Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study

Abstract

BACKGROUND

Guidelines recommend that patients with newly elevated office blood pressure undergo ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to rule-out white coat hypertension before being diagnosed with hypertension. We explored patients’ perspectives of the barriers and facilitators to undergoing ABPM or HBPM.

METHODS

Focus groups were conducted with twenty English- and Spanish-speaking individuals from underserved communities in New York City. Two researchers analyzed transcripts using a conventional content analysis to identify barriers and facilitators to participation in ABPM and HBPM.

RESULTS

Participants described favorable attitudes toward testing including readily understanding white coat hypertension, agreeing with the rationale for out-of-office testing, and believing that testing would benefit patients. Regarding ABPM, participants expressed concerns over the representativeness of the day the test was performed and the intrusiveness of the frequent readings. Regarding HBPM, participants expressed concerns over the validity of the monitoring method and the reliability of home blood pressure devices. For both tests, participants noted that out-of-pocket costs may deter patient participation and felt that patients would require detailed information about the test itself before deciding to participate. Participants overwhelmingly believed that out-of-office testing benefits outweighed testing barriers, were confident that they could successfully complete either testing if recommended by their provider, and described the rationale for their testing preference.

CONCLUSIONS

Participants identified dominant barriers and facilitators to ABPM and HBPM testing, articulated testing preferences, and believed that they could successfully complete out-of-office testing if recommended by their provider.

Inaccurate blood pressure readings in the clinic setting place patients at risk for inappropriate medical care. Approximately 1 in 5 patients who meet criteria for a diagnosis of hypertension in clinical settings are normotensive outside of the clinical setting, a phenomenon known as white coat hypertension.¹ The risk for cardiovascular morbidity and mortality in patients with white coat hypertension is comparable to patients with normal office blood pressures, precluding the need for antihypertensive medications.^2–5 Since the start of the 21st century, ambulatory blood pressure monitoring (ABPM) has been consistently recommended by international guidelines to exclude white coat hypertension before diagnosis of hypertension.⁶ Masked hypertension, defined as nonelevated blood pressure in the medical setting but elevated blood pressure when measured out of the clinic such as at work or home, is another blood pressure phenotype associated with inaccurate readings in clinical settings.⁶ In contrast with white coat hypertension, those with masked hypertension are at similar risk of cardiovascular events as those with sustained hypertension.⁷

Most recently, AHA/ACC hypertension guidelines place renewed interest in out-of-office testing via ABPM or home blood pressure monitoring (HBPM) to exclude white coat hypertension before diagnosis of hypertension.^8,9 While 15%–25% of adults with elevated clinic blood pressure are believed to have white coat hypertension and about 17% of adults with nonelevated clinic blood pressure are estimated to have masked hypertension, ABPM and HBPM are used infrequently in the United States, particularly in the context of hypertension screening.^10–12 System-level and physician-level factors present barriers to clinicians’ referring patients for out-of-office blood pressure monitoring, including a lack of availability of ABPM testing services, reimbursement concerns, and a lack of formalized training in how to conduct testing.^13,14 Less is known about patient-level barriers and facilitators to out-of-office testing.

Patient-centered decision making, defined as the adaption of research evidence to patient context,¹⁵ is increasingly recognized as a requisite of primary care.^16,17 Studies suggest that patient-centered decision making is associated with improved treatment adherence and patient outcomes.^15,18,19 An appreciation of the barriers and facilitators to out-of-office testing as perceived by patients may facilitate clinicians’ ability to provide patient-centered care and improve guideline uptake. Using qualitative methods, we explored patient barriers and facilitators to out-of-office blood pressure testing in the context of hypertension screening.

