Evaluation of blood pressure measurement and agreement in an academic health sciences center

Inter-observer reliability and anatomical landmarks for arm circumference to determine cuff size for blood pressure measurement

Accurate arm circumference (AC) measurement is required for accurate blood pressure (BP) readings. Standards stipulate measuring arm circumference at the midpoint between the acromion process (AP) and the olecranon process. However, which part of the AP to use is not stipulated. Furthermore, BP is measured sitting but arm circumference is measured standing. We sought to understand how landmarking during AC measurement and body position affect cuff size selection. Two variations in measurement procedure were studied. First, AC was measured at the top of the acromion (TOA) and compared to the spine of the acromion (SOA). Second, standing versus seated measurements using each landmark were compared. AC was measured to the nearest 0.1 cm at the mid-point of the upper arm by two independent observers, blinded from each other's measurements. In 51 participants, the mean (±SD) mid-AC measurement using the anchoring landmarks TOA and SOA in the standing position were 32.4 cm (±6.18) and 32.1 cm (±6.07), respectively (mean difference of 0.3 cm). In the seated position, mean arm circumference was 32.2 (±6.10) using TOA and 31.1 (±6.03) using SOA (mean difference 1.1 cm). Kappa agreement for cuff selection in the standing position between TOA and SOA was 0.94 (p < 0.001). The landmark on the acromion process can change the cuff selection in a small percentage of cases. The overall impact of this landmark selection is small. However, standardizing landmark selection and body position for AC measurement could further reduce variability in cuff size selection during BP measurement and validation studies.

Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults

Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.

Implementing a home-based virtual hypertension programme-a pilot feasibility study

INTRODUCTION

Implementing a health system-based hypertension programme may lower blood pressure (BP).

METHODS

We performed a randomized, controlled pilot study to assess feasibility, acceptability, and safety of a home-based virtual hypertension programme integrating evidence-based strategies to overcome current barriers to BP control. Trained clinical pharmacists staffed the virtual collaborative care clinic (vCCC) to remotely manage hypertension using a BP dashboard and phone "visits" to monitor BP, adherence, side effects of medications, and prescribe anti-hypertensives. Patients with uncontrolled hypertension were identified via electronic health records. Enrolled patients were randomized to either vCCC or usual care for 3 months. We assessed patients' home BP monitoring behaviour, and patients', physicians', and pharmacists' perspectives on feasibility and acceptability of individual programme components.

RESULTS

Thirty-one patients (vCCC = 17, usual care = 14) from six physician clinics completed the pilot study. After 3 months, average BP decreased in the vCCC arm (P = 0.01), but not in the control arm (P = 0.45). The vCCC participants measured BP more (9.9 vs. 1.2 per week, P < 0.001). There were no intervention-related adverse events. Participating physicians (n = 6), pharmacists (n = 5), and patients (n = 31) rated all programme components with average scores of >4.0, a pre-specified benchmark. Nine adaptations in vCCC design and delivery were made based on potential barriers to implementing the programme and suggestions.

CONCLUSION

A home-based virtual hypertension programme using team-based care, technology, and a logical integration of evidence-based strategies is safe, acceptable, and feasible to intended users. These pilot data support studies to assess the effectiveness of this programme at a larger scale.

Low Concordance Between Blood Pressures Measured in Periodic Health Examinations and in a Workplace-Based Hypertension Management Program

