Dataset Information

Barriers to Accurate Blood Pressure Measurement in the Medical Office.

ABSTRACT:

Background

Despite the high prevalence of blood pressure (BP) measurement errors in the outpatient setting, little is known about why primary care clinics struggle to achieve consistently accurate BP measurements in routine practice. We investigated barriers affecting measurement of BP for adult patients in primary care.

Methods

We conducted a qualitative evaluation in 6 adult primary care clinics. BP measurement was observed during 54 routine patient encounters. Six managers completed semistructured interviews and 18 clinical staff members participated in focus group discussions. We used an inductive, data-driven approach to identify and organize findings into cohesive, overarching themes describing factors affecting BP measurement.

Results

Observed errors in BP measurement spanned the entire spectrum of steps required to obtain BP properly. Barriers to proper BP measurement were related to staff knowledge and behavior (inadequate knowledge, training, and feedback); workflow constraints (need to multitask, inadequate time); and equipment issues (BP monitors, seating). Patient characteristics and behavior also affected BP measurement.

Conclusions

Correct measurement of BP is affected by a wide range of factors and is challenging to accomplish consistently in primary care. These findings may inform the design of performance improvement programs to maximize the quality of BP measurement in the outpatient setting.

SUBMITTER: Hwang KO

PROVIDER: S-EPMC6287289 | biostudies-literature | 2018 Jan-Dec

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Barriers to Accurate Blood Pressure Measurement in the Medical Office.

Hwang Kevin O KO Aigbe Aitebureme A Ju Hsiao-Hui HH Jackson Victoria C VC Sedlock Emily W EW

Journal of primary care & community health 20180101

<h4>Background</h4>Despite the high prevalence of blood pressure (BP) measurement errors in the outpatient setting, little is known about why primary care clinics struggle to achieve consistently accurate BP measurements in routine practice. We investigated barriers affecting measurement of BP for adult patients in primary care.<h4>Methods</h4>We conducted a qualitative evaluation in 6 adult primary care clinics. BP measurement was observed during 54 routine patient encounters. Six managers comp ...[more]

PMID: 30764705

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Project description:ImportanceAutomated office blood pressure (AOBP) measurement involves recording several blood pressure (BP) readings using a fully automated oscillometric sphygmomanometer with the patient resting alone in a quiet place. Although several studies have shown AOBP measurement to be more accurate than routine office BP measurement and not subject to a "white coat effect," the cumulative evidence has not yet been systematically reviewed.ObjectiveTo perform a systematic review and meta-analysis to examine the association between AOBP and office BP readings measured in routine clinical practice and in research studies, and ambulatory BP recorded during awake hours, as the latter is a standard for predicting future cardiovascular events.Data sourcesThe MEDLINE, Embase, and Cochrane Library were searched from 2003 to April 25, 2018.Study selectionStudies on systolic and diastolic BP measurement by AOBP in comparison with awake ambulatory BP, routine office BP, and research BP measurements were included if they contained 30 patients or more.Data extraction and synthesisStudy characteristics were abstracted independently and random effects meta-analyses and meta-regressions were conducted.Main outcomes and measuresPooled mean differences (95% CI) of systolic and diastolic BP between types of BP measurement.ResultsData were compiled from 31 articles comprising 9279 participants (4736 men and 4543 women). In samples with systolic AOBP of 130 mm Hg or more, routine office and research systolic BP readings were substantially higher than AOBP readings, with a pooled mean difference of 14.5 mm Hg (95% CI, 11.8-17.2 mm Hg; n = 9; I2 = 94.3%; P < .001) for routine office systolic BP readings and 7.0 mm Hg (95% CI, 4.9-9.1 mm Hg; n = 9; I2 = 85.7%; P < .001) for research systolic BP readings. Systolic awake ambulatory BP and AOBP readings were similar, with a pooled mean difference of 0.3 mm Hg (95% CI, -1.1 to 1.7 mm Hg; n = 19; I2 = 90%; P < .001).Conclusions and relevanceAutomated office blood pressure readings, only when recorded properly with the patient sitting alone in a quiet place, are more accurate than office BP readings in routine clinical practice and are similar to awake ambulatory BP readings, with mean AOBP being devoid of any white coat effect. There has been some reluctance among physicians to adopt this technique because of uncertainty about its advantages compared with more traditional methods of recording BP during an office visit. Based on the evidence, AOBP should now be the preferred method for recording BP in routine clinical practice.

Project description:The commonly used techniques for systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurement are the auscultatory Korotkoff-based sphygmomanometry and oscillometry. The former technique is relatively accurate but is limited to a physician's office because its automatic variant is subject to noise artifacts. Consequently, the Korotkoff-based measurement overestimates the blood pressure in some patients due to white coat effect, and because it is a single measurement, it cannot properly represent the variable blood pressure. Automatic oscillometry can be used at home by the patient and is preferred even in clinics. However, the technique's accuracy is low and errors of 10-15 mmHg are common. Recently, we have developed an automatic technique for SBP measurement, based on an arm pressure cuff and a finger photoplethysmographic probe. The technique was found to be significantly more accurate than oscillometry, and comparable to the Korotkoff-based technique, the reference-standard for non-invasive blood pressure measurements. The measurement of SBP is a mainstay for the diagnosis and follow-up of hypertension, which is a major risk factor for several adverse events, mainly cardiovascular. Lowering blood pressure evidently reduces the risk, but excessive lowering can result in hypotension and consequently hypoperfusion to vital organs, since blood pressure is the driving force for blood flow. Erroneous measurement by 10 mmHg can lead to a similar unintended reduction of SBP and may adversely affect patients treated to an SBP of 120-130 mmHg. In particular, in elderly patients, unintended excessive reduction of blood pressure due to inaccurate SBP measurement can result in cerebral hypoperfusion and consequent cognitive decline. By using a more accurate technique for automatic SBP measurement (such as the photoplethysmographic-based technique), the optimal blood pressure target can be achieved with lower risk for hypotension and its adverse events.

Dataset Information

Barriers to Accurate Blood Pressure Measurement in the Medical Office.

Background

Methods

Results

Conclusions

Publications

Barriers to Accurate Blood Pressure Measurement in the Medical Office.

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