Unattended Automated Measurements: Office and Out-of-Office Blood Pressures Affected by Medical Staff and Environment

In-office and out-of-office blood pressure measurement

Accurate blood pressure measurement is the key procedure for the diagnosis and treatment of hypertension. In-office and out-of-office blood pressure measurements both have advantages and weak points, and multifaceted blood pressure information in individuals should be appropriately obtained and assessed. Validation of blood pressure measurement devices has long been an important issue, and several consortiums have emerged to try address it. Clinical guidelines should meet the demands of the region in which they are applied, and out-of-office measurements have been widely stated and recommended in the recently published guidelines worldwide. Appropriate assessment of blood pressure should be performed routinely in order to provide timely and accurate evidence regarding hypertension under any situation, including an unexpected pandemic.

Use of unattended automated office blood pressure in Utah primary care clinics

AIM

Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation. u-AOBP is recommended as the preferred office BP measurement technique by multiple hypertension guidelines. This study examines utilization, performance, and potential barriers to implementation of u-AOBP in Utah primary care clinics following 5 years of promotional efforts by the Utah Million Hearts Coalition (UMHC).

METHODS

An online questionnaire was administered to 285 Utah primary care clinics to evaluate self-reported use of u-AOBP and u-AOBP technique, interpretation of results, and perceived barriers to implementation.

RESULTS

Seventy-nine of 285 clinics (27.7%) completed the full questionnaire. Fifty-nine clinics (74.7%) use u-AOBP. Nearly 65% first learned about u-AOBP through UMHC promotional efforts rather than from the medical literature. One-half of these clinics noted no significant barriers to u-AOBP implementation, and over 80% noted no reduction in medical staff productivity. However, important knowledge deficits concerning correct u-AOBP performance and interpretation of results were apparent from answers to the questionnaire.

CONCLUSION

After 5 years of UMHC promotional efforts, at least 20% of the 285 Utah primary care clinics invited to take the questionnaire and 75% of the 79 clinics completing the survey have incorporated u-AOBP and found it feasible in a primary care setting. Ongoing promotion of u-AOBP implementation at the local and regional level is required to extend its utilization. Effective, accessible educational materials and local technical assistance from public health and community partners are needed to correct knowledge and performance deficits to optimize u-AOBP utilization in primary care.

Home and ambulatory blood pressure levels below target range and clinical effort to detect this condition: a population-based study in older treated hypertensives

BACKGROUND

With implementation of stricter blood pressure (BP) treatment targets, potential for excessive BP lowering becomes an important issue, especially in older patients.

OBJECTIVES

Assess the magnitude, indicators and detection effort of BP levels below-target-range (BTR-BP) recommended by the European hypertension guidelines in older treated hypertensive patients (130-139/70-79 mmHg).

DESIGN

Cross-sectional, retrospective study (Seniors-ENRICA-2 cohort).

SETTING

General population.

SUBJECTS

1,329 treated hypertensive patients aged ≥65, assessed with three home casual BP measurements and 24-hour ambulatory BP monitoring (ABPM).

METHODS

Based on the European hypertension guidelines and the literature, BTR-BPs were defined as mean BP <130/70, <125/65, <130/70 and <110/55 mmHg, for casual BP, 24-hour BP, daytime BP and nighttime BP, respectively, and hypotension as <110/70, <105/65, <110/70 and <90/55 mmHg, respectively.

RESULTS

Participants' mean age was 72 ± 4.4 (50.3%, women). Based on casual BP, 7.2% of patients were in target range (130-139/70-79 mmHg), 44.3% in BTR-BP (<130/70) and 20.8% hypotensive (<110/70). Some 44.9, 54.9 and 22.0% of patients were in BTR-BP for 24-hour BP, daytime BP and nighttime BP, respectively, and 11.0, 21.1 and 5.6%, respectively, were hypotensive. The number of patients needed for ABPM to detect one case of 24-hour-, daytime-, and nighttime-BTR-BP was 3, 2 and 5, respectively, and 10, 5 and 18, respectively, for detecting one hypotensive case. Cardiovascular disease and female sex were associated with both BTR-BP and hypotension, and the number of antihypertensive drugs was only associated with hypotension.