METHODS

We used the Evaluative Criteria for Qualitative Research in Health Care to guide the reporting of qualitative methods and findings.²⁰ Four focus groups were conducted between November 2015 and February 2016 with 20 English- and Spanish-speaking individuals from underserved communities in New York City. Participants were referred to the study via primary care providers who practiced at a primary care clinic affiliated with New York-Presbyterian Hospital located in Upper Manhattan and through advertisements at a community health center in the same neighborhood. Individuals were eligible if they were 18 years or older, had not previously been diagnosed with hypertension, and did not have established cardiovascular disease. We conducted focus groups with recruited participants until data saturation was reached such that focus group discussion was confirmatory and contributed little to no new information.

Focus groups were conducted in a conference room of the research team office suite or in a private group meeting space of a local community health center. Separate focus groups were held for English- and Spanish-speaking individuals. We aimed to have 4–8 participants per focus group, as recommended by experts as this group size is thought to best enhance meaningful participation and interaction between all focus group participants while encouraging the sharing of ideas.^21,22 To facilitate a shared understanding of core focus group concepts, researchers began the sessions by briefly explaining white coat hypertension, national expert recommendations for out-of-office testing, and what ABPM and HBPM testing entails. Specifically, researchers described that in ABPM testing, patients conduct their routine activities while wearing the ABPM device, which is programmed to take their blood pressure every 15–60 minutes over a 24-hour period.⁵ In contrast, patients that undergo HBPM take their blood pressure while at rest using an automatic blood pressure device, with measurements taken in the morning and before bed for approximately 1 week.³ Participants were also given an opportunity to see and wear ambulatory and home blood pressure devices. Using a semi-structured interview guide (Supplementary Appendix), researchers then asked participants to describe their understanding of white coat hypertension; describe patient barriers and facilitators to participating in ABPM and, separately, HBPM; and to explain their preference for ABPM vs. HBPM, if any. All focus groups were audiorecorded, transcribed in English using a professional transcription service, and reviewed for accuracy.

Transcripts were coded using a conventional content analysis, in which codes emerged from transcript data.²³ In using this method, researchers (I.M.K., E.J.C., C.A., A.M.S., N.M.) independently reviewed focus groups to ensure a shared understanding of focus group content and together developed a listing of codes and code definitions. Subsequently, E.J.C. and A.M.S. independently coded transcripts in NVivo 11 (QSR International), assessed interrater reliability using the coding comparison query, and resolved discrepancies through discussion. This study was approved by the institutional review board of Columbia University Medical Center with a waiver of written informed consent.

Composition of research team

The study team was comprised of internal medicine physicians (I.M.K. and N.M.), a PhD-prepared nurse (E.J.C.) and clinical psychologist (C.A.) who were trained in qualitative methods, and a masters-prepared clinical research coordinator (A.M.S.).

Verification techniques

Multiple recommended verification techniques were used throughout the course of the study to ensure study rigor.²⁰ First, we performed peer review/debriefings, in which researchers who coded transcripts discussed the barriers and facilitators that they had identified with the larger research team in an iterative process. By the end of the third focus group, there was consensus that saturation of information regarding testing barriers and facilitators had been achieved, and no further focus groups were scheduled. Second, we performed informal and formal member checking. During focus groups, researchers summarized their understanding of group discussion in real-time and asked participants if their understanding was accurate. Similarly, when data analysis was complete, researchers presented English- and Spanish-translated summaries of study findings to participants. Participants were asked to comment on data inaccuracies and misrepresentations. No concerns were raised. Lastly, we triangulated data by comparing findings across each focus group and ensuring a shared understanding of study findings among study investigators.

RESULTS

A total of 20 individuals participated in focus groups, described in Table 1. Five participants were recruited via advertisements at a community health center in Upper Manhattan and 15 participants were recruited from a primary care clinic in the same neighborhood. Focus groups averaged 68 minutes in duration (SD ± 9). Mean age was 55.95 (SD = 10.82) years, and most participants were female and born outside the United States. Half of the participants reported Spanish as their primary language.

Table 1.

Focus group demographics.

