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CompletedNCT03480217EMBRACEUpdated Jun 13, 2025Results posted

Implementing Hypertension Screening Guidelines in Primary Care

An interventional study of Multifaceted Implementation Strategy and Usual care in Hypertension,Essential and White Coat Hypertension, sponsored by Columbia University. Completed at 2 sites in United States. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2025-06-13.

Sponsored by Columbia University · Not applicable, Interventional, and Health services research

Phase
Not applicable
Study type
Interventional
Enrollment
1,186
Allocation
Randomized
Ages
18 Years and older
Sex
All
01

Study summary

The goal of this study is to use a cluster-randomized design (1:1 ratio) among 8 primary care clinics affiliated with New York-Presbyterian Hospital to test the effectiveness of a theory-informed multifaceted implementation strategy designed to increase the uptake of the 2015 United States Preventive Services Task Force (USPSTF) hypertension screening guidelines. The primary outcome is the ordering of out-of-office blood pressure testing, either ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), by primary care clinicians for patients with newly elevated office blood pressure (BP), as recommended by the 2015 guidelines.

Read the detailed description

The goal of this study is to assess the effect of a multifaceted implementation strategy aimed at increasing adherence to the 2015 U.S. Preventive Services Task Force (USPSTF) recommendations for hypertension screening, with a focus on implementation in primary care clinics that reach medically underserved patients. The accurate diagnosis of hypertension is essential for targeting appropriate therapy at the patients who can most benefit from hypertension treatment. On the other hand, inappropriate diagnosis of hypertension can lead to unnecessary treatment with blood pressure (BP) medications, wasteful healthcare utilization, and adverse psychological consequences from being mislabeled as having a chronic disease.

There are challenges to measuring BP in clinical settings that make inappropriate diagnosis common. A systematic review conducted by the USPSTF in 2014 found that 5%-65% of patients with elevated office BP do not have high out-of-office BP readings according to ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM). This is commonly referred to as white-coat hypertension. In contrast to patients with sustained hypertension (elevated BP in office and out-of-office settings), patients with white-coat hypertension do not appear to be at increased cardiovascular risk nor to benefit from antihypertensive treatment. Based primarily on these observations, in 2015, the USPSTF updated their hypertension screening guidelines to recommend that patients with elevated office BP undergo out-of-office BP testing (ABPM or HBPM) to rule-out white-coat hypertension prior to a new diagnosis of hypertension. While ABPM is recommended as the first-line out-of-office screening test, HBPM is cited as a reasonable alternative if ABPM is unavailable.

Despite the USPSTF guideline recommendation, ABPM and HBPM are currently infrequently utilized in the US, particularly as part of hypertension diagnosis. Accordingly, the investigators conducted focus groups with primary care providers, patients, and other key stakeholders (medical directors, nurse supervisors, medical assistants, nurse practitioners, front desk staff) to identify the major barriers to implementation of the new hypertension screening guidelines. The investigators then applied the Behavior Change Wheel, a trans-theoretical intervention development framework, to categorize barriers and select theory-informed intervention components that would address these barriers. The investigators arrived at a theory-informed implementation strategy for improving out-of-office BP testing, which included educational activities for providers (i.e., presentations at grand rounds or other venues at which physicians are present); training registered nurses to be capable of assisting with teaching patients to conduct HBPM; disseminating information on how to order ABPM and HBPM to clinicians, nurses, and front desk staff via huddles, emails, and other electronic communications; creating a computerized electronic health record (EHR)-embedded clinical decision support tool that prompts recall of the USPSTF hypertension guidelines and facilitates ordering of HBPM and ABPM for eligible patients; creating and disseminating patient information materials on ABPM and HBPM; providing periodic feedback about clinic-level success with adhering to the guideline, and developing an easily accessible, culturally-adapted and locally tailored ABPM service.

The investigators now aim to test this multifaceted implementation strategy to increase the uptake of the USPSTF hypertension recommendations in the ambulatory care network (ACN) of New York-Presbyterian Hospital (NYP), a network of primary care clinics serving 120,000 patients from underserved communities in New York City. Specifically, the investigators are conducting a 2-year cluster randomized trial (Phase II of the project) following a 6-month implementation phase in which we randomize matched pairs of 8 ACN clinics (1:1) to either receive the multicomponent guideline implementation strategy (N = 4 clinics) or a wait-list control (N = 4 clinics). The investigators aim to assess the effectiveness of this intervention on the completion of out-of-office BP testing (ABPM or HBPM) prior to hypertension diagnosis (primary outcome) as well as the effect on out-of-office test ordering, irrespective of test completion (secondary outcome).

