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Quester R, Björck S, Manhem K, Nåtman J, Andersson S, Hjerpe P. Improving cardiovascular control in a hypertensive population in primary care. Results from a staff training intervention. Scand J Prim Health Care 2024; 42:347-354. [PMID: 38456742 PMCID: PMC11003316 DOI: 10.1080/02813432.2024.2326470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE A pilot study to evaluate a staff training intervention implementing a nurse-led hypertension care model. DESIGN AND SETTING Clinical and laboratory data from all primary care centres (PCCs) in the Swedish region Västra Götaland (VGR), retrieved from regional registers. Intervention started 2018 in 11 PCCs. A total of 190 PCCs served as controls. Change from baseline was assessed 2 years after start of intervention. INTERVENTION Training of selected personnel, primarily in drug choice, team-based care, measurement techniques, and use of standardized medical treatment protocols. PATIENTS Hypertensive patients without diabetes or ischemic heart disease were included. The intervention and control groups contained approximately 10,000 and 145,000 individuals, respectively. MAIN OUTCOME MEASURES Blood pressure (BP) <140/90 mmHg, LDL-cholesterol (LDL-C) <3.0 mmol/L, BP ending on -0 mmHg (digit preference, an indirect sign of manual measuring technique), choice of antihypertensive drugs, cholesterol lowering therapy and attendance patterns were measured. RESULTS In the intervention group, the percentage of patients reaching the BP target did not change significantly, 56%-61% (control 50%-52%), non-significant. However, the percentage of patients with LDL-C < 3.0 mmol/L increased from 34%-40% (control 36%-36%), p = .043, and digit preference decreased, 39%-27% (control 41%-35%), p = 0.000. The number of antihypertensive drugs was constant, 1.63 - 1.64 (control 1.62 - 1.62), non-significant, but drug choice changed in line with recommendations. CONCLUSION Although this primary care intervention based on staff training failed to improve BP control, it resulted in improved cardiovascular control by improved cholesterol lowering treatment.
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Affiliation(s)
- Rebecka Quester
- Närhälsan Bollebygd Health Care Centre, Bollebygd, Sweden
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Karin Manhem
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Per Hjerpe
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Skövde, Sweden
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2
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Senthinathan A, Thompson W, Gomes Z, Kiflen M, Bonilla AO, Stephenson E, Butt D, O’Neill B, Udell JA, Tu K. Assessing Primary Care Blood Pressure Documentation for Hypertension Management During the COVID-19 Pandemic by Patient and Provider Groups. CJC Open 2023; 5:916-924. [PMID: 38204848 PMCID: PMC10774078 DOI: 10.1016/j.cjco.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/10/2023] [Indexed: 01/12/2024] Open
Abstract
Background Primary care electronic medical record (EMR) data can be used to identify, manage, and screen hypertension cases. However, this approach relies on completeness and accessibility of documented blood pressure (BP) values. With the large switch to virtual care due to the COVID-19 pandemic, we assessed BP documentation in primary care EMRs during the pandemic, across patient and physician groups. Methods Hypertension-related visits were identified during the pre-pandemic (January 2017 to February 2020) and pandemic (March 2020 to December 2021) periods from a primary care EMR database in Ontario, Canada. Clustered logistic regression models were used to analyze the relationship of physician and patient characteristics with an outcome variable of documented BP. A chart review of 3200 hypertension visits without a BP recorded in structured data fields was conducted to determine if BP was recorded in progress notes. Results Pre-pandemic, 75.7% of hypertension-related visits (113,966 of 150,511) had a BP recorded in structured documentation, but this significantly decreased to 36.4% (26,660 of 73,239) during the pandemic (odds ratio [OR] = 0.18, 95% confidence interval [CI]: 0.18-0.19). For virtual visits, 14.3% (6357 of 44,572) had a documented BP, vs 74.0% (20,056 of 27,089) for in-person visits. Chart review found that 55.9% of hypertension visits had no associated BP in structured documentation, but did have a BP recorded in the progress note. Male providers, compared to female providers, were less likely to record BPs pre-pandemic (OR = 0.45, 95% CI: 0.32-0.63) and during the pandemic, for both virtual visits (OR = 0.48, 95% CI: 0.32-0.71) and in-person visits (OR = 0.46, 95% CI: 0.33-0.64). Conclusions BP documented in primary care EMRs declined during the pandemic, most likely due to high rates of virtual visits impacting hypertension detection and management.