Characteristic	Group 1	Group 2	Group 3	Group 4	Total
Participants, No.	4	6	4	6	20
Gender
Male	0	2	1	2	5
Female	4	4	3	4	15
Race
White	0	0	1	3	4
Black	0	0	2	1	3
Mixed	0	1	0	1	2
Other	3	0	0	1	4
Declined	3	3	1	0	7
Ethnicity
Hispanic	5	4	1	2	12
Non-Hispanic	0	0	3	4	7
Declined	1	0	0	0	1
US Born	2	0	0	3	5
Age, mean (SD)	47.75 (8.42)	58.33 (14.24)	53.75 (4.99)	60.50 (9.77)	55.95 (10.82)
Preferred Language
English	4	0	0	6	10
Spanish	0	6	4	0	10
Annual household income in Dollars, mean	$28,000	$9,950	$11,500	$7,500	$12,287

Favorable attitudes towards out-of-office blood pressure testing

Participants described 4 favorable attitudes towards out-of-office blood pressure testing that may facilitate testing (Figure 1). First, participants readily understood the concept of white coat hypertension and described common scenarios in which a patient’s blood pressure might be uncharacteristically high e.g., “It’s the [waiting room] environment sometimes it’s not conducive to relaxing. You’re waiting and you’re waiting…” Second, participants believed that patients would benefit from out-of-office testing as testing would lead to more accurate diagnoses of hypertension and prevent patients from taking medication unnecessarily. This sentiment was particularly strong among participants that had a family history of hypertension. A participant summarized, “My mom has been in for high blood pressure before and they give her something for it. But if you don’t need it, then it shouldn’t be given.” Third, we found that participants’ agreement to undergo testing was contingent on a trusted provider’s recommendation to take the test. One participant stated, “If my doctor recommends it, I’ll do it.” Lastly, while participants described barriers to out-of-office testing, we found that participants overwhelmingly believed that testing benefits outweighed testing barriers.

Figure 1.

Representative quotes of favorable attitudes towards ambulatory blood pressure monitoring and home blood pressure monitoring.

Barriers and facilitators specific to out-of-office blood pressure testing

We present the barriers to ABPM and HBPM testing separately below along with the strategies that participants identified to overcome these barriers.

ABPM testing.

We found that concerns about the representativeness of blood pressure readings presented substantial barriers to patient participation in ABPM. Participants overwhelmingly believed that a patient’s environment and experience impacted blood pressure readings, and some felt that, even across 24 hours, the ABPM test might be insufficiently representative of their overall blood pressure. One individual reflected, “[L]et’s say the doctor says okay, I want you to put it on such and such day, and that’s the day I’m gonna be walking in this neighborhood up and down, you know the hills…I mean, would there be like a diary…?” In believing that testing should be performed on a day that was representative of a patient’s routine schedule, one proposed facilitator was that clinicians and patients together decide on a day that would be ideal for ABPM testing and that patients use a diary to keep track of their activity over the course of ABPM testing. Participants reasoned that their recorded blood pressure readings could then be linked to their environmental contexts during that time period (Table 2).

Table 2.

Barriers and corresponding facilitators to patients’ successful participation in ambulatory blood pressure monitoring