Poor adherence to standard protocols of blood pressure (BP) measurement in routine clinical practice leads to higher readings than "research-quality" measurements. Whether this phenomenon exists in periodic health examinations was unknown. We aimed to explore the concordance between BP measurements in periodic health examinations and those measured following a standard measurement protocol. We used data from the Kailuan Study, an ongoing longitudinal cohort study in China, of which participants received biennial health examinations in health management centers. In addition, BPs were measured following standard protocols in a workplace-based hypertension management program nested in the Kailuan Study. We compared BP readings of the same person between the two settings using generalized linear mixed-effects models. A total of 3988 men (the mean age was 44.9 years) had at least two BP measurements both in health examinations and management program with a time interval between the two settings that less than 90 days. The mean systolic blood pressures (SBP) and diastolic blood pressures (DBP) in health examinations were 4.2 (95% CI 3.9-4.5) mm Hg and 3.3 (95% CI 3.1-3.5) mm Hg higher than those in the management program, respectively. Bland-Altman analyses showed the wide agreement intervals ranging from - 27.7- to 36.5-mm Hg for SBP and - 18.3- to 24.7-mm Hg for DBP. In conclusion, BP measurements in periodic health examinations were generally higher than BPs measured following a standard protocol. Our findings highlight the importance of standard BP measurement to avoid overestimation of hypertension prevalence and treatment initiation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-022-00067-w.

Arterial hypertension diagnosis: A problem?

INTRODUCTION

Arterial hypertension (AHT), a leading risk factor in terms of attributable mortality, is a major public health problem, especially for primary care where most patients are diagnosed and followed up. Correct AHT diagnosis requires adequate theoretical knowledge and technical skills in physicians and nurses. The aim of this study was to evaluate the knowledge and skills used in initial AHT diagnosis by health professionals and to describe the factors that contribute to variability.

METHODOLOGY

Cross-sectional observational study in a sample of 385 primary care physicians and nurses recruited in a Catalan health region. Using a validated questionnaire called ARC, we evaluated theoretical knowledge and analysed factors that may contribute to response variability. We also evaluated practical measurement skills using objective structured clinical examination tests.

RESULTS

Medical and nursing primary care professionals had deficient knowledge and skills for initial AHT diagnosis and measurement, despite self-perceiving their knowledge to be sufficient. However, professionals who had received postgraduate or other AHT training in the previous year scored better in the ARC questionnaire.

CONCLUSIONS

The results of this study point to insufficient AHT expertise to ensure quality clinical practice, suggesting that ongoing theoretical and practical training needs to be improved.

Self-reported practices of doctors and nurses for the measurement of blood pressure

BACKGROUND

Hypertension is one of the most common health problems worldwide and can be diagnosed with an accurate blood pressure measurement (BPM). We aim to evaluate the self-reported practices of family physicians and nurses for BPM.

METHODS

This study was conducted in the form of a survey administered through face-to-face interviews with 131 physicians and 371 nurses. The survey included questions about devices, patients, and BPM techniques.

RESULTS

The mean age was 31 ± 7.4 years. The most commonly used device was the aneroid model (47.8%). The majority of participants reported that they had sufficient technical knowledge about the devices (81.1%), and the devices were regularly calibrated (77.5%). Only 44.8% reported that they had asked patients about caffeine or nicotine use. About half of those in both groups (54%) performed BPM only once during a presentation. The most commonly used position during BPM was sitting. BPM was performed mostly on one arm without preference for any side (67.5%). Approximately half of the respondents reported that they performed BPM by actively supporting the arm at the heart level.

CONCLUSION

We found physicians and nurses had lack of adherence to proper techniques related to the use of appropriate positions and other relevant situations that should be considered during BPM. Accurate BPM is the most important factor for proper diagnosis and treatment of hypertension. Thus, BPM should be performed in accordance with the designated guidelines and can be performed with accurate results only as a result of repeated comprehensive training programs.

Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión

La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.

Optimizing observer performance of clinic blood pressure measurement: a position statement from the Lancet Commission on Hypertension Group

High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-to-middle-income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.

Home Blood Pressure Monitoring in Cases of Clinical Uncertainty to Differentiate Appropriate Inaction From Therapeutic Inertia

PURPOSE

Conventional clinic blood pressure (BP) measurements are routinely used for hypertension management and physician performance measures. We aimed to check home BP measurements after elevated conventional clinic BP measurements for which physicians did not intensify treatment, to differentiate therapeutic inertia from appropriate inaction.