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Affiliation(s)
- Arrani Senthinathan
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wade Thompson
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Zoya Gomes
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michel Kiflen
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Angela Ortigoza Bonilla
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ellen Stephenson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Butt
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Scarborough Health Network, Toronto, Ontario, Canada
| | - Braden O’Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Jacob A. Udell
- Women’s College Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto, Ontario, Canada
- Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada
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3
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Lapostolle F, Schneider E, Agostinucci JM, Nadiras P, Martineau L, Metzger J, Bertrand P, Petrovic T, Vianu I, Adnet F. Digit preference and biased conclusions in cardiac arrest studies. Am J Emerg Med 2023; 69:114-120. [PMID: 37086656 DOI: 10.1016/j.ajem.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/07/2023] [Accepted: 03/05/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND In cardiac arrest (CA), time is directly predictive of patients' prognosis. The increase in mortality resulting from delayed cardiopulmonary resuscitation has been quantified minute by minute. Times reported in CA management studies could reflect a timestamping bias referred to as "digit preference". This phenomenon leads to a preference for certain numerical values (such as 2, 5, or 10) over others (such as 13). Our objective was to investigate whether or not digit preference phenomenon could be observed in reported times of the day related to CA management, as noted in a national registry. METHODS We analyzed data from the French National Electronic Registry of Cardiac Arrests. We analyzed twelve times-of-the-day corresponding to each of the main steps of CA management reported by the emergency physicians who managed the patients in prehospital settings. We postulated that if CA occurred at random times throughout the day, then we could expect to see events related to CA management occurring at a similar rate each minute of each hour of the day, at a fraction of 1/60. We compared the fraction of times reported as multiples of 15 (0, 15, 30, and 45 - on the hour, quarters, half hour) with the expected fraction of 4/60 (i.e. 4 × 1/60). MAIN RESULTS A total of 47,211 times-of-the-day in relation to 6131 CA were analyzed. The most overrepresented numbers were: 0, with 3737 occurrences (8% vs 2% expected, p < 0.0001) and 30, with 2807 occurrences (6% vs 2% expected, p < 0.0001). Times-of-the-day as multiples of 15 were overrepresented (22% vs 7% expected, p < 0.0001). CONCLUSION Prospectively collected times were considerably influenced by digit preference phenomenon. Studies that are not based on automatic time recordings and that have not evaluated and considered this bias should be interpretated with caution.
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Affiliation(s)
- Frédéric Lapostolle
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Elodie Schneider
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Jean-Marc Agostinucci
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Pierre Nadiras
- SMUR, Groupe hospitalier intercommunal Le Raincy-Montfermeil, 10, rue du Général Leclerc, 93370 Montfermeil, France.
| | - Laurence Martineau
- SMUR, Urgences, Centre hospitalier intercommunal Robert Ballanger, Boulevard Robert Ballanger, 93600 Aulnay-sous-Bois, France.
