Background: Despite the high prevalence of blood pressure (BP) measurement errors in the outpatient setting, little is known about why primary care clinics struggle to achieve consistently accurate BP measurements in routine practice. We investigated barriers affecting measurement of BP for adult patients in primary care. Methods: We conducted a qualitative evaluation in 6 adult primary care clinics. BP measurement was observed during 54 routine patient encounters. Six managers completed semistructured interviews and 18 clinical staff members participated in focus group discussions. We used an inductive, data-driven approach to identify and organize findings into cohesive, overarching themes describing factors affecting BP measurement. Results: Observed errors in BP measurement spanned the entire spectrum of steps required to obtain BP properly. Barriers to proper BP measurement were related to staff knowledge and behavior (inadequate knowledge, training, and feedback); workflow constraints (need to multitask, inadequate time); and equipment issues (BP monitors, seating). Patient characteristics and behavior also affected BP measurement. Conclusions: Correct measurement of BP is affected by a wide range of factors and is challenging to accomplish consistently in primary care. These findings may inform the design of performance improvement programs to maximize the quality of BP measurement in the outpatient setting.

Background Diabetes mellitus can lead to severe and debilitating foot complications, such as infections, ulcerations, and amputations. Despite substantial progress in diabetes care, foot disease remains a major challenge in managing this chronic condition that causes serious health complications worldwide. Objective The primary aim of this study was to examine the feasibility and usability of a telehealth program focused on preventive diabetes foot care. A secondary aim was to descriptively measure self-reported changes in diabetes knowledge, self-care, and foot care behaviors before and after participating in the program. Methods The study used a single-arm, pre-post design in 2 large family medical practice clinics in Texas. Participants met individually with the nurse practitioner once a month for 3 months using synchronous telehealth videoconferencing. Each participant received diabetes foot education guided by the Integrated Theory of Health Behavior Change. Feasibility was measured with rates of enrollment and program and assessment completion. Usability was measured with the Telehealth Usability Questionnaire. Diabetes knowledge, self-care, and foot care behaviors were measured with validated survey instruments at baseline, 1.5 months, and 3 months. Results Of 50 eligible individuals, 39 (78%) enrolled; 34 of 39 (87%) completed the first videoconference and 29 of 39 (74%) completed the second and third videoconferences. Of the 39 who consented, 37 (95%) completed the baseline assessment; 50% (17/34) of those who attended the first videoconference completed the assessment at 1.5 months, and 100% (29/29) of those who attended the subsequent videoconferences completed the final assessment. Overall, participants reported a positive attitude toward the use of telehealth, with a mean Telehealth Usability Questionnaire score of 6.24 (SD 0.98) on a 7-point scale. Diabetes knowledge increased by a mean of 15.82 (SD 16.69) points of 100 (P<.001) from baseline to 3 months. The values for the Summary of Diabetes Self-Care Activities measure demonstrated better self-care, with participants performing foot care on average 1.74 (SD 2.04) more days per week (P<.001), adhering to healthy eating habits on average 1.57 (SD 2.12) more days per week (P<.001), and being physically active on average 1.24 (SD 2.21) more days per week (P=.005). Participants also reported an improvement in the frequency of foot self-examinations and general foot care behaviors. The mean scores for foot care increased by a mean of 7.65 (SD 7.04) points (scale of 7 to 35) from baseline to 3 months postintervention (P<.001). Conclusions This study demonstrates that a nurse-led telehealth educational program centered on diabetes foot care is feasible, acceptable, and has the potential to improve diabetes knowledge and self-care, which are precursors to preventing debilitating foot complications.

BACKGROUND Diabetes mellitus can lead to severe and debilitating foot complications, such as infections, ulcerations, and amputations. Despite substantial progress in diabetes care, foot disease remains a major challenge in managing this chronic condition that causes serious health complications worldwide. OBJECTIVE The primary aim of this study was to examine the feasibility and usability of a telehealth program focused on preventive diabetes foot care. A secondary aim was to descriptively measure self-reported changes in diabetes knowledge, self-regulation, and foot care behaviors before and after participating in the program. METHODS The study used a single-arm, pre-post design in two large family medical practice clinics in Texas. Participants met individually with the nurse practitioner once a month for 3 months using synchronous telehealth videoconferencing. Each participant received diabetes foot education guided by the Integrated Theory of Health Behavior Change. Feasibility was measured with rates of enrollment and program and assessment completion. Usability was measured with the Telehealth Usability Questionnaire (TUQ). Diabetes knowledge, self-regulation, and foot care were measured with validated survey instruments at baseline, 1.5 months, and 3 months. RESULTS Of 50 eligible individuals, 39 (78%) enrolled; 34/39 (87%) completed the first videoconference, and 29/39 (74%) completed the second and third videoconferences. Of the 39 consented, 37 (95%) completed the baseline assessment; 50% (17/34) of those who attended the first videoconference completed the assessment at 1.5 months, and 100% (29/29) of those who attended the subsequent videoconferences completed the final assessment. Overall, participants reported a positive attitude toward the use of telehealth, with a mean TUQ score of 6.24 (SD = 0.98) on a 7-point scale. At baseline, the mean diabetes knowledge score was 70.48 (SD = 17.86) out of 100. At 1.5 months and 3 months, the mean score was 75.92 (SD = 15.81) and 83.89 (SD = 10.70), respectively. The values for Summary of Diabetes Self-Care Activities demonstrated better self-regulation, with an increase in the number of days out of the week (d/w) that participants adhered to foot care before compared to after participating in the telehealth program (+1.71 d/w), healthy eating habits (+1.4 d/w), and physical activity recommendations (+1.13 d/w). The frequency of self-reported foot examination and care behaviors also improved. Out of possible scores from 7 to 35, the mean scores for foot care increased from 17.75 (SD = 7.42) at baseline to 25.46 (SD = 6.20) at 3 months. CONCLUSIONS This study demonstrates that a nurse-led telehealth educational program centered on diabetes foot care is feasible, acceptable, and has the potential to improve diabetes knowledge and self-regulation that are precursors to preventing debilitating foot complications.

Diabetes self-management is a complex process and central to well-being of patients with this chronic disorder. A patient-centered telehealth program may potentially meet needs of those in underserved populations to reduce socioeconomic disparities. Achieving this goal requires a focused concentration on health behaviors and practices of individuals in underserved populations.