Measuring blood pressure for decision making and quality reporting: where and how many measures?
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2011-06
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Abstract
Background
The optimal setting and number of blood pressure (BP) measurements that should be used for clinical decision making and quality reporting are uncertain.Objective
To compare strategies for home or clinic BP measurement and their effect on classifying patients as having BP that was in or out of control.Design
Secondary analysis of a randomized, controlled trial of strategies to improve hypertension management. (ClinicalTrials.gov registration number: NCT00237692)Setting
Primary care clinics affiliated with the Durham Veterans Affairs Medical Center.Patients
444 veterans with hypertension followed for 18 months.Measurements
Blood pressure was measured repeatedly by using 3 methods: standardized research BP measurements at 6-month intervals; clinic BP measurements obtained during outpatient visits; and home BP measurements using a monitor that transmitted measurements electronically.Results
Patients provided 111,181 systolic BP (SBP) measurements (3218 research, 7121 clinic, and 100,842 home measurements) over 18 months. Systolic BP control rates at baseline (mean SBP<140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) varied substantially, with 28% classified as in control by clinic measurement, 47% by home measurement, and 68% by research measurement. Short-term variability was large and similar across all 3 methods of measurement, with a mean within-patient coefficient of variation of 10% (range, 1% to 24%). Patients could not be classified as having BP that was in or out of control with 80% certainty on the basis of a single clinic SBP measurement from 120 mm Hg to 157 mm Hg. The effect of within-patient variability could be greatly reduced by averaging several measurements, with most benefit accrued at 5 to 6 measurements.Limitation
The sample was mostly men with a long-standing history of hypertension and was selected on the basis of previous poor BP control.Conclusion
Physicians who want to have 80% or more certainty that they are correctly classifying patients' BP control should use the average of several measurements. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients.Primary funding source
U.S. Department of Veterans Affairs Health Services Research and Development Service.Type
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Powers, Benjamin J, Maren K Olsen, Valerie A Smith, Robert F Woolson, Hayden B Bosworth and Eugene Z Oddone (2011). Measuring blood pressure for decision making and quality reporting: where and how many measures?. Annals of internal medicine, 154(12). pp. 781–788. 10.7326/0003-4819-154-12-201106210-00005 Retrieved from https://hdl.handle.net/10161/30096.
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Scholars@Duke
Maren Karine Olsen
Health services research, longitudinal data methods, missing data methods
Valerie A. Smith
Valerie A. Smith, DrPH, is an Associate Professor in the Duke University Department of Population Health Sciences and Senior Research Director of the Biostatistics Core at the Durham Veterans Affairs Medical Center's Center of Innovation. Her methodological research interests include: methods for semicontinuous and zero-inflated data, economic modeling methods, causal inference methods, observational study design, and longitudinal data analysis. Her current methodological research has focused on the development of marginalized models for semicontinuous data.
Dr. Smith works largely in collaboration with a multidisciplinary team of researchers, with a focus on health policy interventions, health care utilization and expenditure patterns, program and policy evaluation, obesity and weight loss, bariatric surgery evaluation, and family caregiver supportive services.
Areas of expertise: Biostatistics, Health Services Research, Health Economics, and Health Policy
Eugene Zaverio Oddone
I am a health services researcher whose primary research interests are: 1) evaluating the effectiveness of primary care with an emphasis on chronic disease, 2) assessing the reasons and testing interventions to reduce racial variation in access the health care and utilization of health services, 3) determining appropriate interventions to improve blood pressure control for hypertensive patients treated in primary care. I have research expertise in racial variation, blood pressure control, disease management, and tele-medicine. I also have methodologic expertise in designing and testing health services interventions in multi-site clinical trials.
Key words: primary care, racial variation, quality of care, hypertension
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