Abstract
Objectives:
Optimal hypertension (HTN) control is critical for reducing cardiovascular risk. National quality measures and clinical guidelines for HTN define the most recent BP reading of ≥140/90 mmHg during the performance year as uncontrolled. In the current study, we aim to improve and standardize HTN management and control through process improvement cycles in an Academic outpatient primary care setting.
Methods:
Using our outpatient database, we first identified a sample of Medicare beneficiaries with HTN determined to be uncontrolled during performance years 2023 and 2024, and performing root-case analyses to find any contributing factors, and develop a strategy for improving HTN control and quality metrics.
Results:
A lack of repeat BP measurement and inadequate follow-up were found to be the major factors contributing to uncontrolled BP. Home Blood Pressure Monitoring (HBPM) with timely follow-up was tested as a potential opportunity for improving HTN quality metrics in these patients. Device validation showed that 40 of 42 home BP monitors provided accurate readings. Subsequently, 38 BP uncontrolled patients were engaged through home or office BP assessments. After 2 weeks, 25 of 38 (66%) patients achieved Medicare-defined BP controlled, including 10 through HBPM alone, 8 with follow up during an office visit. Thirteen patients were still BP uncontrolled with a relative risk (RR) of 0.34 (95% CI: 0.22-0.52, P < .001).
Conclusion:
These results support HBPM together with close follow-up as an effective approach to reduce the risk of uncontrolled hypertension and associated noncompliance in value-based care reporting.
Keywords
Introduction
Hypertension (HTN) is a major risk factor for heart disease and stroke, and the global burden of HTN is high. 1 The American Medical Association (AMA) MAP Framework is a practical model that summarizes best practices in 3 intuitive domains for the management of hypertension: Measure accurately, Act rapidly, and Partner with patients. 2 Key approaches that improve HTN control include many aspects: improving social determinants of health, accurate BP measurement and increased use of home blood pressure monitoring (HBPM), lifestyle modification strategies, standardized treatment protocols using team-based care, improved medication acceptance and adherence, continuous quality improvement (QI), financial strategies that sustain the implementation of effective treatment strategies, and large-scale dissemination and implementation. 3
HTN control in the US is still suboptimal with control rate of about 66% in 2023 with criteria of <140/90 (https://data.hrsa.gov/topics/health-centers/hypertension-control). Optimal BP control faces multiple barriers, including (1) patient-level barriers such as medication adherence, health literacy, social economic factors, behavior factors, cognitive impairment; (2) provider-level barriers such as clinical inertia, time constraints, lack of team-based care and documentation issues; (3) system-level barriers such as fragmented care without effective communication between providers, electronic health record (EHR) limitations ad quality metric misalignment; and (4) measurement and reporting barriers such as HTN with white-coat effect or lack of HBPM device. 3
Medicare uses quality metrics to evaluate and improve the effectiveness, safety, and equity of care provided to beneficiaries across various value-based care programs (https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2024_Measure_236_MedicarePartBClaims.pdf). Medicare also uses quality metrics to evaluate how well healthcare providers manage hypertension in their patient populations with adults aged 18 to 85 with a diagnosis of essential hypertension. The most recent BP reading <140/90 mmHg during a performance year demonstrates HTN control and is considered compliant, otherwise a reading of ≥140/90 mmHg is defined as BP uncontrolled. Currently this group of patients defined as “Medicare hypertension noncompliant” has not been characterized including its risk and contributing factors; in addition, no specific approaches have been studied to improve their quality metrics and noncompliance, even though there is a significant amount of literature on improving BP control in general hypertension patients.2,4,5
Given the importance of BP control in patients with hypertension, we have implemented a series of quality improvement initiatives aimed at enhancing HTN control in an outpatient clinic setting. These process improvement initiatives were orchestrated through a health system-level Hypertension Clinical Steering Committee with stakeholders from clinical practices, network leadership, Information Technology, and quality professionals. We conducted a targeted analysis of Medicare beneficiaries with HTN uncontrolled with the specific objective to assess risk and to identify opportunities for intervention and improvement. This included evaluating the accuracy of home BP devices and assessing the impact of patient engagement in self-measured blood pressure (SMBP) monitoring or HBPM combined with close clinical follow-up.