METHODS

We conducted a pre and post study of home BP monitoring for patients with uncontrolled hypertension as determined by conventional clinic BP measurements for which physicians did not intensify hypertension management. Physicians were notified of average home BP 2-4 weeks after the initial clinic visit. Outcome measures were the proportion of patients with controlled hypertension using average home BP measurements, changes in hypertension management by physicians, changes in physicians' hypertension metrics, and factors associated with home-clinic BP differences.

RESULTS

Of 90 recruited patients who had elevated conventional clinic BP recordings, 65.6% had average home BP measurements that were <140/90 mm Hg. Physicians changed treatment plans for 61% of patients with average home BP readings of ≥140/90 mm Hg, whereas decisions to not change treatment for the remaining patients were based on contextual factors. Substituting average home BP for conventional clinic BP for 4% of patients from 2 physicians' hypertension registries improved the physicians' hypertension control rates by 3% to 5%. Greater body mass index and increased number of BP medications were associated with home BP measurement ≥140/90 mm Hg. Clinic BP levels did not estimate normal home BP levels.

CONCLUSIONS

Documented home BP in cases of clinical uncertainty helped differentiate therapeutic inertia from appropriate inaction and improved physicians' hypertension metrics.

Dow A. Pharmacist-physician collaborative care model and time to goal blood pressure in the uninsured population

Pharmacist-physician collaborative practice models (PPCPMs) improve blood pressure (BP) control, but their effect on time to goal BP is unknown. This retrospective cohort study evaluated the impact of a PPCPM on time to goal BP compared with usual care using data from existing medical records in uninsured patients with hypertension. The primary outcome was time from the initial visit to the first follow-up visit with a BP <140/90 mm Hg. The study included 377 patients (259 = PPCPM; 118 = usual care). Median time to BP goal was 36 days vs 259 days in the PPCPM and usual care cohorts, respectively (P < .001). At 12 months, BP control was 81% and 44% in the PPCPM and usual care cohorts, respectively (P < .001) and therapeutic inertia was lower in the PPCPM cohort (27.6%) compared with usual care (43.7%) (P < .0001). Collaborative models involving pharmacists should be considered to improve BP control in high-risk populations.

Blood Pressure Measurement Training Program and Adherence of Public Health Nurses to BP Measurement Guidelines

Objective

To compare the level of adherence of public health nurses to BP measurement guidelines based on their knowledge if the guidelines and skills in BP measurement before and after Blood Pressure Measurement Training Program (BPMTP).

Methods

An experimental pre- and post-test design using two-staged cluster randomization was conducted. 118 PHNs (mean age ± 38.45 years, mean years of experience ± 13.45 years; 84.1% women) from six districts in Manila were equally assigned to either the BPMTP group or control group. Structured instruments were used.

Results

Demographic characteristics, current BP measurement practices, and level of adherence to BP measurement guidelines based on knowledge of the guidelines and skills in BP measurement were equivalent in both groups at baseline. Nurses in the BPMTP group showed improved adherence (p=<0.05) compared to nurses in the control group. Both groups did not show significant change in their skill on recording, interpretation, and referral (p=1.000).

Conclusion

This study showed that Blood Pressure Measurement Training Package is feasible in improving adherence of nurses based on their increased knowledge of the BP measurement guidelines and skills in BP measurement. A larger-scale study is warranted to show that BPMTP can potentially improve clinical management of hypertension in public health clinics globally.

Clinical Implications of Different Blood Pressure Measurement Techniques

PURPOSE OF REVIEW

The appropriate treatment targets for individuals with elevated blood pressure (BP) have received increased attention in light of recent clinical trial results. However, it is well known that the method used to measure BP can have a significant impact on the observed BP. In this review, we summarize the existing literature on the impact of BP measurement technique on observed BP readings.

