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

Abstract Rationale & Objective Blood pressure (BP) control in dialysis patients is often inadequate, partly due to a lack of standardized home BP monitoring. We aimed to implement and evaluate a remote BP monitoring program (RBPM) for in-center 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 in-center 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 utilization 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 one day after midweek HD, number of BP medications, and target weight before and after RBPM initiation using paired t-test or Wilcoxon signed-rank sum test. Additionally, mixed-effects models were used to assess changes over time. Results Among 79 patients screened, 48 referred to RBPM, 30 started monitoring, and 27 completed the 3-month follow up. The mean pre-dialysis systolic BP before RBPM initiation was 145 (SD, 20) mmHg. During Month 1, home systolic BP post-midweek HD was lower than pre-HD measurement by 14 mmHg (p=0.005). The median number of BP medication decreased from 2.5 to 2.0 at Month 3 (p=0.005). Median monthly home BP measurements decreased from 17 during Month 1 to 6 during Month 3 (p<0.001). At Month 3, 67% of participants (18/27) were actively monitoring their BP, with only 13 (48%) measuring BP post-midweek 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 BPs, underscoring its potential utility. However, the observed decline in patient engagement highlights the challenge of maintaining long-term adherence.