Methods
Approval of QI Projects
According to Medicare quality metrics, BP control in HTN patients is defined as having a most recent BP reading of <140/90 mmHg. To identify potential areas for improvement in hypertension control, 3 QI projects were proposed stepwise based on Deming’s system for data-driven quality improvement, and approved by our outpatient medical director: (1) identification of opportunities to improve hypertension control, approved in March 2024; (2) implementing SMBP using standardized home monitor validation in primary care, approved in December 2024; and (3) improving HTN control by follow-up communications after elevated BP during a patient visit, approved in June 2025. The projects aimed to explore contributing factors to uncontrolled BP and to identify actionable opportunities for intervention and improve quality care.
Identification of Opportunities for Optimal BP Control Among HTN Patients with Medicare Beneficiaries Classified as BP Uncontrolled
We conducted a retrospective chart review of Medicare beneficiaries flagged as HTN and BP uncontrolled at the conclusion of calendar years 2023 and 2024 in our Academic medical institution. Specific areas of focus included: (1) verification of BP measurement accuracy: assessment of whether repeat BP measurements were performed to confirm initial readings; (2) severity stratification of BP elevation: categorization of SBP levels into ranges (140-145 mmHg, 146-150 mmHg, and >150 mmHg) to evaluate the degree of uncontrolled BP; (3) availability of HBPM: determination of whether patients had access to HBPM to address potential white-coat HTN or HTN with white-coat effect; (4) provider response to elevated BP: evaluation of whether hypertension was appropriately addressed during clinical encounters, with attention to possible provider inertia; (5) guideline-concordant follow-up: review of whether follow-up care was initiated in accordance with established hypertension management guidelines; (6) subspecialty variation: identification of particular subspecialties where additional efforts may be needed to improve BP control; (7) practice-level variation: analysis of whether specific practice locations demonstrated a need for targeted HTN management interventions.
The chart review was conducted collaboratively by a medical attending, internal medicine residents, and a Clinical Integrated Network (CIN) quality manager. Data extraction via our electronic health records and analyses were performed by the CIN quality manager to identify systemic and provider-level opportunities for improving hypertension control among Medicare patients.
Assessment of Home BP Device Accuracy
In accordance with the 2025 Hypertension Guidelines, oscillometric BP monitors that automatically record measurements at preset intervals are preferred over manual devices due to their consistency and reduced observer variability.6,7 Clinically validated devices such as those listed on ValidateBP.org demonstrate high accuracy, typically within ±5 mmHg of professional-grade sphygmomanometers.
To ensure reliability of SMBP data, patients’ home BP monitors were evaluated in-office using protocols endorsed by the American Heart Association (AHA) and American Medical Association (AMA) (targetbp.org). Clinical staff received standardized in-service training to ensure uniformity in device validation procedures (see appendix for BP device accuracy validation protocol). 8
Integration of HBPM and Timely Office Follow-Up to Capture Accurate BP Measurements
To enhance the accuracy of BP assessment and support hypertension management, both home BP readings and prompt office-based follow-up were utilized. In June 2025, a list of Medicare patients identified as BP uncontrolled based on quality measure definitions was provided by the Clinical Integrated Network (CIN) quality manager. These patients were attributed to 2 primary care providers. Following identification, patients were contacted via telephone. If direct communication was unsuccessful, secure messages were sent through the electronic patient portal. Patients were asked to either report their home BP readings or schedule an in-office BP evaluation. BP data were subsequently collected through the following modalities: Patient-reported home BP readings submitted via phone or portal; and In-office BP measurements obtained during dedicated visits or as part of routine clinical follow up appointments. All BP readings were documented within a 2-week window following initial patient outreach. This dual approach with leveraging HBPM and timely clinical follow-up enabled a more comprehensive and representative assessment of patients’ BP control status in real-world settings. The relative risk of BP non-compliance was calculated using Chi-squared test between after and before intervention.
Results
Potential Opportunities for Improvement in BP Management
A retrospective analysis was initially conducted on Medicare beneficiaries with HTN identified as BP uncontrolled during performance years (PY) 2023 and 2024 for our primary care clinic in an academic setting. We have found that BP uncontrolled rates were 19.6% in 2023 and 17.4% in 2024. The objectives were to identify systemic and clinical gaps contributing to suboptimal BP control and to highlight actionable opportunities for improvement.