RECENT FINDINGS

Manual BPs obtained in-clinic routinely differ from those obtained using automated devices. Further, clinic-based readings (either manual or automated) typically correlate poorly with readings from ambulatory BP monitoring or home-based devices. However, few studies utilize randomization or sound experimental design to explore differences in BP readings by method or technique. While numerous studies report differences in BP by method, most lack statistical rigor and therefore provide limited insight into the true effect of technique on BP measurements.

The role of the unusual threonine string in the conversion of prion protein

The conversion of normal prion protein (PrP) into pathogenic PrP conformers is central to prion disease, but the mechanism remains unclear. The α-helix 2 of PrP contains a string of four threonines, which is unusual due to the high propensity of threonine to form β-sheets. This structural feature was proposed as the basis for initiating PrP conversion, but experimental results have been conflicting. We studied the role of the threonine string on PrP conversion by analyzing mouse Prnp^a and Prnp^b polymorphism that contains a polymorphic residue at the beginning of the threonine string, and PrP mutants in which threonine 191 was replaced by valine, alanine, or proline. The PMCA (protein misfolding cyclic amplification) assay was able to recapitulate the in vivo transmission barrier between PrP^a and PrP^b. Relative to PMCA, the amyloid fibril growth assay is less restrictive, but it did reflect certain properties of in vivo prion transmission. Our results suggest a plausible theory explaining the apparently contradictory results in the role of the threonine string in PrP conversion and provide novel insights into the complicated relationship among PrP stability, seeded conformational change, and prion structure, which is critical for understanding the molecular basis of prion infectivity.

Orthostatic Circulatory Disorders: From Nosology to Nuts and Bolts

When patients complain of altered consciousness or discomfort in the upright posture, either relieved by recumbency or culminating in syncope, physicians may find themselves baffled. There is a wide variety of disorders that cause abnormal regulation of blood pressure and pulse rate in the upright posture. The aim of this focused review is 3-fold. First, to offer a classification (nosology) of these disorders; second, to illuminate the mechanisms that underlie them; and third, to assist the physician in the practical aspects of diagnosis of adult orthostatic hypotension, by extending clinical skills with readily available office technology.

Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force

BACKGROUND

Elevated blood pressure (BP) is the largest contributing risk factor to all-cause and cardiovascular mortality.

PURPOSE

To update a systematic review on the benefits and harms of screening for high BP in adults and to summarize evidence on rescreening intervals and diagnostic and predictive accuracy of different BP methods for cardiovascular events.

DATA SOURCES

Selected databases searched through 24 February 2014.

STUDY SELECTION

Fair- and good-quality trials and diagnostic accuracy and cohort studies conducted in adults and published in English.

DATA EXTRACTION

One investigator abstracted data, and a second checked for accuracy. Study quality was dual-reviewed.

DATA SYNTHESIS

Ambulatory BP monitoring (ABPM) predicted long-term cardiovascular outcomes independently of office BP (hazard ratio range, 1.28 to 1.40, in 11 studies). Across 27 studies, 35% to 95% of persons with an elevated BP at screening remained hypertensive after nonoffice confirmatory testing. Cardiovascular outcomes in persons who were normotensive after confirmatory testing (isolated clinic hypertension) were similar to outcomes in those who were normotensive at screening. In 40 studies, hypertension incidence after rescreening varied considerably at each yearly interval up to 6 years. Intrastudy comparisons showed at least 2-fold higher incidence in older adults, those with high-normal BP, overweight and obese persons, and African Americans.

LIMITATION

Few diagnostic accuracy studies of office BP methods and protocols in untreated adults.

CONCLUSION

Evidence supports ABPM as the reference standard for confirming elevated office BP screening results to avoid misdiagnosis and overtreatment of persons with isolated clinic hypertension. Persons with BP in the high-normal range, older persons, those with an above-normal body mass index, and African Americans are at higher risk for hypertension on rescreening within 6 years than are persons without these risk factors.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.