| | - Jacques Metzger
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Philippe Bertrand
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Tomislav Petrovic
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Isabelle Vianu
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France
| | - Frédéric Adnet
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
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4
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Darvish Noori Kalaki S, Darabi F, Gubari MIM, Yaseri M, Motlagh ME, Heshmat R, Qorbani M, Jones ME, Safari S, Baratloo A, Baikpour M, Yousefifard M, Hosseini M, Kelishadi R. Prevalence of Hypertension among Children Based on the New American Academy of Pediatrics Clinical Practice Guidelines. IRANIAN JOURNAL OF PUBLIC HEALTH 2023; 52:166-174. [PMID: 36824248 PMCID: PMC9941449 DOI: 10.18502/ijph.v52i1.11679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/05/2022] [Indexed: 01/18/2023]
Abstract
Background In 2017, the American Academy of Pediatrics (AAP) updated clinical practice guidelines for the diagnosis and management of hypertension in children. The present study aimed to assess the prevalence of hypertension in Iranian children based on the latest guidelines. Methods Data on 7301 student participants (3589 boys and 3712 girls) aged between 7-12 yr were assessed. The data were extracted from the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable Disease (CASPIAN V) school-based study conducted in the 30 provinces of Iran in 2015. Blood pressure (BP) was classified as normal, elevated BP, and stage 1 and 2 hypertension using weighted analysis and the 2017 AAP guidelines. All analyses were performed in STATA 14.0 statistical software, with findings presented in terms of prevalence. Results The overall prevalence of high BP in Iranian children was 14.7%. In addition, 15.1% of boys had high BP, with 9.4% and 1.7% of them with stage 1 and 2 hypertension, respectively. Moreover, 14.3% of girls had high BP, of which 10% had stage 1 and 1.3% with stage 2 hypertension. For elevated hypertension, it was observed in 4% of boys and 3% of girls. Conclusion Using the 2017 AAP guidelines demonstrated a higher prevalence of hypertension in children (14.7%) in Iran. The prevalence of hypertension in boys was slightly higher compared to girls.
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Affiliation(s)
- Simin Darvish Noori Kalaki
- Department of Anthropology, Faculty of Social Sciences, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Fatemeh Darabi
- Department of Public Health, Asadabad School of Medical Sciences, Asadabad, Iran
| | - Mohammed I M Gubari
- Community Medicine, College of Medicine, University of Sulaimani, Sulaimani, Iraq
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran,Department of Community Medicine, Alborz University of Medical Sciences, Karaj, Iran,Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Michael E. Jones
- Division of Genetics and Epidemiology, the Institute of Cancer Research, London, UK
| | - Saeed Safari
- Emergency Department, Shohadye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Baratloo
- Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Baikpour
- Department of Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran,Paediatric Chronic Kidney Disease Research Center, The Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Authors: ;
| | - Mostafa Hosseini
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran,Paediatric Chronic Kidney Disease Research Center, The Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Authors: ;
| | - Roya Kelishadi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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5
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Wilding A, Munford L, Guthrie B, Kontopantelis E, Sutton M. Family doctor responses to changes in target stringency under financial incentives. JOURNAL OF HEALTH ECONOMICS 2022; 85:102651. [PMID: 35858512 DOI: 10.1016/j.jhealeco.2022.102651] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
Healthcare providers may game when faced with targets. We examine how family doctors responded to a temporary but substantial increase in the stringency of targets determining payments for controlling blood pressure amongst younger hypertensive patients. We apply difference-in-differences and bunching techniques to data from electronic health records of 107,148 individuals. Doctors did not alter the volume or composition of lists of their hypertension patients. They did increase treatment intensity, including a 1.2 percentage point increase in prescribing antihypertensive medicines. They also undertook more blood pressure measurements. Multiple testing increased by 1.9 percentage points overall and by 8.8 percentage points when first readings failed more stringent target. Exemption of patients from reported performance increased by 0.8 percentage points. Moreover, the proportion of patients recorded as exactly achieving the more stringent target increased by 3.1 percentage points to 16.6%. Family doctors responded as intended and gamed when set more stringent pay-for-performance targets.
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Affiliation(s)
- Anna Wilding
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K..