Key findings from Table 1 include the following:
Lack of repeat BP measurement: 90% of patients had no documented repeat BP measurement despite an initially elevated reading. This suggests a missed opportunity to confirm BP elevation and reduce measurement error.
Limited access to home BP monitoring: 77% of patients did not have a home BP monitor.
Inadequate follow-up: 82% of BP uncontrolled patients lacked appropriate follow-up appointments aligned with guideline-recommended intervals for hypertension management.
Marginal elevations in SBP: A substantial proportion of patients had systolic BP values within 5 mmHg of the control threshold, indicating that minor interventions could potentially bring many patients into compliance.
HTN not addressed during visits: Despite elevated office BP readings, HTN was not addressed in 61% of patients, suggesting possible provider inertia, competing clinical priorities or providers think patient’s BP is controlled at home but failed to document.
Potential Opportunities for Improving Hypertension Control Among Medicare Beneficiaries With Uncontrolled Hypertension.
Key Areas for Improving BP Control
An analysis of Medicare beneficiaries flagged for BP uncontrolled revealed key areas for improvement in hypertension management. The most prominent gaps identified were the lack of home BP monitoring and insufficient follow-up care.
From Table 1, clinical intervention defined as either lifestyle modification or antihypertensive medication adjustment was documented in 39% of cases. However, only 18% of patients received follow-up appointments consistent with guideline-recommended intervals. Notably, in 61% of encounters, elevated BP readings were not addressed by the provider. Potential contributing factors include acute clinical events during the visit such as urgent care visits, missed doses of antihypertensive medications, or HTN with white-coat effect, where office BP readings may not reflect true home BP control.
These findings underscore the importance of integrating SMBP monitoring and timely follow-up to more accurately assess and manage hypertension, in alignment with the 2025 hypertension guidelines. 9
Assessment of Home BP Device Accuracy
To increase the access to home BP monitoring, we first checked its accuracy among our patients. A total of 42 patients underwent in-office evaluation of their personal home BP monitors at 1 clinical site. The assessment was conducted by trained nursing and medical assistant staff who had received standardized in-service training, as outlined in appendix for BP device accuracy validation protocol. In addition to verifying device accuracy, the encounter served as an opportunity to educate patients on proper usage techniques to ensure reliable SMBP readings. Of the 42 devices tested, 40 (95%) demonstrated readings within the acceptable accuracy range when compared to clinic-standard measurements. The 2 devices that failed validation were notably outdated, with both patients unable to recall the date of purchase, suggesting prolonged use beyond the recommended lifespan of consumer-grade BP monitors. These findings support the reliability of most commercially available home BP devices when used appropriately. They also reinforce the feasibility of incorporating SMBP into routine hypertension management, consistent with current clinical guidelines.
Intervention and Follow-Up Strategy
Following confirmation of device accuracy, we then implemented a targeted outreach initiative to reassess BP control among patients previously identified as uncontrolled. A list of 40 patients was provided by the Clinical Integrated Network (CIN) quality manager, representing patients from 2 primary care providers.
Patients were contacted via telephone or secure portal messaging. Those without a home BP monitor were encouraged to acquire a validated device from the ValidateBP.org list. Patients unable to obtain a device were invited to the clinic for BP measurement. After a 2-week follow-up period from intervention, BP control was reassessed using 3 data sources (Table 2): (1) home BP readings: 26% (10 out of 38) of patients achieved Medicare BP compliance based on SMBP; (2) follow-up office visits: 21% (8 out of 38 patients) demonstrated BP compliance; and (3) subsequent electronic medical record (EMR) documentation: 18% (7 out of 38 patients) showed BP control in later clinical encounters that we were not aware of.
BP Compliance After 2-weeks Intervention.
The relative risk of non-compliance RR = 0.34 (95% CI: 0.22-0.52, P < .001). It was calculated using Chi-squared test between after and before the intervention.
Two patients were excluded from the analysis on the basis of diagnoses, including frailty, that are specifically excluded under Medicare eligibility criteria. Overall, 66% of the previously BP uncontrolled patients achieved BP control through this intervention. The relative risk (RR) for Medicare BP uncontrolled was reduced at 0.34 which is statistically significant reduction (95% CI: 0.22-0.52, P < .001) compared to before intervention. This result showed that the approach of using HBPM together with close follow-up can effectively improve HTN quality metrics.
