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Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland.

ABSTRACT: OBJECTIVE:Simple forms of blood pressure (BP) telemonitoring require patients to text readings to central servers creating an opportunity for both entry error and manipulation. We wished to determine if there was an apparent preference for particular end digits and entries which were just below target BPs which might suggest evidence of data manipulation. DESIGN:Prospective cohort study SETTING: 37 socioeconomically diverse primary care practices from South East Scotland. PARTICIPANTS:Patients were recruited with hypertension to a telemonitoring service in which patients submitted home BP readings by manually transcribing the measurements into text messages for transmission ('patient-texted system'). These readings were compared with those from primary care patients with uncontrolled hypertension using a system in which readings were automatically transmitted, eliminating the possibility of manipulation of values ('automatic-transmission system'). METHODS:A generalised estimating equations method was used to compare BP readings between the patient-texted and automatic-transmission systems, while taking into account clustering of readings within patients. RESULTS:A total of 44?150?BP readings were analysed on 1068 patients using the patient-texted system compared with 20?705 readings on 199 patients using the automatic-transmission system. Compared with the automatic-transmission data, the patient-texted data showed a significantly higher proportion of occurrences of both systolic and diastolic BP having a zero end digit (OR 2.1, 95%?CI 1.7 to 2.6) although incidence was <2% of readings. Similarly, there was a preference for systolic 134 and diastolic 84 (the threshold for alerts was 135/85) (134 systolic BP OR 1.5, 95%?CI 1.3 to 1.8; 84 diastolic BP OR 1.5, 95%?CI 1.3 to 1.9). CONCLUSION:End-digit preference for zero numbers and specific-value preference for readings just below the alert threshold exist among patients in self-reporting their BP using telemonitoring. However, the proportion of readings affected is small and unlikely to be clinically important. TRIAL REGISTRATION NUMBER:ISRCTN72614272; Post-results.

SUBMITTER: Parker RA

PROVIDER: S-EPMC5878245 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland.

Parker Richard A RA Paterson Mary M Padfield Paul P Pinnock Hilary H Hanley Janet J Hammersley Vicky S VS Steventon Adam A McKinstry Brian B

BMJ open 20180131 1

<h4>Objective</h4>Simple forms of blood pressure (BP) telemonitoring require patients to text readings to central servers creating an opportunity for both entry error and manipulation. We wished to determine if there was an apparent preference for particular end digits and entries which were just below target BPs which might suggest evidence of data manipulation.<h4>Design</h4>Prospective cohort study SETTING: 37 socioeconomically diverse primary care practices from South East Scotland.<h4>Parti ...[more]

PMID: 29391369

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Project description:ImportanceTerminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording.ObjectiveTo 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 participantsThis 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.ExposuresManual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015.Main outcomes and measuresThe 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.ResultsThe 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 relevanceIn 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.

Project description:BackgroundAccurate blood pressure (BP) measurement is essential for the diagnosis and management of hypertension. In clinical practice, BP is estimated using noninvasive methods with significant variability of application of guidelines in clinical practice, impacting the accuracy and certainty of BP measurements.ObjectiveWe sought to assess how BP is measured in clinical practice.MethodsA survey was administered through professional societies that included predominantly cardiologists. Assessment of adherence to guideline recommendations for BP assessment was measured and compared to the level of confidence in clinic BP measurement.ResultsThere were 571 surveys completed. The majority of respondents were cardiologists (61.1%), with 47 preventive cardiologists. BP was routinely checked in both arms by 53% at the initial visit, 48% check BP once each visit, and 64% wait 5 min before initial BP assessment. Automated BP assessment is used by 58% respondents. The majority (83%) trust their BP readings, and those who trust their BP readings are more likely to perform the initial BP assessment themselves, compared to those who do not trust the clinic BP readings (30.2% vs. 13.6%, P = 0.009). Accurate BP measurement is performed by 23% of cardiologists, and more likely performed accurately by a preventive cardiologist (38.3%) compared with other cardiologists (20.0%, P = 0.007). Accurate BP measurement is more likely for those who perform the initial BP themselves rather than any other staff (36.8% vs. 17.9%; P<0.001); and for those who repeat BP manually (80% vs. 54%; P<0.001), compared to those who do not measure BP accurately. Despite the inaccuracy of BP measurement, there is a high level of confidence in the BP readings.ConclusionsAccurate BP assessment continues to remain suboptimal in clinical practice. Reliability of BP assessment requires education, identifying barriers to implementation of recommendations and engagement of the entire team to improve BP assessment.

Dataset Information

Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland.

Publications

Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland.

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