| | - Luke Munford
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Bruce Guthrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, U.K
| | - Evangelos Kontopantelis
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Matt Sutton
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K.; Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Australia
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6
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Kottke TE, Anderson JP, Zillhardt JD, Sperl-Hillen JM, O’Connor PJ, Green BB, Williams RA, Averbeck BM, Stiffman MN, Beran M, Rakotz M, Margolis KL. Association of an Automated Blood Pressure Measurement Quality Improvement Program With Terminal Digit Preference and Recorded Mean Blood Pressure in 11 Clinics. JAMA Netw Open 2022; 5:e2229098. [PMID: 36044216 PMCID: PMC9434355 DOI: 10.1001/jamanetworkopen.2022.29098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Terminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording. OBJECTIVE To evaluate whether converting from manual BP measurement with aneroid sphygmomanometers to automated BP measurement was associated with terminal digit preference, mean levels of recorded BP, and the rate at which hypertension was diagnosed. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was conducted from May 9, 2021, to March 24, 2022, using interrupted time series analysis of medical record data from 11 primary care clinics in a single health care system from April 2008 to April 2015. The study population was patients aged 18 to 75 years who had their BP measured and recorded at least once during the study period. EXPOSURES Manual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015. MAIN OUTCOMES AND MEASURES The main outcome was the distribution of terminal digits and mean systolic BP (SBP) values obtained during 4 years of manual measurement vs 3 years of automated measurement, assessed using a generalized linear mixed regression model with a random intercept for clinic and adjusted for seasonal fluctuations and patient demographic and clinical characteristics. RESULTS The study included 1 541 227 BP measurements from 225 504 unique patients during the entire study period, with 849 978 BP measurements from 165 137 patients (mean [SD] age, 47.1 [15.2] years; 58.2% female) during the manual measurement period and 691 249 measurements from 149 080 patients (mean [SD] age, 48.4 [15.3] years; 56.3% female) during the automated measurement period. With manual measurement, 32.8% of SBP terminal digits were 0 (20% was the expected value because nursing staff was instructed to record BP to the nearest even digit). This proportion decreased to 12.4% during the automated measurement period (expected value, 10%) when both even and odd digits were to be recorded. After automated measurement was implemented, the mean SBP estimated with statistical modeling increased by 5.09 mm Hg (95% CI, 4.98-5.19 mm Hg). Fewer BP values recorded during the automated than the manual measurement period were below 140/90 mm Hg (69.9% vs 84.3%; difference, -14.5%; 95% CI, -14.6% to -14.3%) and below 130/80 mm Hg (42.1% vs 60.0%; difference, -17.9%; 95% CI, -18.0% to -17.7%). The proportion of patients with a diagnosis of hypertension was 4.3 percentage points higher (23.4% vs 19.1%) during the automated measurement period. CONCLUSIONS AND RELEVANCE In this quality improvement study, automated BP measurement was associated with decreased terminal digit preference and significantly higher mean BP levels. The method of BP measurement was also associated with the rate at which hypertension was diagnosed. These findings may have implications for pay-for-performance programs, which may create an incentive to record BP levels that meet a particular goal and a disincentive to adopt automated measurement of BP.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - MarySue Beran
- Park Nicollet Health Services, Saint Louis Park, Minnesota
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7
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Minhas J, Baird G, Appleby D, McClelland R, Min J, Mazurek J, Ventetuolo CE, Al-Naamani N, Kawut SM. Terminal Digit Preference in Pulmonary Hypertension Endpoints. Am J Respir Crit Care Med 2022; 205:1482-1485. [PMID: 35380935 DOI: 10.1164/rccm.202108-2015le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jasleen Minhas
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States;
| | - Grayson Baird
- Lifespan Hospital System, Biostatistics Core, Providence, Rhode Island, United States
| | - Dina Appleby
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, & Informatics, Philadelphia, Pennsylvania, United States
| | - Robyn McClelland
- University of Washington School of Public Health, Biostatistics, Seattle, Washington, United States
