Should Blood Pressure Measurement Be Repeated During Primary Care Visit?

MedicalResearch.com Interview with:
“Doctors” by Tele Jane is licensed under CC BY 2.0Doug Einstadter, MD, MPH

Center for Health Care Research and Policy
MetroHealth System and Case Western Reserve University 

MedicalResearch.com: What is the background for this study?  

Response: Despite the recognized importance of blood pressure (BP) control for those with hypertension, based on national surveys only 54% of patients with hypertension seen in primary care have their BP controlled to less than 140/90 mm Hg.

Blood pressure measurement error is a major cause of poor BP control. Reducing measurement error has the potential to avoid overtreatment, including side effects from medications which would be intensified or started due to a falsely elevated blood pressure. One way to reduce measurement error is to repeat the BP measurement during an office visit. The American Heart Association recommends repeating a blood pressure at the same clinic visit with at least 1 minute separating BP readings, but due to time constraints or lack of evidence for the value of repeat measurement, busy primary care practices often measure BP only once. Repeating the BP at the same office visit when the initial blood pressure measurement is high has the potential to improve clinical decision-making regarding BP treatment. Several studies have described the effect of a repeat BP measurement in the inpatient setting, but there are little data available to characterize the effect of repeating blood pressure measurement in an outpatient primary care setting.

MedicalResearch.com: What are the main findings?

Response: In our study, we examined more than 38,000 patients with hypertension who made over 86,000 visits to the primary care clinics at one hospital system during 2016. We observed that the initial blood pressure reading was elevated (≥140/90 mm Hg) at 39% of visits and an initially elevated BP was re-measured 83% of the time. Re-measuring an elevated BP was associated with a median 8 mm Hg drop in the systolic BP. Additionally, the drop in systolic BP on re-measurement was positively associated with the initial blood pressure  value; the higher the initial systolic BP, the greater the change when the BP was repeated. Among those with a repeat BP, the final blood pressure readings were <140/90 mm Hg 36% of the time. Thus repeating an initially elevated BP increased the overall rate of good BP control in our population from 61% to 72%. We estimate that about 65% of the observed decrease in systolic BP seen on repeat of an initially elevated BP was due to regression to the mean. 

MedicalResearch.com: What should readers take away from your report? 

Response: Among patients with hypertension seen in primary care, repeat measurement of an initially elevated BP may be associated with a meaningful improvement in systolic BP, comparable to that seen with addition of an antihypertensive medication. In primary care settings, implementing routine repeat measurement for an initially elevated BP may contribute to improved decision-making around hypertension management and should be considered a standard component of programs to improve blood pressure control.  

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Future studies will need to replicate our results in other systems and practice settings. Additional studies should evaluate the effect of routinely repeating the measurement of an initially elevated BP on long-term clinical outcomes such as heart attack, stroke, renal disease and mortality.

No disclosures

Citations:

Einstadter D, Bolen SD, Misak JE, Bar-Shain DS, Cebul RD. Association of Repeated Measurements With Blood Pressure Control in Primary Care. JAMA Intern Med. Published online April 16, 2018. doi:10.1001/jamainternmed.2018.0315

 

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