The quality of routine blood pressure (BP) readings in clinical practice “remains poor” despite a national effort to make BP measurement guidelines well-known and educational efforts to ensure health care professionals are getting the most accurate readings.
That’s the conclusion of nearly two dozen experts that the National Heart, Lung and Blood Institute (NHLBI) of the U.S. National Institutes of Health assembled as a working group to review blood pressure assessment data, a body that included the AMA’s Vice President of Health Outcomes Michael Rakotz, MD.
The AMA has developed online tools and resources created using the latest evidence-based information to support physicians to help manage their patients’ high BP. These resources are available to all physicians and health systems as part of Target: BP™, a national initiative co-led by the AMA and American Heart Association.
Target: BP offers annual, recurring gold-level recognition for all participating sites that achieve hypertension control rates of 70 percent or higher among their adult patient population, and participation level recognition for those sites that prioritize improving BP control each year and submit data. In 2018, more than 800 organizations were recognized for their efforts focusing on BP control within the populations they serve.
The NHLBI working group met for two days to look at what is known about BP assessment in clinical practice and clinic-based research. They also looked at knowledge gaps about current BP assessment methods and the research and clinic changes needed to improve the quality of BP measurements, among other areas.
In the report, “Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research,” published in the Journal of the American College of Cardiology, the group stated that inaccurate readings result from:
- No standardization.
- Infrequent technician/clinician training and retraining.
- Using devices that haven’t been validated and/or regularly calibrated.
- Not using an appropriately sized cuff.
- Improper conditions and technique.
- Inadequate documentation of the procedure.
The experts also said that despite guideline recommendations, the averaging of BP within and across visits is rarely done.
With accurate readings so essential to diagnosing and managing hypertension, the importance of improving measurements being taken in clinical practice or clinic-based research cannot be overstated, said Dr. Rakotz, noting that “many practicing physicians assume the BPs obtained in their practice settings are accurate. In the majority, unfortunately, this is not likely the case.”
Incorporating out-of-clinic data
The 2017 ACC/AHA Hypertension Clinical Practice Guideline recommends using BP readings from 24-hour ambulatory BP monitoring or self-measured BP monitoring at home and to help confirm suspected diagnosis and for reassessment of BP prior to intensification for treatment in people diagnosed with hypertension. Unfortunately, these out-of-office monitoring methods have not been widely adopted by clinicians for these purposes, and when they are performed, the data often is not documented into electronic health records (EHRs).
“Even when BP is accurately measured in clinical practice settings, it is unlikely that a single BP, which is a ‘snapshot’ in time of a person’s BP, is representative of their BP when they are outside of the clinical setting living their lives, working and in their homes,” said Dr. Rakotz.
He sees the widespread adoption of out-of-office BP measurement as one of the most important areas of future study.
“This is because these BP measurements are thought to better predict future heart attacks and strokes than those obtained in clinical settings,” said Dr. Rakotz. “We need to perform research to better understand the role of these two types of BP measurements in both diagnosing and guiding treating to determine which methods of BP measurement are better in different situations.”
Improving measuring devices
EHRs are a great opportunity to document BP measurements and to create a resource for researchers to tap into for data, but the BP readings being recorded may not be as accurate as they could be, the working group determined.
“Efforts to standardize BP measurement procedures and improve their quality in routine clinical practice are needed,” the report stated. “This may include documentation of [BP] training, selection of validated devices and periodic device calibration by accreditation bodies.”
How EHRs function could be improved, too, the experts concluded. Among their suggestions are:
- Being able to document key features of BP measurement.
- Creating seamless data transmission from measurement tools to the EHR, including from devices measuring blood pressure outside of the clinical setting.
- Inventing tools to manipulate and average BP data from an individual visit and over time.
- Improving how data is presented to provide better patient care and improving research applications.
Advancing the research
The working group called for more research to “provide an evidence base for future clinical practice guidelines and clinical research.” Among the objectives they identified:
- Determining the validity of novel approaches, for example, cuff-less devices.
- Evaluating apps for simplifying and organizing data coming from out-of-clinic measurements.
- Assessing approaches to measuring blood pressure in morbidly obese adults, including where it should be measured—the forearm, finger or wrist.