Barriers	Facilitators
Concerns about representativeness of data	Have providers and patients decide a representative day for patients to participate
“If it is high, how would they know it was while you were asleep? I think it would lack accurate information.”—Focus Group 3 (Spanish)
	“Discussing the day that you wear this is really important.”—Focus Group 4 (English)
“I’m just thinking because I usually go and work out on Saturday mornings, if, if I was to wear it like after my workout, because I would want to wear it over the weekend instead of wearing it to go to work, so that would be like my reading will be higher, probably I’m not sure.”—Focus Group 4 (English)	Encourage patients to keep track of activity
	“I would want to know hour by hour where I was, why it went up kind of thing… [A diary] would be a good thing.”—Focus Group 4 (English)
Issues regarding possible sleep interruption	None reported
“I think the inconvenience would be if the person thinks they would be waking up every time the pressure is measured. That would be another challenge in relation with the device.”—Focus Group 2 (Spanish)
“I don’t know that I would be able to sleep with it on.”—Focus Group 3 (Spanish)
Apprehension about side effects	Have providers offer face-to-face education and an educational brochure
“Would it have any radiation?”—Focus Group 2 (Spanish)
	“When you have that physician next to you or nurse, at least you are able to ask questions at the moment there [and provide] a pamphlet…you can always go back and be like okay, this is what they said.”—Focus Group 1 (English)
Concerns about reliability of testing
“If you remove it, does it deactivate?”—Focus Group 1 (English)
“What if I dropped it on the floor? Is that gonna recalibrate it? Do you know what I mean? It’s like a little computer in there?”—Focus Group 4 (English)
Issues about cost of testing	Recommend that practices have flexible payment and cost options
“If the doctor is so serious about it that you have to have this device, I think it should be covered.”— Focus Group 4 (English)
	“A payment plan [may be provided for those] that can’t afford to pay it right away.”—Focus Group 1 (English)
“We [are] all working and paying bills and when you calculate like wow, I have to spend $200, $100 for that. No, I prefer to go to the doctor and just get it checked or go to Rite Aid [pharmacy] and just get it checked, you know? I’m gonna be quite honest.”— Focus Group 1 (English)	“For me, the price doesn’t matter.”—Focus Group 3 (Spanish)
	“It depends on a person’s income.”—Focus Group 2 (Spanish)
Apprehension about physical appearance of testing device	Have provider offer information on the weight, appearance, and wearability of device
“It’s awkward. It’s, it’s very – it would get in the way of doing other things. You know, whether I was meeting my friends, and it would just be kind – I would be kind of embarrassed to like, walk around with that thing… You might have to do a lot of explaining to people.”— Focus Group 4 (English)
	“I’m just curious how much, how much it weighs…the size, the weight. Looks like maybe a deck of cards or something. I’m not sure.”—Focus Group 4 (English)

Participants also expressed moderate concerns over the frequency and intrusiveness of ABPM testing, particularly during the nighttime. While some described nighttime readings as “annoying,” others expressed concerns that nighttime readings would impair sleep. One participant noted, “It would probably wake me up… I don’t see how I could sleep through that.”

Another barrier was related to a lack of information regarding ABPM at the time of referral. Participants believed that patients would desire detailed information on ABPM testing before deciding to participate (e.g., information on whether the device could be worn in the shower, how the device was calibrated, conditions that would cause the device to deactivate) and that a lack of such information may hinder participation. Furthermore, in Spanish-speaking focus groups, participants expressed misconceptions regarding adverse effects of testing that could impede participation, such as concern over whether ABPM testing exposed patients to radiation. To ensure that patients received the information desired, participants recommended that clinicians educate patients on ABPM testing in-person and provide patients with an educational brochure for future reference.

The financial cost of testing was viewed as a barrier to ABPM testing. Participants were divided in the amount that patients would be willing to pay for the test. While some participants would undergo testing only if the test was covered by insurance and/or if out-of-pocket fees were minimal, others expressed willingness to enter a payment plan and pay as much as $200 for testing.

To a lesser extent, participants noted that physical aspects of ABPM testing would present testing challenges. A minority of participants reported that the device was heavy, bulky to wear, and would draw unwanted attention from others. One participant described, “I would be kind of embarrassed to like, walk around with that thing… You might have to do a lot of explaining to people.” To overcome these barriers, participants suggested that clinicians inform patients of the weight, appearance, and wearability of the device by comparing the device to household items such as a mobile phone or iPad.

HBPM testing.

Concerns over the validity of test results and reliability of home blood pressure devices posed the most considerable barriers to HBPM testing. Participants were skeptical of whether HBPM would be able to truly determine if patients had high blood pressure given that patients would be expected to take their blood pressure in non-representative settings (i.e., while at home and at rest). Participants were also concerned that store-bought home blood pressure devices varied in quality and could not be trusted to take accurate readings. A participant described, “Any machine that I have to do something at home like that, I, I always wonder how reliable these home – at home testing is” (Table 3).

