Perceptions of Responsibilities by Primary Care Staff in a Patient-Centered Medical Home.

OBJECTIVE: To examine the extent to which Veterans Health Administration (VHA) Patient-Aligned Care Team (PACT) members have a shared understanding/ agreement upon and enact responsibilities within the team. BACKGROUND: The PACT model focuses on team-based care management. However, lack of a shared understanding of team-based care management roles and responsibilities makes system-wide implementation a challenge. METHODS: Quantitative and qualitative analysis of national survey data collected in 2022 from primary care personnel working in a VHA-affiliated primary care facility. RESULTS: Significant discrepancies exist in responses about what core team members say they do and what others perceive they should be doing, indicating either a lack of agreement, knowledge, or training about what core team members should do. CONCLUSIONS: Successful implementation of a team-based model requires adequate support and training for teamwork including shared mental models to work according to their clinical competency. Clear guidance and communication of expectations are critical for role clarity.

Implementation of Video Blood Pressure Visits in the Veterans Health Administration.

Introduction: Almost half of veterans (44.6%) seen in the U.S. Department of Veterans Affairs outpatient setting are diagnosed with hypertension (HTN). Because of the widespread nature of HTN, use of virtual visits has the potential to improve blood pressure (BP) management. This evaluation assessed the effectiveness of video blood pressure visits (VBPVs) in the management of HTN in veterans enrolled in Veterans Health Administration primary care. Methods: The program was implemented within the existing veteran-centered medical home. VBPVs are scheduled where the nurse observes veterans taking their BP and provides teaching or counseling. A national training curriculum was delivered to local nurse champions through Microsoft Teams. We analyzed improvement in BP over a 2-year period. We also captured actions taken by nurses during the VBPV by searching the electronic notes. Ratings of training and comments were summarized using feedback forms completed after training. Results: In total, 81,476 veterans participated in VBPVs over 2 years. Of those, 44,682 veterans had an existing ICD-10 code related to HTN. Of the 18,078 veterans who had a pre- and post-VBPV BP, the average change to systolic measurement was -10.6 mm Hg (range -82 to 78). Average change to diastolic measurement was -4.61 mm Hg (range -59 to 55). Most interventions addressed medication management (77%). Nurses' evaluations of the program were positive. Conclusions: Video visits provide reliable and convenient veteran-centered care. Such visits enable care when unanticipated interruptions occur such as the coronavirus disease 2019 pandemic. In addition to medication management, nurse-led interventions such as counseling on lifestyle changes can be effective in HTN management.

Decision-Making Involvement, Self-Efficacy, and Transition Readiness in Youth With Sickle Cell Disease.

BACKGROUND: Transition to adult healthcare is a critical time for adolescents and young adults (AYAs) with sickle cell disease, and preparation for transition is important to reducing morbidity and mortality risks associated with transition. OBJECTIVE: We explored the relationships between decision-making involvement, self-efficacy, healthcare responsibility, and overall transition readiness in AYAs with sickle cell disease prior to transition. METHODS: This cross-sectional, correlational study was conducted with 50 family caregivers-AYAs dyads receiving care from a large comprehensive sickle cell clinic between October 2019 and February 2020. Participants completed the Decision-Making Involvement Scale, the Sickle Cell Self-Efficacy Scale, and the Readiness to Transition Questionnaire. Multiple linear regression was used to assess the relationships between decision-making involvement, self-efficacy, healthcare responsibility, and overall transition readiness in AYAs with sickle cell disease prior to transition to adult healthcare. RESULTS: Whereas higher levels of expressive behaviors, such as sharing opinions and ideas in decision-making, were associated with higher levels of AYA healthcare responsibility, those behaviors were inversely associated with feelings of overall transition readiness. Self-efficacy was positively associated with overall transition readiness but inversely related to AYA healthcare responsibility. Parent involvement was negatively associated with AYA healthcare responsibility and overall transition readiness. DISCUSSION: While increasing AYAs' decision-making involvement may improve AYAs' healthcare responsibility, it may not reduce barriers of feeling unprepared for the transition to adult healthcare. Facilitating active AYA involvement in decision-making regarding disease management, increasing self-efficacy, and safely reducing parent involvement may positively influence their confidence and capacity for self-management.