02

Conditions studied

  • Hypertension,Essential
  • White Coat Hypertension

Keywords

  • hypertension
  • screening
  • guidelines
  • implementation
  • randomized
03

Who can participate

Ages eligible
18 Years and older
Sexes eligible
All
Accepts healthy volunteers
No

Eligibility criteria

Patient Inclusion Criteria (as per electronic medical records):

  • Elevated blood pressure (BP) (systolic BP>=140 mmHg or diastolic BP >=90 mmHg) at a scheduled clinic visit with a primary care provider from a clinic that is participating in the study; if multiple BP readings were taken from a visit, then the average of the readings will be used

Patient Exclusion Criteria (as per electronic medical records):

  • Prior diagnosis of hypertension
  • Prior diagnosis of white-coat hypertension
  • Prior evaluation for white-coat hypertension by 24-hr ABPM or HBPM
  • Prescribed antihypertensive medication
  • Manual office BP \<140/90 mmHg
  • Severely elevated BP (systolic BP>=180 mmHg or diastolic BP>=110 mmHg)
  • Evidence of target-organ damage (chronic kidney disease, cardiovascular disease)

Clinic Inclusion Criteria:

  • Primary care clinics that are part of the New York-Presbyterian Hospital Ambulatory Care Network and were not part of implementation development

Clinic Exclusion Criteria:

  • Medical director of clinic declines to participate in cluster randomized trial
04

Study design

Phase
Not applicable
Primary purpose
Health services research
Allocation
Randomized
Intervention model
Parallel assignment
Masking
Single (Outcomes assessor)
Enrollment
1,186 participants (actual)

Study arms

  • Experimental
    Intervention Clinics, Pre-Implementation

    Usual care

    Other: Usual care

  • Experimental
    Intervention Clinics, Post-Implementation

    Patients will be screened for hypertension by primary care clinicians, registered nurses, medical assistants, and front desk staff from clinics randomized to receive the Multifaceted Implementation Strategy.

    Behavioral: Multifaceted Implementation Strategy

  • Other
    Control Clinics, Pre-Implementation

    Usual care

    Other: Usual care

  • Other
    Control Clinics, Post-Implementation

    Usual care

    Other: Usual care

Interventions

  • BehavioralMultifaceted Implementation Strategy

    Key components include: * educational presentations to primary care providers at grand rounds * patient information materials on ABPM and HBPM * training registered nurses to assist providers with teaching patients to conduct HBPM * information on how to order ABPM and HBPM to clinicians, nurses and front desk staff via huddles, emails, and other electronic communications * a computerized EHR-embedded clinical decision support tool that prompts providers to recall the USPSTF hypertension guidelines and facilitates ordering of HBPM and ABPM for guideline-eligible patients * periodic feedback to primary care providers about clinic-level success with appropriately ordering ABPM and HBPM for eligible patients * an accessible, culturally-adapted and locally tailored ABPM service

  • OtherUsual care

    Primary care clinicians diagnose hypertension according to usual care

05

What researchers measure

Primary outcomes

  1. Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Pre-Implementation Period

    Patient completed out-of-office BP testing \[ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)\] (either Y/N) per eligible visits were tallied.

    Time frame: 6 months (Pre-Implementation period)

  2. Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Post-Implementation Period

    Patient completed out-of-office BP testing \[ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)\] (either Y/N) per eligible visits were tallied.

    Time frame: 6 months (Post-Implementation period)

Secondary outcomes

  1. Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Pre-Implementation Period

    Primary care clinician ordered out-of-office BP testing \[ABPM or HBPM\] (either Y/N) for eligible visits were tallied.

    Time frame: 6 months (Pre-Implementation period)

  2. Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Post-Implementation Period

    Primary care clinician ordered out-of-office BP testing \[ABPM or HBPM\] (either Y/N) for eligible visits were tallied.