Table 3.

Barriers and corresponding facilitators to patients’ successful participation in HBPM

Barriers	Facilitators
Concerns about reliability of testing	None reported
“You take [your blood pressure] first thing in the morning before you supposedly have, have stress. And the end of the day, maybe I had a lousy day running around… Any machine that I have to do something at home like that, I, I always wonder how reliable these home – at home testing is.”—Focus Group 4 (English)
Lack of desire to initiate HBPM readings	None reported
“I don’t think I would want to do it…Many people wouldn’t want to do that themselves.”—Focus Group 3 (Spanish)
Concerns about testing forgetfulness	Encourage alarm use
“I would forget.”—Focus Group 1 (English)	“I would put that alarm on…I could do it in the evening it would be a time that I know for sure I’m already at home…And then I would, I would do it there.”—Focus Group 1 (English)
Lack of knowledge about testing protocol	Have provider teach and patient demonstrate proper technique
“There will be people that won’t know how to do it.”—Focus Group 2 (Spanish)	“The doctor should show you and they…should even…have you do it. See whether you’re doing it right.”—Focus Group 4 (English)
“Where does it go on my arm?”—Focus Group 4 (English)
Issues about cost of testing	Future use of device
“You’re asking… people to buy it [who] might not have high blood pressure issues. So they spend, they spend a lot of money on something they might [need].”—Focus Group 1 (English)	“For the future you know you have it there. Sometimes…you might… want to just monitor [your]self here and there.”—Focus Group 1 (English)
“I wouldn’t buy [a home BP monitor]…I can go to Duane Reade [pharmacy], and it [doesn’t] cost me anything.”—Focus Group 4 (English)	“When someone is present in your home that has problems with blood pressure… you can give first aid.”—Focus Group 2 (Spanish)

Abbreviation: HBPM, home blood pressure monitoring.

Another considerable challenge to HBPM testing was insufficient motivation to muster the effort to take multiple blood pressure readings. While some participants believed that morning and evening blood pressure readings could be easily incorporated into one’s daily routine, others believed that patients would have to rearrange their schedule and might be unwilling to do so. Participants also acknowledged that patients may forget to take their blood pressure readings and expressed concern that skipped readings would jeopardize testing results. To overcome anticipated forgetfulness, participants recommended that clinicians encourage patients to set alarms, which would remind patients to take their blood pressure at regular intervals.

A lack of knowledge about blood pressure procedures was noted to pose important barriers to HBPM testing. Participants reported that they were unsure of optimal blood pressure cuff positioning. This uncertainty was worsened by experiencing inconsistent blood pressure measurement techniques while at their doctor’s office. A participant noted, “Sometimes I’ve been to the doctor and [the cuff was] almost down by my elbow…So I don’t know.” To overcome this barrier, participants recommended that clinicians teach patients proper measurement technique and have patients demonstrate correct form.

Similar to ABPM testing, the financial cost of testing was viewed as a barrier to HBPM participation. In particular, participants voiced concerns over having to purchase a home blood pressure device, especially if they could have a blood pressure reading taken at no cost at local pharmacies. An individual summarized, “I wouldn’t buy [a home BP monitor]…I can go to Duane Reade [pharmacy], and it [doesn’t] cost me anything.” To overcome cost concerns, participants recommended that clinicians emphasize that owning a home blood pressure device could be convenient for future use by patients, family, and friends.

Preferences for ABPM vs. HBPM

When asked which testing method they preferred, participants were divided in their responses (Table 4). Participants that preferred ABPM reasoned that the test would be more likely to be covered by insurance, would be set-up by their provider in-person, and would only take 24 hours. Individuals also believed that ABPM would provide a more accurate understanding of a patient’s blood pressure, and forgetfulness pertaining to the HBPM protocol would not be an issue. In contrast, participants that preferred HBPM reasoned that the test was more convenient as fewer BP readings were required and as the test would be taken in the comfort of home during non-sleep hours. While participants expressed preferences for a testing method, all participants believed that both forms of out-of-office BP testing would benefit patients and reported that they would be able to successfully complete both types of testing.

