of genistein, 2'-hydroxygenistein, and their prenylated derivatives that are thought to function as lupin phytoalexins. Effect on quantitative changes of glycosylated flavonoids and isoflavonoids in the roots and aerial parts was less significant. Moreover, different light conditions applied during seedling growth caused relative changes of flavonoid and isoflavonoid conjugates composition, especially in the leaves of white lupin plants. The chemical structures of flavonoid and isoflavonoid conjugates present in Lupinus angustifolius were elucidated. In addition to genistein and 2'-hydroxygenistein glycosides, flavonol conjugates were identified in leaves, while the composition of root isoflavonoids was similar to that of L. albus reported earlier.

Ozonation of chlorophenylurea pesticides in water: reaction monitoring and degradation pathways

The degradation of mono- and dichlorophenylureas under ozone/hydrogen peroxide conditions was investigated in order to establish the effect of the structural parameters. The N-dimethyl phenylureas (mono- and dichloro) appear to differ strongly from the corresponding N-methyl N-methoxy analogues in terms of disappearance of the parent pesticide and evolution of the by-products identified by MS and MS-MS. The degradation rate of the latter is slower by a factor of 2.5 giving rise to additional pathways (hydroxylation of the phenyl ring and carbinolamine intermediate). Experiments with 14C-labelled compounds allow a complete determination of the mass balances obtained after solid-phase-extraction (SPE). This study demonstrates the interest of SPE for reaction monitoring and compares the performances of different types of phases for this purpose used alone or in combination. Mineralisation is also evaluated regarding 14CO2 production and found to contribute up to 20% in the degradation process.

Profiling changes in metabolism of isoflavonoids and their conjugates in Lupinus albus treated with biotic elicitor

Liquid chromatography with ultraviolet and mass spectrometric detection was applied to monitor changes in profiles of isoflavonoid glycosides and free isoflavonoid aglycones in Lupinus albus L. Four isoflavonoid aglycones, fourteen isoflavonoid glycosides, four flavonol glycosides and flavone glycoside were identified in lupin tissue after LC/ESI/MS analyses. An elicitor preparation from purified yeast cell wall was used to inject the shoots of 3-week old seedlings or to infiltrate the cut lupin leaves. Qualitative and quantitative changes of isoflavonoids were measured at different time points after elicitation. In elicited lupin seedlings increased amounts of prenylated isoflavone aglycones were identified. The concentrations of glycosidic conjugates of isoflavones present in plant tissue were less affected.

Tandem solid-phase extraction of atrazine ozonation products in water

The preconcentration of aqueous solutions containing atrazine degradation products was investigated using solid-phase extraction on octadecyl and cation-exchanger silica phases. The retention and elution steps were studied and evaluated separately in order to define and optimize the critical experimental parameters involved. A strategy which combines sequentially both phases is proposed to fractionate compounds into two groups of increasing polarities: firstly, the native pesticide, hydroxyatrazine and most chlorotriazines on octadecyl support, and secondly monodealkylated hydroxytriazines, ammeline and ammelide on cation-exchanger. This tandem procedure was successfully applied for analysing and quantifying atrazine ozonation products and its efficiency demonstrated using [U-ring 14C]-labelled atrazine experiments.

Sex pheromone of the oleander scale, Aspidiotus nerii: structural characterization and absolute configuration of an unusual functionalized cyclobutane

The sex pheromone emitted by the female oleander scale, Aspidiotus nerii (Homoptera, Diaspididae), has been isolated and characterized as (1R, 2S)-cis-2-isopropenyl-1-(4'-methyl-4'-penten-1'-yl)cyclobutaneethanol acetate by using advanced MS and NMR spectroscopic methods, as well as a variety of microderivatization sequences. The structure has been confirmed by stereo- and enantioselective synthesis of the four possible stereoisomers. The absolute configuration has been determined by comparison of the activity of the cis (1S,2R) and (1R, 2S) enantiomers with that exhibited by the natural material in greenhouse bioassays and field tests. The structure of this sesquiterpenoid pheromone is new in the coccids and in the pheromone field in general.

Ram sexual pheromone: first approach of chemical identification

A series of experiments has been designed with the aim of identifying the pheromone of the ram responsible for the primer effect--induction of a LH peak and ovulation--in anoestrous ewes. In a first experiment, the pheromonal activity of various sources was tested, extract of ram fleece and ante orbital gland secretion induced characteristic changes in LH secretion, whereas urine was ineffective. A second experimental series showed that an accurate separation of the ram's fleece extract in acid and neutral fractions resulted in each case in a complete loss of activity whereas both together were efficient, indicating that the pheromonal action involves several components. From GC-MS analysis of both fractions, and after comparison of male and female wool extract, semi-synthetic formulations were tested. The association of synthetic 1,2-hexadecanediol and 1,2-octadecanediol with the natural acid fraction was efficient in stimulating LH release in anoestrous ewes. As the most frequent linear fatty acids have been shown not to be necessary, a role of branched and oxygenated fatty acids has been hypothesised.