Many Providers Don't Follow Hypertension Guidelines

Megan Brooks

September 14, 2020

Many healthcare professionals are not following current, evidence-based guidelines to screen for and diagnose hypertension, and appear to have substantial gaps in knowledge, beliefs, and use of recommended practices, results from a large survey suggest.

Beverly Green

"One surprising finding was that there was so much trust in the stethoscope, because the automated monitors are a better way to take blood pressure," lead author Beverly Green, MD, with Kaiser Permanente Washington Health Research Institute, Seattle, told theheart.org | Medscape Cardiology.

The results of the survey were presented September 10 at the virtual American Heart Association (AHA) Hypertension 2020 Scientific Sessions.

The US Preventive Services Task Force (USPSTF) and the American Heart Association/American College of Cardiology recommend out-of-office blood pressure (BP) measurements — using ambulatory blood pressure monitoring (ABPM) or home BP monitoring — before making a new diagnosis of hypertension.

To gauge provider knowledge, beliefs, and practices related to BP diagnostic tests, the researchers surveyed 282 providers: 102 medical assistants (MA), 28 licensed practical nurses (LPNs), 33 registered nurses (RNs), 86 primary care physicians, and 33 advanced practitioners (APs).

More than three-quarters of providers (79%) felt that BP measured manually using a stethoscope and ABPM were "very or highly" accurate ways to measure BP when making a new diagnosis of hypertension.

Most did not think that automated clinic BPs, home BP, or kiosk BP measurements were very or highly accurate.

Nearly all providers surveyed (96%) reported that they "always or almost always" rely on clinic BP measurements when diagnosing hypertension, but the majority of physicians/APs would prefer using ABPM (61%) if available.

The problem with ABPM, said Green, is "it's just not very available or convenient for patients, and a lot of providers think that patients won't tolerate it." Yet, without it, there is a risk for misclassification, she said.

Karen A. Griffin, MD, who chairs the AHA Council on Hypertension, said it became "customary to use clinic BP since ABPM was not previously reimbursed for the routine diagnosis of hypertension."

"Now that the payment for ABPM has been expanded, the number of machines at most institutions is not adequate for the need. Consequently, it will take some time to catch up with the current guidelines for diagnosing hypertension," she told theheart.org | Medscape Cardiology.

The provider survey by Green and colleagues also shows slow uptake of updated thresholds for high blood pressure.

Eighty-four percent of physicians/APs and 68% of MA/LPN/RNs said they used a clinic BP threshold of at least 140/90 mm Hg for making a new diagnosis of hypertension.

Only 3.5% and 9.0%, respectively, reported using the updated threshold of at least 130/80 mm Hg put forth in 2017.

Griffin said part of this stems from the fact that the survey began before the updated guidelines were released in 2017, "not to mention the fact that some societies have opposed the new threshold of 130/80 mm Hg."

"I think, with time, the data on morbidity and mortality associated with the goal of 130/80 mm Hg will hopefully convince those who have not yet implemented these new guidelines that it is a safe and effective BP goal," Griffin said.

This research had no specific funding. Green and Griffin have no relevant disclosures.

Hypertension 2020 Scientific Sessions: Abstract P163. Presented September 10, 2020.

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