Discussion
Our study showed a limited access to home BP monitoring, with 77% of patients in PY2023-2024 without a home BP monitor, raising concerns about the accuracy and representativeness of clinic-based BP readings alone. Our study also showed inadequate follow-up. Analyses show that 82% of BP uncontrolled patients lacked appropriate follow-up appointments aligned with guideline-recommended intervals for hypertension management. Collectively, these findings underscored a significant opportunity to improve BP control metrics by implementing SMBP monitoring and ensuring timely, guideline-concordant follow-up. This approach aligns with the 2025 hypertension management guidelines and supports more accurate assessment and intervention in real-world settings. Providers will be more confident adjusting medication if the BP readings they receive are reliable and accurately reflect patients’ home BP readings.
This analysis has demonstrated the substantial risk of uncontrolled BP for Medicare patients with HTN and highlighted the effectiveness of combining HBPM with timely office-based follow-up in improving HTN control. Among patients previously classified as BP uncontrolled under Medicare quality metrics, we have showed significant risk reduction using this approach (RR = 0.34, 95% CI: 0.22-0.52, P < .001). The high accuracy of validated home BP devices and the ease of patient engagement make HBPM a practical and scalable alternative to gold standard ambulatory blood pressure monitoring (ABPM) in most outpatient settings.
From 2025 HTN guideline, among adults with suspected hypertension, out-of-office BP measurements by either ABPM (Ambulatory BP monitoring) or HBPM (Home BP monitoring) are recommended to confirm the diagnosis of hypertension. In adults who are taking anti-hypertensive medication, HBPM is recommended for monitoring the titration of BP-lowering medication, along with cointerventions such as patient education, telehealth counseling, and clinical interventions.9,10 With the increased inconsistency of office and out-of-office BP readings, more attention is paid to HBPM, which is sometimes called SMBP (Self-Measured Blood Pressure). Office BP readings may be affected by factors such as acute illness, white-coat effect, recent missed medication, or situational stress, resulting in limited reliability for clinical decision-making.
HBPM provides multiple readings over time, allowing for a more accurate representation of a patient’s true BP profile with stronger association with CVD risk than an office BP.11-13 It is also useful in identifying white-coat HTN, HTN with white-coat effect, and masked HTN, which can result in inappropriate management if not recognized. While ABPM is the gold standard for out-of-office measurement, SMBP is often more practical and accessible in routine practice.
Systemic challenges in hypertension management were also identified, including the lack of repeat BP documentation following elevated readings, limited access to home BP monitors, and inadequate scheduling of follow-up visits. Despite these barriers, over 60% of patients achieved BP control within 2 weeks when HBPM was implemented alongside structured clinical follow-up, demonstrating the potential impact of targeted interventions.
Clinicians often hesitate to modify antihypertensive therapy based on a single elevated office BP reading due to concerns about transient factors such as acute illness, medication nonadherence, or HTN with white coat effect. However, the integration of SMBP data into clinical decision-making enables more confident, guideline-concordant treatment adjustments, thereby improving both patient outcomes and compliance with quality measures.
In the current exploratory study, we have demonstrated a practical approach that incorporating routine HBPM together with close follow-up can significantly improve HTN quality metrics and optimal BP control. This is the proof-of-concept intervention, we have expanded its use in a wider patient population in our clinic.
This Study Also Provides Significant Clinical Implications for HTN Outpatient Care
Conclusion
This study has demonstrated that major contributing factors for uncontrolled hypertension in Medicare patients include a lack of home BP monitoring and timely follow-up. A practical strategy using structured outreach, combined with home BP monitoring and timely follow-up, can significantly improve the identification of true BP control status and enhances compliance with Medicare hypertension quality metrics. Further studies with a larger patient population are needed to confirm the effectiveness of the approach.
This study has its limitations: this is a relatively small study. However, the intervention reached a statistically significant outcome. Not every patient can afford a home BP device. However, patients can borrow home BP devices from local libraries. Currently, Medicare does not cover home BP devices. In NY state, Medicaid covers home BP devices though requiring prior authorization to justify the equipment especially if it needs replacement.
Footnotes
Appendix
Acknowledgements
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Ethical Considerations
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Consent to Participate
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Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Available upon request
Any Other Identifying Information Related to the Authors and/or Their Institutions,Funders,Approval Committees,etc,that Might Compromise Anonymity
None