Abstract
Background: Diagnosis of hypertension, treatment, and follow-up depend on accurate measurement. This research study attempted to determine whether family physicians are all measuring blood pressure (BP) according to Canadian guidelines.
Methods: A short survey was mailed to all physicians within the Department of Family Medicine, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
Results: Fifty-one percent of the surveys were completed and returned. Eleven of the recommendations were followed “always or most of the time.” BP is measured manually by 63% of the respondents, and the most frequent barrier to following the recommendations was time.
Conclusion: The results of the survey indicated that measurement of BP according to Canadian Hypertension Education Program recommendations was felt to be important and conducted in most cases, but there is room for improvement.
Accurate, reproducible measurement of blood pressure (BP) is critical when making decisions about patient care. Diagnosis of hypertension, treatment, and follow-up depend on accurate measurement. There are many effective medications to treat BP, but their use assumes accurate measurement. The Committee on Utilization, Research and Education attempted to determine whether family physicians are measuring BP in the same way and according to Canadian guidelines.
The 2010 Canadian Hypertension Education Program (CHEP) included detailed recommendations1 for how BP should be measured. The Committee on Utilization, Research and Education developed a short survey to ascertain how the majority of family physicians measure BP in their own practices and to determine whether it is practical to follow the guidelines.
Methods
Practicing community family physicians from the Department of Family Medicine, St. Joseph's Healthcare, Hamilton, Ontario, Canada, were invited by mail to participate. They were asked to identify the frequency (using a 5-point Likert scale) with which they followed 11 selected CHEP recommendations for measuring a patient's BP. They also were asked to identify which of the recommendations they deemed important as well as barriers to following the recommendations. They were asked who measured patient BP and how was it measured. Analysis was performed using IBM SPSS Statistics Base version 18.0 (IBM, Chicago, IL).
Results
Of 106 physicians invited to participate, 54 (51%) returned the survey. BP measurement is a shared responsibility (physician/nurse/assistant) in 50% of the family practices that responded. BP is measured manually in 63% of the offices and measurement is automated in 22% of the offices, whereas 15% use both. On average, 4 readings were taken when an automatic machine was used. One of the most frequent (63%) barriers to following the recommendations was time.
The physician responses on the 5-point scale were collapsed into 3 response categories: “always or most of the time,” “sometimes,” and “rarely and never followed.” As seen in Table 1, 8 of the 11 recommendations (A through E and I through K) were reportedly followed “always or most of the time.” Five of these items (C, E, I, J, and K) were not rated as important items to follow: their importance ratings varied between 9% and 39%.
Discussion
The results of the survey indicated that measurement of BP according to CHEP recommendations was felt to be important and was conducted in most cases. It would seem that there is room for improvement. This may have been partially achieved in our department by simply completing the survey. The practicality of following all CHEP guidelines could be questioned. The importance or “weighting” of various guidelines should be clarified.
Although incorrect technique or inaccurate equipment may generate BP values that are consistent from time to time in a given office, these values may not be appropriate for therapeutic decision making and may not be comparable to values obtained by another observer in different circumstances, including self-measurement by patients at home.
Because there is a large number of medications to treat elevated BP and because guidelines seem to be suggesting lower and lower targets, resulting in the potential for defining more patients as hypertensive, it would seem critical that BP be measured accurately and reproducibly. Many environmental or procedural factors may change BP values as much as or more than medications. For example, as stated in the 2005 American Heart Association BP measurement recommendations,2 “The individual should be comfortably seated, with the legs uncrossed, and the back and arm supported, such that the middle of the cuff on the upper arm is at the level of the right atrium (the mid-point of the sternum).” Disregarding this factor can cause a systematic error in blood pressure readings of as much as 10 mm Hg.3
Notes
This article was externally peer reviewed.
Funding: Unrestricted funding was received from Eli Lilly Canada, Inc., and Merck Canada, Inc.
Conflict of interest: none declared.
- Received for publication February 3, 2012.
- Revision received October 18, 2012.
- Accepted for publication October 23, 2012.
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