CONCLUSIONS

BTR-BP levels were common in older treated patients at home and in everyday life, more frequent than many trials report, and daytime ABPM is highly size-efficient for detecting the low ambulatory BP conditions.

Direct comparison of the reproducibility of in-office and self-measured home blood pressures

OBJECTIVE

The aim was to compare short-term and long-term reproducibilities of in-office unattended blood pressure (BP), namely automated office blood pressure (AOBP), conventionally measured attended office BP, and self-measured home BP.

METHODS

A multicentre, clinical study was conducted in Japan, and 287 Japanese outpatients on antihypertensive drug medication were followed-up for 1 year.

RESULTS

The intensity of drug treatment was sustained consistently throughout the study period (defined daily doses, 1.62-1.68; P = 0.12). The mean SBP differences between baseline and 1 month later, as well as baseline and 1 year later, were less than 1.5 mmHg, whereas the standard deviations of the differences for home, AOBP, and attended office measurements for the 1-year interval were 7.7, 14.5, and 15.3 mmHg, respectively. The coefficients of variation were significantly smaller for home BP than for AOBP among all patients at both 1-month and 1-year intervals (P < 0.0001). In the 1-month interval, partial correlation coefficients of home BP (r, 0.73/0.88 for systolic/diastolic measures) were significantly higher than of conventional BP (r, 0.47/0.69). However, the correlations converged to the modest level regardless of BP information (r, 0.49-0.54/0.63-0.73) when the 1-year interval was assessed. Results were confirmatory when patients on the same drug regimen (n = 167) were analysed.

CONCLUSION

A higher reproducibility of home BP was demonstrated compared with in-office BP, including AOBP. However, the modest correlations for the 1-year interval support the importance of regular assessment of BP, regardless of in-office or home measurements for treatment of hypertension.

Differences between home blood pressure and strictly measured office blood pressure and their determinants in Japanese men

Conventional office blood pressure (OBP) and home blood pressure (HBP) measurements are often inconsistent. The purpose of this research was (1) to test whether strictly measured OBP values with sufficient rest time before measurement (st-OBP) is comparable to HBP at the population level and (2) to ascertain whether there are particular determinants for the difference between HBP and st-OBP at the individual level. Data from a population-based group of 1056 men aged 40-79 years were analyzed. After a five-min rest, st-OBP was measured twice. HBP was measured after a 2-min rest every morning for seven consecutive days. To determine factors related to ΔSBP (HBP minus st-OBP measurements), multiple linear regression analyses and analyses of covariance were performed. While st-OBP and HBP were comparable (136.5 vs. 137.2 mmHg) at the population level, ΔSBP varied with a standard deviation of 13.5 mmHg. Smoking was associated with a larger ΔSBP regardless of antihypertensive usage, and BMI was associated with a larger ΔSBP in participants using antihypertensive drugs. The adjusted mean ΔSBP in the highest BMI tertile category was 4.6 mmHg in participants taking antihypertensive drugs. st-OBP and HBP measurements were comparable at the population level, although the distribution of ΔSBP was considerably broad. Smokers and obese men taking antihypertensive drugs had higher HBP than st-OBP, indicating that their blood pressure levels are at risk of being underestimated. Therefore, this group would benefit from the addition of HBP measurements.

Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization

Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation, but there are reservations about its time efficiency in primary care. We used time-stamp methodology to measure u-AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5-4.9 years u-AOBP experience. We documented the clinical activities of 30 medical assistants during the u-AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u-AOBP performance and interpretation. Median u-AOBP procedure time was <5 minutes, and MAs engaged in productive clinical activities during 83% of the procedures. Ninety-three percent of MAs and 100% of clinicians in the clinics agreed that u-AOBP is an efficient method to improve hypertension management. Barriers to effective u-AOBP implementation and ongoing utilization included initial difficulty incorporating u-AOBP into clinic workflow and medical staff knowledge deficiencies concerning correct u-AOBP performance and interpretation despite prior training and experience with the procedure. Intensive u-AOBP education and training programs are needed to facilitate effective u-AOBP implementation into primary care. The time required to perform u-AOBP can be utilized productively by staff.