Table 4.

Preferences for ABPM and HBPM

Preference rationale	ABPM	HBPM	Representative quote
Provider set-upPatients believed the in-person provider set-up offered by ABPM would benefit patients.	X		“I’d try the 24 hours also, because you have someone who really knows you understand, how to really put it on you correctly.”—Focus Group 4 (English)
Cost Patients expressed willingness to participate in ABPM due to Medicare coverage.	X		“I would have the [24-hour] machine…Medicare pays for that.”—Focus Group 4 (English)
Validity Patients believed that ABPM would provide a more accurate reading of a patient’s blood pressure.	X		“I think the 24-hour monitoring system is more precise.”—Focus Group 3 (Spanish)
Automated readings Patients reported that the automated readings of ABPM would be “easy,” while patients would have to modify their behavior to successfully complete HBPM.	X		“I would choose the 24-hour monitoring because it’s faster, shorter. I don’t have to worry about doing it myself.”—Focus Group 2 (Spanish)
Discomfort Patients expressed concern over the number and timing of blood pressure readings taken during ABPM test.		X	“I think for me I would choose the home...The 24-hour one I think would be a little aggravating on my medium nerves after a while.”—Focus Group 1 (English)
Convenience Patients believed that ABPM and HBPM offer patients with a different set of conveniences.	X	X	“I would choose the 24-hour monitoring…Because I would put it on and take it off after 24 hours.”—Focus Group 2 (Spanish)
			“I would prefer the home one…because…you just take it…And then it’s gone. You get away and then you come and take it. For me home is better.”—Focus Group 1 (English)
Additional testing benefits Patients felt that ABPM and HBPM testing would result in additional patient benefits.	X	X	“If I knew there were a few things that annoyed me or how going up and down the stairs affects me…[it] would make me more a little bit more involved...”—Focus Group 4 (English)
			“And 24-hours you can pay for it and then you cannot keep it, but this one [HBPM] you paying for it [the device] and you keep it.”—Focus Group 2 (Spanish)

Abbreviations: ABPM, ambulatory blood pressure monitoring; HBPM, home blood pressure monitoring; X, test preference.

DISCUSSION

Across focus groups with English- and Spanish-speaking patients in underserved communities, we found that participants’ out-of-office testing preferences were largely driven by contextual factors such as situational costs and familial experiences. Similar to a previous study that found patients were significantly more likely to perform HBPM if their provider recommended testing²⁴ and another study that explored implementation of out-of-office testing in the Netherlands,²⁵ we found that participants described high levels of self-efficacy and believed that patients could successfully complete testing if the test was recommended by their clinician. In contrast, Kronish et al.¹⁴ described out-of-office testing barriers identified by clinicians and found that top barriers included (i) anticipated patient noncompliance (specific to HBPM) and (ii) the perceived inability of patients to complete testing due to discomfort (specific to ABPM). Accordingly, clinicians might be overly pessimistic about the ability of their patients to successfully complete ABPM and HBPM testing.

Participants viewed out-of-office testing as an opportunity to become further engaged in their care by learning more about their blood pressure. In particular, those who were interested in ABPM testing wished to record their activity levels and environmental surroundings during ABPM testing in order to link their blood pressure readings to the activity they were engaged in at that time. While such activity recording mechanisms are not part of all out-of-office BP guidelines, it highlights patients’ desire to be actively engaged in their health and may require additional prescriber time and resources.

