A Comparison of the Diagnostic Accuracy of Common Office Blood Pressure Measurement Protocols

Effectiveness of Hypertension Management Strategies in SPRINT-Eligible US Adults: A Simulation Study

BACKGROUND

Despite reducing cardiovascular disease (CVD) events and death in SPRINT (Systolic Blood Pressure Intervention Trial), intensive systolic blood pressure goals have not been adopted in the United States. This study aimed to simulate the potential long-term impact of 4 hypertension management strategies in SPRINT-eligible US adults.

METHODS AND RESULTS

The validated Blood Pressure Control-Cardiovascular Disease Policy Model, a discrete event simulation of hypertension care processes (ie, visit frequency, blood pressure [BP] measurement accuracy, medication intensification, and medication adherence) and CVD outcomes, was populated with 25 000 SPRINT-eligible US adults. Four hypertension management strategies were simulated: (1) usual care targeting BP <140/90 mm Hg (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care), (2) intensive care per the SPRINT protocol targeting BP <120/90 mm Hg (SPRINT intensive), (3) usual care targeting guideline-recommended BP <130/80 mm Hg (American College of Cardiology/American Heart Association usual care), and (4) team-based care added to usual care and targeting BP <130/80 mm Hg. Relative to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, among the 18.1 million SPRINT-eligible US adults, an estimated 138 100 total CVD events could be prevented per year with SPRINT intensive, 33 900 with American College of Cardiology/American Heart Association usual care, and 89 100 with team-based care. Compared with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, SPRINT intensive care was projected to increase treatment-related serious adverse events by 77 600 per year, American College of Cardiology/American Heart Association usual care by 33 300, and team-based care by 27 200.

CONCLUSIONS

As BP control has declined in recent years, health systems must prioritize hypertension management and invest in effective strategies. Adding team-based care to usual care may be a pragmatic way to manage risk in this high-CVD-risk population.

Effectiveness and Cost-Effectiveness of Team-Based Care for Hypertension: A Meta-Analysis and Simulation Study

BACKGROUND

Team-based care (TBC), a team of ≥2 healthcare professionals working collaboratively toward a shared clinical goal, is a recommended strategy to manage blood pressure (BP). However, the most effective and cost-effective TBC strategy is unknown.

METHODS

A meta-analysis of clinical trials in US adults (aged ≥20 years) with uncontrolled hypertension (≥140/90 mm Hg) was performed to estimate the systolic BP reduction for TBC strategies versus usual care at 12 months. TBC strategies were stratified by the inclusion of a nonphysician team member who could titrate antihypertensive medications. The validated BP Control Model-Cardiovascular Disease Policy Model was used to project the expected BP reductions out to 10 years and simulate cardiovascular disease events, direct healthcare costs, quality-adjusted life years, and cost-effectiveness of TBC with physician and nonphysician titration.

RESULTS

Among 19 studies comprising 5993 participants, the 12-month systolic BP change versus usual care was -5.0 (95% CI, -7.9 to -2.2) mm Hg for TBC with physician titration and -10.5 (-16.2 to -4.8) mm Hg for TBC with nonphysician titration. Relative to usual care at 10 years, TBC with nonphysician titration was estimated to cost $95 (95% uncertainty interval, -$563 to $664) more per patient and gain 0.022 (0.003-0.042) quality-adjusted life years, costing $4400/quality-adjusted life year gained. TBC with physician titration was estimated to cost more and gain fewer quality-adjusted life years than TBC with nonphysician titration.

CONCLUSIONS

TBC with nonphysician titration yields superior hypertension outcomes compared with other strategies and is a cost-effective way to reduce hypertension-related morbidity and mortality in the United States.

Cost-Effectiveness of Masked Hypertension Screening and Treatment in US Adults With Suspected Masked Hypertension: A Simulation Study

BACKGROUND

Recent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension.

METHODS

We estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e., office BP 120-129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e., no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events.

RESULTS

Relative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility.

CONCLUSIONS

The results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension.

Comparison of the mean of the first two blood pressure readings with the overall mean of three readings on a single occasion

OBJECTIVE

Guidelines differed on the required number of blood pressure (BP) readings for accurate BP assessment. We, therefore, compared the mean of the first two BP readings with the overall mean of three readings in the diagnosis of hypertension.

METHODS

BP was measured three times consecutively with a 1 min interval using a validated automated electronic BP monitor in volunteers aged at least 18 years. The mean of the first and second BP readings was compared with the mean of the three blood pressure readings for the diagnostic accuracy of hypertension.

RESULTS

Of the 77 520 study participants, 65.2 and 25.2% had a SBP or DBP difference at least 5 mmHg and at least 10 mmHg between the first and second BP readings, respectively. Regardless whether the BP difference between the first two BP readings was at least 5 mmHg or at least 10 mmHg for systolic and diastolic alone or both, significant (P < 0.0001) SBP/DBP differences between the mean of the first two BP readings and the overall mean of three readings were observed with an absolute value up to 1.28/1.11 mmHg. However, the mean of the first two BP readings exhibited good reliability and sufficient agreement in the diagnosis of hypertension with a kappa statistic at least 0.88, except that the difference between the first and second BP readings was at least 10 mmHg for both systolic and diastolic (κ=0.79). The diagnostic accuracy was similar across age quartile, sex, and BP category.