| | - Jeff Min
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Jeremy Mazurek
- University of Pennsylvania, 6572, Division of Cardiology, Philadelphia, Pennsylvania, United States
| | | | - Nadine Al-Naamani
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Steven M Kawut
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
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8
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Nuyujukian DS, Zhou JJ, Koska J, Reaven PD. Refining determinants of associations of visit-to-visit blood pressure variability with cardiovascular risk: results from the Action to Control Cardiovascular Risk in Diabetes Trial. J Hypertens 2021; 39:2173-2182. [PMID: 34232160 PMCID: PMC8500916 DOI: 10.1097/hjh.0000000000002931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES As there is uncertainty about the extent to which baseline blood pressure level or cardiovascular risk modifies the relationship between blood pressure variability (BPv) and cardiovascular disease, we comprehensively examined the role of BPv in cardiovascular disease risk in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial. METHODS Using data from ACCORD, we examined the relationship of BPv with development of the primary CVD outcome, major coronary heart disease (CHD), and total stroke using time-dependent Cox proportional hazards models. RESULTS BPv was associated with the primary CVD outcome and major CHD but not stroke. The positive association with the primary CVD outcome and major CHD was more pronounced in low and high strata of baseline SBP (<120 and >140 mmHg) and DBP (<70 and >80 mmHg). The effect of BPv on CVD and CHD was more pronounced in those with both prior CVD history and low blood pressure. Dips, not elevations, in blood pressure appeared to drive these associations. The relationships were generally not attenuated by adjustment for mean blood pressure, medication adherence, or baseline comorbidities. A sensitivity analysis using CVD events from the long-term posttrial follow-up (ACCORDION) was consistent with the results from ACCORD. CONCLUSION In ACCORD, the effect of BPv on adverse cardiovascular (but not cerebrovascular) outcomes is modified by baseline blood pressure and prior CVD. Recognizing these more nuanced relationships may help improve risk stratification and blood pressure management decisions as well as provide insight into potential underlying mechanisms.
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Affiliation(s)
| | - Jin J Zhou
- Phoenix VA Healthcare System, Phoenix
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson
| | | | - Peter D Reaven
- Phoenix VA Healthcare System, Phoenix
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona, USA
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9
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Foti KE, Appel LJ, Matsushita K, Coresh J, Alexander GC, Selvin E. Digit Preference in Office Blood Pressure Measurements, United States 2015-2019. Am J Hypertens 2021; 34:521-530. [PMID: 33246327 DOI: 10.1093/ajh/hpaa196] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Blood pressure (BP) measurement error may lead to under- or overtreatment of hypertension. One common source of error is terminal digit preference, most often a terminal digit of "0." The objective was to evaluate national trends in terminal digit preference in office BP measurements among adults with treated hypertension. METHODS Data were from IQVIA's National Disease and Therapeutic Index, a nationally representative, serial cross-sectional survey of office-based physicians. The analysis included office visits from 2015 to 2019 among adults aged ≥18 years receiving antihypertensive treatment. Annual trends were examined in the percent of systolic and diastolic BP measurements ending in zero by patient sex, age, and race/ethnicity, physician specialty, and first or subsequent hypertension treatment visit. RESULTS From 2015 to 2019, there were ~60 million hypertension treatment visits annually (unweighted N: 5,585-9,085). There was a decrease in the percent of visits with systolic (41.7%-37.7%) or diastolic (42.7%-37.8%) BP recordings ending in zero. Trends were similar by patient characteristics. However, a greater proportion of measurements ended in zero among patients aged ≥80 (vs. 15-59 or 60-79) years, first (vs. subsequent) treatment visits, visits to cardiologists (vs. primary care physicians), and visits with systolic BP ≥140 or diastolic BP ≥90 (vs. <140/90) mm Hg. CONCLUSIONS Despite modest improvement, terminal digit preference remains a common problem in office BP measurement in the United States. Without bias, 10%-20% of measurements are expected to end in zero. Reducing digit preference is a priority for improving BP measurement accuracy and hypertension management.
