Diagnosing Hypertension in Primary Care Clinics According to Current Guidelines

Sarah Woolsey; Brittany Brown; Brenda Ralls; Michael Friedrichs; Barry Stults

doi:10.3122/jabfm.2017.02.160111

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Figure 1.
Flow of participants in study.

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Table 1.

Characteristics of Responding Clinics Compared to All Utah Primary Care Clinics

Clinic Characteristics	Respondents (n = 123)	Utah Primary Care Clinics (n = 398)
Clinic type
Family medicine	83 (67.5)	252 (63.3)
General practice	12 (9.8)	10 (2.5)
Internal medicine	19 (15.4)	54 (13.6)
Geriatrics	3 (2.4)	7 (1.8)
Multispecialty	3 (2.4)	41 (10.3)
Other	3 (2.4)	34 (8.5)
Total	123 (100.0)	398 (100.0)
Geographic density
Urban	76 (61.8)	243 (61.1)
Rural/frontier	47 (38.2)	155 (38.9)
Total	123 (100.0)	398 (100.0)
Integration level^*
Low	57 (46.3)	275 (69.1)
High	66 (53.7)	123 (30.9)
Total	123 (100.0)	398 (100.0)

Data are n (%).
↵* Low integration indicates a solo, independent clinic or a clinic that is part of a health care system that does not include a hospital. High integration represents a clinic that is part of a health care system that includes a hospital.

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Table 2.

Characteristics of Clinics Responding to Assessment

Practice Characteristics	No. (%)
Setting
Federally qualified health center	20 (16.3)
Hospital-based practice	3 (2.4)
University-based practice	11 (8.9)
Group practice (>2 providers)	61 (49.6)
Small or solo practice (1 or 2 providers)	22 (17.9)
School-based community clinic	2 (1.6)
Other	4 (3.3)
Total	123 (100.0)
Practice type
Family medicine	83 (67.5)
General practice	12 (9.8)
Internal medicine	19 (15.4)
Geriatrics	3 (2.4)
Multispecialty	3 (2.4)
Other	3 (2.4)
Total	123 (99.9)^*
Practice size^{^†}
1–2	40 (32.5)
3–5	35 (28.5)
6–10	30 (24.4)
≥10	15 (12.2)
Missing	3 (2.4)
Total	123 (100.0)
Geographic density
Urban	76 (61.8)
Rural	47 (38.2)
Total	123 (100.0)
Integration level^{^‡}
Low	57 (46.3)
High	66 (53.7)
Total	123 (100.0)

↵* This total did not equal 100% because of rounding.
↵† Full-time equivalent physicians and advanced practice clinicians.
↵‡ Low integration indicates a solo, independent clinic or a clinic that is part of a health care system that does not include a hospital. High integration indicates a clinic that is part of a health care system that includes a hospital.

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Table 3.

Percentage of Clinics Adherent to US Preventive Services Task Force Recommendations

USPSTF Recommendation⁶	Utah Million Hearts Assessment Question	Clinics Adherent to Recommendation, % (95% CI)
In-office blood pressure measurement
Use the mean of 2 measurements	Q11: Repeat the measurement within 1 to 2 minutes and use the mean of 2 measures	58.5 (49.7–67.4)
Measure while the patient is seated	Q5: Patient seated in a chair with back support	87.0 (81.0–93.0)
Allow for ≥5 minutes between entry into office and BP measurement	Q8: Measure BP after the patient has rested quietly for 5 minutes before measurement	57.7 (48.9–66.6)
Use an appropriately sized arm cuff	Q10: Use a cuff size appropriate to the patient's midarm circumference	93.5 (89.1–97.9)
Place the patient's arm at the level of the right atrium	Q7: Measure BP with the patient arm and cuff at midsternal level	84.6 (78.1–91.0)
Out-of-office hypertension diagnosis confirmation
ABPM may be used to confirm a diagnosis after initial screening	Q18: Practice has access to 24-hour ABPM studies	25.2 (17.4–33.0)
HBPM may be used to confirm a diagnosis after initial screening	Q15: Practice has a written policy for training patients on accurate HBPM	27.6 (19.6–35.7)
	Q16: Staff distribute materials for HBPM for newly diagnosed patients or those with uncontrolled hypertension	36.6 (28.0–45.2)
	Q17: Practice designates at least 1 member of the care team to provide individualized training in accurate HBPM	48.8 (39.8–57.7)
Recommends use of a regular screening interval	Q23: Practice has a system to alert patients with uncontrolled hypertension of a missed appointment or overdue BP check	55.3 (46.4–64.2)

ABPM, 24-hour ambulatory blood pressure monitoring; CI, confidence interval; BP, blood pressure; HBPM, home blood pressure monitoring; USPSTF, US Preventive Services Task Force.

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Table 4.

Level of Clinic Integration and Number of US Preventive Services Task Force Recommendations Adhered to by Clinic

Integration Level^*	Number of USPSTF Recommendations Adhered To			Total
Integration Level^*	0–4	5–7	8–10	Total
Low	20 (35.1)	31 (54.4)	6 (10.5)	57 (100.0)
High	17 (25.8)	25 (37.9)	24 (36.4)	66 (100.0)
Total	37 (30.1)	56 (45.5)	30 (24.4)	123 (100.0)

Data are n (%).
Differences are statistically significant (P < .01).
↵* Low integration indicates a solo, independent clinic or a clinic that is part of a health care system that does not include a hospital. High integration represents clinics that are part of a health care system that includes a hospital.
USPSTF, US Preventive Services Task Force.