    Time frame: 6 months (Post-Implementation period)

06

Results

Posted Jun 13, 2025
Limitations and caveats
The Coronavirus Disease 2019 (COVID-19) pandemic led to the closure of the ABPM testing service during the maintenance period which precluded an evaluation of the implementation strategy during the maintenance period. Additionally, a new electronic health record was adopted in 2020 which also precluded an evaluation of the use of HBPM during the maintenance period.

Participant flow

Patients were passively recruited from the electronic health record.

Pre-Implementation (12 Months)
Participant flow — Pre-Implementation (12 Months)
MilestoneIntervention ClinicsControl (Usual Care) Clinics
Started456139
Completed456139
Not completed00
Post-Implementation (12 Months)
Participant flow — Post-Implementation (12 Months)
MilestoneIntervention ClinicsControl (Usual Care) Clinics
Started401190
Completed401190
Not completed00

Outcome measures

PrimaryPercentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Pre-Implementation Period

Patient completed out-of-office BP testing \[ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)\] (either Y/N) per eligible visits were tallied.

Time frame:
6 months (Pre-Implementation period)
Reported as:
Number · percentage of visits
Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Pre-Implementation Period
percentage of visitsIntervention ClinicsControl Clinics
Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Pre-Implementation Period0.65.4
SecondaryPercentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Pre-Implementation Period

Primary care clinician ordered out-of-office BP testing \[ABPM or HBPM\] (either Y/N) for eligible visits were tallied.

Time frame:
6 months (Pre-Implementation period)
Reported as:
Number · percentage of visits
Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Pre-Implementation Period
percentage of visitsIntervention ClinicsControl Clinics
Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Pre-Implementation Period2.88.7
PrimaryPercentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Post-Implementation Period

Patient completed out-of-office BP testing \[ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)\] (either Y/N) per eligible visits were tallied.

Time frame:
6 months (Post-Implementation period)
Reported as:
Number · percentage of visits
Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Post-Implementation Period
percentage of visitsIntervention ClinicsControl Clinics
Percentage of Patient Visits With Completion of Out-of-office BP Monitoring Within 6 Months of an Eligible Visit During the Post-Implementation Period5.74.3
SecondaryPercentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Post-Implementation Period

Primary care clinician ordered out-of-office BP testing \[ABPM or HBPM\] (either Y/N) for eligible visits were tallied.

Time frame:
6 months (Post-Implementation period)
Reported as:
Number · percentage of visits
Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Post-Implementation Period
percentage of visitsIntervention ClinicsControl Clinics
Percentage of Patient Visits With Out-of-office BP Monitoring Test Ordered by Clinician During the Post-Implementation Period7.99.2

Adverse events

Collected over Adverse event data were recorded up to 6 months after the 12-month pre-implementation and 12-month post-implementation periods.. Non-serious events are listed at a 0% frequency threshold.

Adverse event summary by group
GroupDeathsSeriousOther
Intervention Clinics0/857 (0%)0/857 (0%)0/857 (0%)
Control Clinics0/329 (0%)0/329 (0%)0/329 (0%)

Baseline characteristics

The clinics are either implementing the intervention (4 out of 8) or providing usual care (4 out of 8) after the implementation period begins. The baseline analysis for the participants that visited these clinics are calculated separately - those who visited the Intervention Clinics before and after the implementation (456+401=857 total) and those who visited the Control Clinics before and after the implementation (139+190=329 total).