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Affiliation(s)
- Kathryn E Foti
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lawrence J Appel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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10
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Parker RA, Padfield P, Hanley J, Pinnock H, Kennedy J, Stoddart A, Hammersley V, Sheikh A, McKinstry B. Examining the effectiveness of telemonitoring with routinely acquired blood pressure data in primary care: challenges in the statistical analysis. BMC Med Res Methodol 2021; 21:31. [PMID: 33568079 PMCID: PMC7877114 DOI: 10.1186/s12874-021-01219-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/26/2021] [Indexed: 11/24/2022] Open
Abstract
Background Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data. Methods Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6–12 months follow-up prior to analysis. The fourth analysis used linear mixed modelling based on all available data. Results The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6–12 months follow-up (-4.06, 95% CI -6.30 to -1.82, p < 0.001) for patients with systolic BP below 135 at baseline. For the standardisation with matching and regression adjustment for propensity score analyses, systolic BP was significantly lower overall (− 5.96, 95% CI -8.36 to − 3.55 , p < 0.001) and (− 3.73, 95% CI− 5.34 to − 2.13, p < 0.001) respectively, even after assuming that − 5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -3.37 (95% CI -5.41 to -1.33 , p < 0.001) after 1 year. Conclusions The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01219-8.
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Affiliation(s)
| | - Paul Padfield
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Janet Hanley
- School of Health and Social Care. Edinburgh Napier University, Edinburgh, UK
| | | | - John Kennedy
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | | | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Temperature-adjusted hypertension prevalence and control rate: a series of cross-sectional studies in Guangdong Province, China. J Hypertens 2020; 39:911-918. [PMID: 33273194 DOI: 10.1097/hjh.0000000000002738] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have shown negative relationships between ambient temperature and blood pressure (BP). However, few studies estimated temperature-adjusted hypertension prevalence and control rate in different population. OBJECTIVE To estimate the effects of temperature on BP, and further calculate temperature-adjusted hypertension prevalence and control rate. METHODS Meteorological and BP data in Guangdong Province from 2004 to 2015 were collected. There were 31 351 participants aged 18 years and over. Based on 2018 European society Arterial Hypertension Guidelines, participants were divided into normotensive patients (n = 23 046), known hypertensive patients (n = 2807), and newly detected hypertensive patients (n = 5498). We first used generalized additive model to establish the nonlinear relationship between daily mean temperature and BP, and then calculated the linear effects of temperature on BP among populations with different hypertension status. Finally, we calculated the temperature-adjusted hypertension prevalence and control rate. RESULTS Generally, there is an inverse relationship between temperature and BP. For a 1 °C increase in temperature, the decreased SBPs for normotensive patients, newly detected hypertensive patients, and known hypertensive patients were 0.37 [95% confidence interval (CI): -0.40, -0.33] mmHg, 0.21 (95% CI: -0.32, -0.10) mmHg and 0.81 (95% CI: -1.02, -0.59) mmHg, while reduced DBPs were 0.19 (95% CI: -0.21, -0.16) mmHg, 0.01 (95% CI: -0.06,0.08) mmHg, and 0.44 (95% CI: -0.56, -0.32) mmHg, respectively. At 5, 10, 15, 20, and 25 °C, the hypertension prevalence rates were 32.5, 29.7, 27.7, 26.0, and 25.0%, respectively, and the control rates were 12.0, 17.5, 23.5, 30.1, and 37.1%, respectively. CONCLUSION Low temperature increased BP for all populations, especially for known hypertensive patients, which makes hypertension prevalence increase and control rate decrease if temperature reduce. Our findings suggest that temperature should be considered in hypertension clinic management and epidemiological survey.