Delegation of Work Within a Patient-Centered Medical Home.

OBJECTIVE: The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. BACKGROUND: Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. METHODS: This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. RESULTS: Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. CONCLUSIONS: Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans.

Purpose: This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans. Methods: Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations. Results: Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR. Conclusions: The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.

Assessing telehealth interventions for physical activity and sedentary behavior self-management in adults with type 2 diabetes mellitus: An integrative review.

Type 2 diabetes is a chronic disease, requiring lifestyle management to prevent chronic complications. Increasing physical activity and reducing sedentary behavior are integral to maintaining glycemic control. The purpose of this study was to (1) appraise and synthesize the literature about physical activity and sedentary behavior intervention delivery via telehealth strategies in adults with type 2 diabetes mellitus and (2) to evaluate what is known about the effectiveness of such interventions on physical activity, sedentary behavior, and glycemic control. An integrative literature review was carried out, including the electronic databases PubMed, CINAHL, and PsychInfo, searching for articles published within the past 10 years, meeting specified inclusion and exclusion criteria, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Seventeen studies were included. Significant improvements in physical activity and sedentary behavior were identified in web and mobile phone-based interventions. Modest improvements in glycemic control were reported. Theoretical framework use and integration was limited, and intervention length and follow-up varied greatly in the studies reviewed. Outcomes were measured using both self-report and objective measures, but objective measures were used less frequently. Further, few studies have been conducted in the United States or in rural populations. Web and mobile phone-based telehealth interventions to increase physical activity, reduce sedentary behaviors, and improve glycemic control have been supported by the literature. A need exists for future studies that are theory-driven, include dose-specific measures, self-report and objective measures, and long-term follow-up. Examining intervention effects in rural populations is needed.

Adherence to the Use of Home Telehealth Technologies and Emergency Room Visits in Veterans with Heart Failure.

Background: Prior studies have posited poor patient adherence to remote patient monitoring as the reason for observed lack of benefits. Introduction: The purpose of this study was to examine the relationship between average adherence to the daily use of home telehealth (HT) and emergency room (ER) visits in Veterans with heart failure. Materials and Methods: This was a retrospective study using administrative data of Veterans with heart failure enrolled in Veterans Affairs (VA) HT Program in the first half of 2014. Zero-inflated negative binomial regression was used to determine which predictors affect the probability of having an ER visit and the number of ER visits. Results: The final sample size was 3,449 with most being white and male. There were fewer ER visits after HT enrollment (mean ± standard deviation of 1.85 ± 2.8) compared with the year before (2.2 ± 3.4). Patient adherence was not significantly associated with ER visits. Age and being from a racial minority group (not white or black) and belonging to a large HT program were associated with having an ER visit. Being in poorer health was associated with higher expected count of ER visits. Discussion: Subgroups of patients (e.g., with depression, sicker, or from a racial minority group) may benefit from added interventions to decrease ER use. Conclusions: This study found that adherence was not associated with ER visits. Reasons other than adherence should be considered when looking at ER use in patients with heart failure enrolled in remote patient monitoring programs.

Why patients stop using their home telehealth technologies over time: Predictors of discontinuation in Veterans with heart failure.

BACKGROUND: Daily use of home telehealth (HT) technologies decreases over time. Barriers to continued use are unclear. PURPOSE: To examine predictors of drop-out from HT in Veterans with heart failure. METHODS: Data for Veterans with heart failure enrolled in the Veterans Affairs HT Program were analyzed using a mixed effects Cox regression model to determine risk of dropping-out over a 1-year period. FINDINGS: Older (hazard ratio [HR] 1.01), sicker (prior hospital readmission [HR 1.39]), higher probability of hospital admission/death [HR 1.23], functional impairments [1.14]) and white Veterans (compared to black; HR 1.41) had higher risk of drop-out in HT Programs. Users of VA's online patient portal (HR 0.90) had lower risk of drop-out. DISCUSSION: Older and sicker patients are at most risk of stopping HT use, yet use of a patient portal shows promise in improving continued use. Interventions targeting patients at high risk for HT discontinuation are needed to promote ongoing engagement.