CONCLUSION

Two BP readings may be sufficient, unless the BP difference between the two readings was at least 10 mmHg for both systolic and diastolic.

Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops

BACKGROUND

In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected.

METHODS

A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as <$50 000 and <$150 000 per QALY gained, respectively.

RESULTS

At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, -$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01-0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased.

CONCLUSIONS

Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.

Comparison of multiple blood pressure frequency methods with optimum blood pressure measurement among Iranian individuals

Background:

Proper blood pressure (BP) measurement frequency method is less evaluated to optimize hypertension (HTN) status among different nations due to cultural patience variations. The aim of this study was to compare the first (BP₁), second (BP₂), and the mean of first and second (BP_1,2) and all the three (BP_1,2,3) with the second and third BP measurements in Iranian individuals.

Materials and Methods:

This cross-sectional study was done on 2264 individuals aged 18 years or more living in Isfahan city, Iran. Their BPs were assessed from right arms by the standard tools and methods after 5 min of rest in a quiet room by a trained staff. The mean second and third readings were considered as reference, and the other aforementioned variables were compared with it.

Results:

The mean age of total population was 40.9 ± 16.1 years (males: 52%). Men had significant higher means of systolic BP (SBP) and diastolic BP (DBP) with any measurement frequency methods than women (P < 0.001 and P = 0.009). Considerable clinical significant (≥5 mmHg) ranges were mostly observed in BP₁ compared with BP_2,3. SBP₂ and DBP₂ indices showed insignificant differences compared with reference mean. Moreover, abnormal BP levels (≥140/90 mmHg) were mostly observed in terms of BP₁ measurement with no remarkable variability in BP₂ reading in comparison to the reference.

Conclusion:

Our considerable data suggested that BP₂ could appropriately categorize BP status similar to BP_2,3 and it may be rational for physicians considering this mean and excluding the first BP measurement as a sole criterion for HTN assessment in Iranian adults. Multiple researches are necessary quantifying appropriate frequencies of BP reading.

Clinic-Based Strategies to Reach United States Million Hearts 2022 Blood Pressure Control Goals

BACKGROUND

The Centers for Disease Control and Prevention's Million Hearts initiative includes an ambitious ≥80% blood pressure control goal in US adults with hypertension by 2022. We used the validated Blood Pressure Control Model to quantify changes in clinic-based hypertension management processes needed to attain ≥80% blood pressure control.

METHODS AND RESULTS

The Blood Pressure Control Model simulates patient blood pressures weekly using 3 key modifiable hypertension management processes: office visit frequency, clinician treatment intensification given uncontrolled blood pressure, and continued antihypertensive medication use (medication adherence rate). We compared blood pressure control rates (using the Seventh Joint National Committee on hypertension targets) achieved over 4 years between usual care and the best-observed values for management processes identified from the literature (1-week return visit interval, 20%-44% intensification rate, and 76% adherence rate). We determined the management process values needed to achieve ≥80% blood pressure control in US adults. In adults with uncontrolled blood pressure, usual care achieved 45.6% control (95% uncertainty interval, 39.6%-52.5%) and literature-based best-observed values achieved 79.7% control (95% uncertainty interval, 79.3%-80.1%) over 4 years. Increasing treatment intensification rates to 62% of office visits with an uncontrolled blood pressure resulted in ≥80% blood pressure control, even when the return visit interval and adherence remained at usual care values. Improving to best-observed values for all 3 management processes would achieve 78.1% blood pressure control in the overall US population with hypertension, approaching the ≥80% Million Hearts 2022 goal.

CONCLUSIONS

Achieving the Million Hearts blood pressure control goal by 2022 will require simultaneously increasing visit frequency, overcoming therapeutic inertia, and improving patient medication adherence. As the relative importance of each of these 3 processes will depend on local characteristics, simulation models like the Blood Pressure Control Model can help local healthcare systems tailor strategies to reach local and national benchmarks.

Automated Office-Based Blood Pressure Measurement: an Overview and Guidance for Implementation in Primary Care

PURPOSE OF REVIEW

The purposes of this study are to review evidence supporting the use of automated office blood pressure (AOBP) measurement and to provide practical guidance for implementing it in clinical settings.

RECENT FINDINGS

Mean AOBP readings correlate with awake ambulatory blood pressure monitor (ABPM) values and predict cardiovascular outcomes better than conventional techniques. However, heterogeneity among readings suggests that AOBP does not replace ABPM. Blood pressure (BP) measurement protocols differ among commonly described AOBP devices, but all produce valid BP estimates. Rest periods should not precede AOBP with BpTRU devices but should occur before use with Omron HEM-907 and Microlife WatchBP Office devices. Attended and unattended AOBP appear to produce similar results. This review also describes a framework to aid AOBP's implementation in clinical practice. Evidence supports AOBP as the preferred method for measuring BP in office settings, but this approach should be a complement to out-of-office measurements, such as self-measured BP monitoring or 24-h ABPM, not a substitute for it.