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Hammersley V, Parker R, Paterson M, Hanley J, Pinnock H, Padfield P, Stoddart A, Park HG, Sheikh A, McKinstry B. Telemonitoring at scale for hypertension in primary care: An implementation study. PLoS Med 2020; 17:e1003124. [PMID: 32555625 PMCID: PMC7299318 DOI: 10.1371/journal.pmed.1003124] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 05/22/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While evidence from randomised controlled trials shows that telemonitoring for hypertension is associated with improved blood pressure (BP) control, healthcare systems have been slow to implement it, partly because of inadequate integration with existing clinical practices and electronic records. Neither is it clear if trial findings will be replicated in routine clinical practice at scale. We aimed to explore the feasibility and impact of implementing an integrated telemonitoring system for hypertension into routine primary care. METHODS AND FINDINGS This was a quasi-experimental implementation study with embedded qualitative process evaluation set in primary care in Lothian, Scotland. We described the overall uptake of telemonitoring and uptake in a subgroup of representative practices, used routinely acquired data for a records-based controlled before-and-after study, and collected qualitative data from staff and patient interviews and practice observation. The main outcome measures were intervention uptake, change in BP, change in clinician appointment use, and participants' views on features that facilitated or impeded uptake of the intervention. Seventy-five primary care practices enrolled 3,200 patients with established hypertension. In an evaluation subgroup of 8 practices (905 patients of whom 427 [47%] were female and with median age of 64 years [IQR 56-70, range 22-89] and median Scottish Index of Multiple Deprivation 2012 decile of 8 [IQR 6-10]), mean systolic BP fell by 6.55 mm Hg (SD 15.17), and mean diastolic BP by 4.23 mm Hg (SD 8.68). Compared with the previous year, participating patients made 19% fewer face-to-face appointments, compared with 11% fewer in patients with hypertension who were not telemonitoring. Total consultation time for participants fell by 15.4 minutes (SD 68.4), compared with 5.5 minutes (SD 84.4) in non-telemonitored patients. The convenience of remote collection of BP readings and integration of these readings into routine clinical care was crucial to the success of the implementation. Limitations include the fact that practices and patient participants were self-selected, and younger and more affluent than non-participating patients, and the possibility that regression to the mean may have contributed to the reduction in BP. Routinely acquired data are limited in terms of completeness and accuracy. CONCLUSIONS Telemonitoring for hypertension can be implemented into routine primary care at scale with little impact on clinician workload and results in reductions in BP similar to those in large UK trials. Integrating the telemonitoring readings into routine data handling was crucial to the success of this initiative.
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Affiliation(s)
- Vicky Hammersley
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard Parker
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Mary Paterson
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Janet Hanley
- School of Health and Social Care. Edinburgh Napier University, Edinburgh, United Kingdom
| | - Hilary Pinnock
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Paul Padfield
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew Stoddart
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Brian McKinstry
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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13
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Garies S, Cummings M, Forst B, McBrien K, Soos B, Taylor M, Drummond N, Manca D, Duerksen K, Quan H, Williamson T. Achieving quality primary care data: a description of the Canadian Primary Care Sentinel Surveillance Network data capture, extraction, and processing in Alberta. Int J Popul Data Sci 2019; 4:1132. [PMID: 34095540 PMCID: PMC8142949 DOI: 10.23889/ijpds.v4i2.1132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Electronic medical record (EMR) databases have become increasingly popular for secondary purposes, such as health research. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is the first and only pan-Canadian primary care EMR data repository, with de-identified health information for almost two million Canadians. Comprehensive and freely available documentation describing the data ‘lifecycle’ is important for assessing potential data quality issues and appropriate interpretation of research findings. Here, we describe the flow and transformation of CPCSSN data in the province of Alberta. Approach In Alberta, the data originate from 54 publicly-funded primary care settings, including one community pediatric clinic, with 318 providers contributing de-identified EMR data for 410,951 patients (as of December 2018). Data extraction methods have been developed for five different EMR systems, and include both backend and automated frontend extractions. The raw EMR data are transformed according to specific rules, including trimming implausible values, converting values and free text to standard terminologies or classification systems, and structuring the data into a common CPCSSN format. Following local data extraction and processing, the data are transferred to a central repository and made available for research and disease surveillance. Conclusion This paper aims to provide important contextual information to future CPCSSN data users.
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Affiliation(s)
- S Garies
- Department of Family Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary Alberta, Canada, T2N 4N1.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6
| | - M Cummings
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - B Forst
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - K McBrien
- Department of Family Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary Alberta, Canada, T2N 4N1.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6
| | - B Soos
- Department of Family Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary Alberta, Canada, T2N 4N1.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6
| | - M Taylor
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - N Drummond
- Department of Family Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary Alberta, Canada, T2N 4N1.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6.,Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - D Manca
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - K Duerksen
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, Canada, T6G 2T4
| | - H Quan
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6
| | - T Williamson
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6
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