Care Management and Care Coordination Within a Patient-Centered Medical Home.

OBJECTIVE: The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH). BACKGROUND: The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care. METHODS: A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted. RESULTS: Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems. CONCLUSIONS: Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Making sense of blood glucose data and self-management in individuals with type 2 diabetes mellitus: A qualitative study.

AIMS AND OBJECTIVES: To describe individuals' with type 2 diabetes mellitus sense-making of blood glucose data and other influences impacting self-management behaviour. BACKGROUND: Type 2 diabetes mellitus prevalence is increasing globally. Adherence to effective diabetes self-management regimens is an ongoing healthcare challenge. Examining individuals' sense-making processes can advance staff knowledge of and improve diabetes self-management behaviour. DESIGN: A qualitative exploratory design examining how individuals make sense of blood glucose data and symptoms, and the influence on self-management decisions. METHODS: Sixteen one-on-one interviews with adults diagnosed with type 2 diabetes mellitus using a semi-structured interview guide were conducted from March-May 2018. An inductive-deductive thematic analysis of data using the Sensemaking Framework for Chronic Disease Self-Management was used. The consolidated criteria for reporting qualitative research (COREQ) checklist were used in completing this paper. RESULTS: Three main themes described participants' type 2 diabetes mellitus sense-making and influences on self-management decisions: classifying blood glucose data, building mental models and making self-management decisions. Participants classified glucose levels based on prior personal experiences. Participants learned about diabetes from classes, personal experience, health information technology and their social network. Seven participants expressed a need for periodic refreshing of diabetes knowledge. CONCLUSION: Individuals use self-monitored glucose values and/or HbA1C values to evaluate glucose control. When using glucose values, they analyse the context in which the value was obtained through the lens of personal parameters and expectations. Understanding how individuals make sense of glycaemic data and influences on diabetes self-management behaviour with periodic reassessment of this understanding can guide the healthcare team in optimising collaborative individualised care plans. RELEVANCE TO CLINICAL PRACTICE: Nurses must assess sense-making processes in self-management decisions. Periodic "refresher" diabetes education may be needed for individuals with type 2 diabetes mellitus.

Cardiac Rehabilitation During COVID-19 Pandemic: Highlighting the Value of Home-Based Programs.

Cardiac rehabilitation (CR) is a class I treatment for cardiovascular disease, however, underutilization of these services remains. Home-based CR (HBCR) models have been implemented as a potential solution to addressing access barriers to CR services. Home-based models have been shown to be effective, however, there continues to be large variation of protocols and minimal evidence of effectiveness in higher risk populations. In addition, lack of reimbursement models has discouraged the widespread adoption of HBCR. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has been present due to decreased availability of on-site services. The COVID-19 pandemic presents a time to highlight the value and experiences of home-based models as clinicians search for ways to continue to provide care. Continued review and standardization of HBCR models are essential to provide care for a wider range of patients and circumstances.

Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management.

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation.

BACKGROUND: There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population. PURPOSE: This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation. METHODS: The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities. RESULTS: Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation. CONCLUSION: This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans.

The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration.

BACKGROUND: Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR. METHODS: This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews. RESULTS: Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites. CONCLUSION: Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.

Taking note: A qualitative study of implementing a scribing practice in team-based primary care clinics.