Concerns about testing reliability and knowledge of correct blood pressure measurement technique emerged as important testing considerations. Participants believed an added benefit of ABPM testing was the in-person provider set-up and stressed the need for HBPM testing to include formal education in which patients were required to demonstrate proper home blood pressure measurement technique. While home blood pressure monitor usage is becoming more frequent, patients rarely receive formal training on proper technique with one study finding that only 8% of hypertensive patients had received specific training on proper HBPM.²⁶ Creating standardized protocols and activating members of the clinic team, especially nonphysicians, to train patients on proper ABPM and HBPM technique may be key to overcoming these barriers. Additional research is needed to identify facilitators to overcome the additional HBPM testing barriers identified by participants, i.e., concerns about reliability of testing, lack of desire among patients to initiate HBPM readings.

Cost emerged as an important testing consideration. Studies have shown that users of home blood pressure monitors are less likely to be Hispanic and originate from low-income households.²⁷ This may be because HBPM devices are not commonly covered by insurance¹³ or because primary care physicians are less inclined to offer HBPM to low-income patients.²⁸ At the time of data collection, out-of-pocket costs of ABPM testing were covered by Medicare but only in the setting of diagnosing hypertension, by Medicaid in some but not all states, and variably by commercial insurers. The cost of HBPM devices, in contrast, was not covered by Medicare and was variably covered by Medicaid and commercial insurers. Among study participants that emphasized financial testing costs, we found that these participants overwhelmingly chose ABPM over HBPM and cited their desire to minimize out-of-pocket costs. Still yet, while participants acknowledged that HBPM could be more costly than ABPM, a minority of participants reflected that they would be willing to absorb these costs as they would want to have a home blood pressure monitor available for future use for themselves and family members.

Participants expressed concern over ABPM nighttime readings, which is consistent with previous reports that describe sleep disturbances among those undergoing ABPM. In one study, among 60 participants, 70% reported the monitor awoke them after falling asleep, 20% reported the monitor prevented them from falling asleep, and nearly 9% reported the monitor caused such disturbance that they removed the monitor at night.²⁹ Additional discomforts and adverse effects of ABPM testing have also been noted and include monitor heaviness, pain, skin irritation, and bruising.^29,30 This study provides an awareness of the attitudes of patients who have not undergone out-of-office testing, which is important as this is the context in which many first time recommendations for testing occur. Further research is needed to develop standardized questionnaires to quantify the actual patient experiences and side effects of ABPM and HBPM testing. Clinicians may subsequently use such questionnaire findings to further guide conversations related to out-of-office testing and inform patient-centered decision making.

This study has several strengths. Numerous techniques were used throughout the course of the study to ensure the rigor of qualitative data collection and analysis, including peer debriefing and member checking. Similarly, focus groups were conducted in English and Spanish and lend a rich description of factors that patients perceive as facilitating or posing barriers to out-of-office BP testing. There were also some limitations. Participants did not have direct experience with either out-of-office testing procedure. Thus, their comments relate to a theoretical presentation of information. It is possible that their responses might have been different if they had prior experience conducting each test. Nevertheless, this situation is typical of patients who are advised to undergo ABPM or HBPM, and will be informative of barriers that clinicians should expect to encounter when recommending these tests. Similarly, study findings may not generalize to other settings. Our study consisted of a large proportion of immigrants and low-income patients; barriers related to out-of-pocket costs and training required of self-monitoring may be different in other populations.

Participants identified dominant barriers and facilitators to ABPM and HBPM testing, described the rationale for their testing preference, and believed that they could successfully complete out-of-office testing if testing was recommended by their provider. Our findings may assist in the uptake of recent ACC/AHA hypertension guidelines, which emphasize the importance of out-of-office testing via ABPM or HBPM to exclude white coat hypertension before diagnosis of hypertension, as well as to consider out-of-office testing to identify masked hypertension in some situations.^8,9 As our findings suggest that attitudes and costs for ABPM and HBPM vary between patients, clinicians should discuss the pros and cons of both testing methods to determine each patient’s preferred approach.

SUPPLEMENTARY MATERIAL

Supplementary data are available at American Journal of Hypertension online.

DISCLOSURE

The authors declared no conflict of interest.