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Blood Pressure Checks for Diagnosing Hypertension: Health Professionals' Knowledge, Beliefs, and Practices
Beverly B Green1, Melissa L Anderson2, Kelly Ehrlich2
1From Kaiser Permanente Washington Health Research Institute (BBG, MLA, KE, LDH, CH, DJ, and JBM); Washington Permanente Medical Group (BBG); Kidney Research Institute, University of Washington Department of Medicine (YNH); Health Partners Institute (KLM); Kaiser Permanente Bernard J Tyson School of Medicine (JBM); University of Washington, Department of Human Centered Design and Engineering (SAM); University of Washington, Department of Family Medicine (MJT). Bev.B.Green@kp.org.
Insights
Healthcare professionals show gaps in hypertension diagnosis knowledge and practices, often relying on clinic BP despite guidelines recommending out-of-office monitoring. System changes are needed to improve hypertension diagnosis and patient outcomes.
Area of Science:
- Cardiology
- Primary Care Medicine
- Clinical Practice Guidelines
Background:
- The US Preventive Services Task Force recommends out-of-office blood pressure (BP) monitoring for hypertension diagnosis and treatment.
- 24-hour ambulatory BP monitoring (ABPM) and home BP monitoring are recommended but not commonly used.
- Gaps exist in healthcare professionals' understanding and application of these evidence-based practices.
Purpose of the Study:
- To assess primary care team members' knowledge, beliefs, and practices regarding hypertension diagnosis.
- To identify barriers to implementing out-of-office BP monitoring recommendations.
- To evaluate current diagnostic thresholds used for hypertension.
Main Methods:
- E-mail-linked surveys were distributed to 421 primary care team members across 10 clinics.
- The survey included questions on the perceived accuracy of different BP measurement methods and current diagnostic practices.
- Data were collected from November 2017 to July 2019.
Main Results:
- Most respondents believed manual stethoscope and ABPM were highly accurate, but doubted automated clinic BP, home BP, and kiosk BP accuracy.
- Nearly all respondents relied on clinic BP measurements for diagnosis (95.7%).
- Few physicians/PAs/APRNs used guideline-concordant thresholds for home (14.0%) or ABPM (8.4%) monitoring, with 140/90 mmHg being the most common threshold.
Conclusions:
- Significant knowledge, belief, and practice gaps exist among healthcare professionals in diagnosing hypertension.
- Current practices for hypertension diagnosis may not align with established evidence-based guidelines.
- System-level interventions are necessary to promote the adoption of recommended out-of-office BP monitoring and improve hypertension care.
Introduction:
The US Preventive Services Task Force recommends out-of-office blood pressure (BP) measurement before making a new hypertension diagnosis and initiating treatment, using 24-hour ambulatory (ABPM) or home BP monitoring. However, this approach is not common.
Methods:
e-mail-linked surveys were sent to primary care team members (n = 421) from 10 clinics. The sample included medical assistants, licensed practical nurses, registered nurses, and advanced practice registered nurses (LPN/RN/APRNs), physician assistants (PAs), and physicians. Those licensed to diagnosis hypertension (physician/PA/APRNs) received additional questions. Data were collected from November 2017 to July 2019.
Results:
2-thirds of invitees responded (163 MA/LPN/RNs, 86 physicians, and 33 PA/APRNs). When making a new hypertension diagnosis, most respondents believed that BP measured manually with a stethoscope (78.6%) or ABPM (84.2%) were very or highly accurate. In contrast, most did not believe that automated clinic BPs, home BP, or kiosk BP measurements were very or highly accurate. Almost all reported always or almost always relying on clinic BP measurements in making a diagnosis (95.7%), but most physician/PA/APRNs (60.5%) would prefer ABPM if it was readily available. Very few physician/PA/APRNs used the guideline-concordant diagnostic threshold (135/85 mmHg) with home monitoring (14.0%) or ABPM (8.4%), with 140/90 mmHg the most commonly reported threshold for home (59.4%) and ABPM (49.6%).
Discussion:
Our study found health care professional knowledge, beliefs, and practices gaps in diagnosing hypertension. These gaps could lead to clinical care that is not aligned with guidelines.
Conclusion:
System changes and interventions to increase use of evidence-based practices could improve hypertension diagnosis and outcomes.
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