Age, Continuous
Age, Continuous(years)Intervention Clinics (Pre-Implementation)Intervention Clinics (Post-Implementation)Control (Usual Care) Clinics (Pre-Implementation)Control (Usual Care) Clinics (Post-Implementation)Total
Mean51.6 ± 14.151.3 ± 14.558.9 ± 16.059.8 ± 19.153.6 ± 15.7
Sex: Female, Male
Sex: Female, Male(Participants)Intervention Clinics (Pre-Implementation)Intervention Clinics (Post-Implementation)Control (Usual Care) Clinics (Pre-Implementation)Control (Usual Care) Clinics (Post-Implementation)Total
Female289257105157808
Male1671443433378
Ethnicity (NIH/OMB)
Ethnicity (NIH/OMB)(Participants)Intervention Clinics (Pre-Implementation)Intervention Clinics (Post-Implementation)Control (Usual Care) Clinics (Pre-Implementation)Control (Usual Care) Clinics (Post-Implementation)Total
Hispanic or Latino1521135053368
Not Hispanic or Latino70791743209
Unknown or Not Reported2342097294609
Race (NIH/OMB)
Race (NIH/OMB)(Participants)Intervention Clinics (Pre-Implementation)Intervention Clinics (Post-Implementation)Control (Usual Care) Clinics (Pre-Implementation)Control (Usual Care) Clinics (Post-Implementation)Total
American Indian or Alaska Native00000
Asian00000
Native Hawaiian or Other Pacific Islander00000
Black or African American5350911123
White86693357245
More than one race00000
Unknown or Not Reported31728297122818
Region of Enrollment
Region of Enrollment(participants)Intervention Clinics (Pre-Implementation)Intervention Clinics (Post-Implementation)Control (Usual Care) Clinics (Pre-Implementation)Control (Usual Care) Clinics (Post-Implementation)Total
United States4564011391901186
07

Study locations

2 sites
  • Center for Behavioral Cardiovascular Health
    New York, New York 10032, United States
  • Weill Cornell Medical Center
    New York, New York 10065, United States
08

References and documents

Publications

  • Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015 Nov 17;163(10):778-86. doi: 10.7326/M15-2223. Epub 2015 Oct 13. PubMed 26458123 ↗
  • Kronish IM, Kent S, Moise N, Shimbo D, Safford MM, Kynerd RE, O'Beirne R, Sullivan A, Muntner P. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens. 2017 Sep;11(9):573-580. doi: 10.1016/j.jash.2017.06.012. Epub 2017 Jul 6. PubMed 28734798 ↗
  • Piper MA, Evans CV, Burda BU, Margolis KL, O'Connor E, Whitlock EP. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015 Feb 3;162(3):192-204. doi: 10.7326/M14-1539. PubMed 25531400 ↗
  • Moise N, Phillips E, Carter E, Alcantara C, Julian J, Thanataveerat A, Schwartz JE, Ye S, Duran A, Shimbo D, Kronish IM. Design and study protocol for a cluster randomized trial of a multi-faceted implementation strategy to increase the uptake of the USPSTF hypertension screening recommendations: the EMBRACE study. Implement Sci. 2020 Aug 8;15(1):63. doi: 10.1186/s13012-020-01017-8. PubMed 32771002 ↗
  • Carter EJ, Moise N, Alcantara C, Sullivan AM, Kronish IM. Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study. Am J Hypertens. 2018 Jul 16;31(8):919-927. doi: 10.1093/ajh/hpy062. PubMed 29788130 ↗
  • Kronish IM, Phillips E, Alcantara C, Carter E, Schwartz JE, Shimbo D, Serafini M, Boyd R, Chang M, Wang X, Razon D, Patel A, Moise N. A Multifaceted Implementation Strategy to Increase Out-of-Office Blood Pressure Monitoring: The EMBRACE Cluster Randomized Clinical Trial. JAMA Netw Open. 2023 Sep 5;6(9):e2334646. doi: 10.1001/jamanetworkopen.2023.34646. PubMed 37747734 ↗

Study documents

  • Protocol and statistical analysis plan · Mar 23, 2023

Documents are hosted by the registry — open the source record to download them.

Individual participant data

Plan to share: Yes — A de-identified data archive that contains raw study data will be posted on an open science platform.

Supporting information: Study protocol, Sap, Analytic code

09

Registry details

Key details

Study ID
NCT03480217
Lead sponsor
Columbia University
Collaborators
Agency for Healthcare Research and Quality (AHRQ), Weill Medical College of Cornell University
Responsible party
Ian Kronish (Florence Irving Associate Professor of Medicine, Columbia University) — Principal investigator
First posted
Mar 29, 2018
Start date
Apr 1, 2018
Primary completion
Jul 1, 2022
Completion
Oct 1, 2022
Results posted
Jun 13, 2025
Last update
Jun 13, 2025

Study contacts

Ian Kronish, MD
principal investigator · Columbia University

Oversight

Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
View the source record on ClinicalTrials.gov ↗

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This study is completed, as verified in May 2025. You cannot join it, but the record below documents what was studied.

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