BACKGROUND: Though much is known about the benefits attributed to medical scribes documenting patient visits (e.g., reducing documentation time for the provider, increasing patient-care time, expanding the roles of licensed and non-licensed personnel), little attention has been paid to how care workers enact scribing as a part of their existing practice. The purpose of this study was to perform an ethnographic process evaluation of an innovative medical scribing practice with primary care teams in Veterans Health Administration (VHA) clinics across the United States. The aim of our study was to understand barriers and facilitators to implementing a scribing practice in primary care. METHODS: At three to six months after medical scribing was introduced, we used semi-structured interviews and direct observations during site visits to five sites to describe the intervention, understand if the intervention was implemented as planned, and to record the experience of the teams who implemented the intervention. This manuscript only reports on semi-structured interview data collected from providers and scribes. Initial matrix analysis based on categories outlined in the evaluation plan informed subsequent deductive coding using the social-shaping theory Normalization Process Theory. RESULTS: Through illustrating the slow accumulation of interactions and knowledge that fostered cautious momentum of teams working to normalize scribing practice in VHA primary care clinics, we show how the practice had 1) an organizing effect, as it centered a shared goal (the creation of the note) between the provider, scribe, and patient, and 2) a generative effect, as it facilitated care workers developing relationships that were both interpersonally and inter-professionally valuable. Based on our findings, we suggest that a scribing practice emphasizes the complementarity of existing professional roles, which thus leverage the interactional possibilities already present in the primary care team. Scribing, as a skill, forged moments of interprofessional fit. Scribing, in practice, created opportunities for interpersonal connection. CONCLUSIONS: Our research suggests that individuals will notice different benefits to scribing based on their professional expectations and organizational roles related to documenting patient visits.

Perception of clinical deterioration cues among medical-surgical nurses.

AIM: To examine medical-surgical nurses' capacity and tendency to perceive cues indicating clinical deterioration and nursing characteristics influencing deterioration cue perception. DESIGN: Cross-sectional, explorative study design. METHODS: Data were collected over 10 weeks between September-November 2017. Medical-surgical nurses completed an online survey consisting of a demographic questionnaire, the Occupational Fatigue, Exhaustion Recovery scale and 50 detection trials. Descriptive statistics and statistical tests were used to describe and interpret data. FINDINGS: A significant association was found between nurses' capacity and tendency to perceive deterioration cues. As nurses' capacity to perceive deterioration cues increased, nurses were more likely to classify patient cues as indicators of deterioration. Fatigue, education, and certification were not identified as characteristics associated with deterioration cue perception. However, experience was observed to significantly influence nurses' capacity to perceive deterioration cues based on levels of skills acquisition. CONCLUSION: Study findings imply that future research should be directed at determining whether other individual factors and organizational system dynamics influence deterioration cue perception. IMPACT: To better understand how nurses perceive deterioration cues, this study integrated concepts from the Situation Awareness model and Signal Detection Theory. Novice, advanced beginner and competent nurses were found to have a lower capacity to perceive deterioration cues compared with proficient and expert nurses. With simulation increasingly being used as a primary teaching modality in nursing, the development of a simulation-based signal detection training intervention may be beneficial in enhancing deterioration cue perception.

Exploring Perceptions of Health Care Providers' Use of Electronic Advance Directive Forms in Electronic Health Records.

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ2[5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.].

The Role of the Electronic Medical Record in the Intensive Care Unit Nurse's Detection of Patient Deterioration: A Qualitative Study.

Failure to detect patient deterioration signals leads to longer stays in the hospital, worse functional outcomes, and higher hospital mortality rates. Surveillance, including ongoing acquisition, interpretation, and synthesis of patient data by the nurse, is essential for early risk detection. Electronic medical records promote accessibility and retrievability of patient data and can support patient surveillance. A secondary analysis was performed on interview data from 24 intensive care unit nurses, collected in a study that examined factors influencing nurse responses to alarms. Six themes describing nurses' use of electronic medical record information to understand the patients' norm and seven themes describing electronic medical record design issues were identified. Further work is needed on electronic medical record design to integrate documentation and information presentation with the nursing workflow. Organizations should involve bedside nurses in the design of handoff formats that provide key information common to all intensive care unit patient populations, as well as population-specific information.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.