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Manual or automated sphygmomanometer? A historical cohort to quantify measurement bias in blood pressure recording.

ABSTRACT: The authors aimed to quantify end-digit and threshold biases in blood pressure (BP) measurement with manual and digital sphygmomanometers. In a 3-year follow-up, end-digit and threshold biases were investigated and a new index, called the deviation index, was used to quantify measurement bias. The distribution of systolic and diastolic BPs became close to normal after implementation of digital sphygmomanometers. The appearance of zero end digits decreased from 97% to 30% (P<.0001). The deviation index decreased from 97% to 20% (P<.0001). Mean systolic and diastolic BPs increased immediately after implementation of automated sphygmomanometers (124.22±0.83 vs 132.90±0.78 and 74.38±0.50 vs 80.43±0.51, respectively; P<.0001 for both) but showed a linear decreasing trend during follow-up (systolic -3.59 mm Hg per year; 95% confidence interval, -5.57 to -1.61 [P<.0001]; diastolic: -2.52 mm Hg per year; 95% confidence interval, -3.78 to -1.26 [P<.0001]). Threshold bias decreased from 12.94% to 6.68% (P<.0001). Replacing manual sphygmomanometers with digital devices decreased end-digit and threshold biases in BP measurement. The deviation index can be used to quantify the magnitude of measurement bias.

SUBMITTER: Nargesi AA

PROVIDER: S-EPMC8031494 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Manual or automated sphygmomanometer? A historical cohort to quantify measurement bias in blood pressure recording.

Nargesi Arash A AA Ghazizadeh Zaniar Z Larry Mehrdad M Morteza Afsaneh A Heidari Firuzeh F Asgarani Firuzeh F Esteghamati Alireza A Mohammad Kazem K Nakhjavani Manouchehr M

Journal of clinical hypertension (Greenwich, Conn.) 20140908 10

The authors aimed to quantify end-digit and threshold biases in blood pressure (BP) measurement with manual and digital sphygmomanometers. In a 3-year follow-up, end-digit and threshold biases were investigated and a new index, called the deviation index, was used to quantify measurement bias. The distribution of systolic and diastolic BPs became close to normal after implementation of digital sphygmomanometers. The appearance of zero end digits decreased from 97% to 30% (P<.0001). The deviation ...[more]

PMID: 25196153

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Project description:ImportanceTerminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording.ObjectiveTo evaluate whether converting from manual BP measurement with aneroid sphygmomanometers to automated BP measurement was associated with terminal digit preference, mean levels of recorded BP, and the rate at which hypertension was diagnosed.Design, setting, and participantsThis quality improvement study was conducted from May 9, 2021, to March 24, 2022, using interrupted time series analysis of medical record data from 11 primary care clinics in a single health care system from April 2008 to April 2015. The study population was patients aged 18 to 75 years who had their BP measured and recorded at least once during the study period.ExposuresManual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015.Main outcomes and measuresThe main outcome was the distribution of terminal digits and mean systolic BP (SBP) values obtained during 4 years of manual measurement vs 3 years of automated measurement, assessed using a generalized linear mixed regression model with a random intercept for clinic and adjusted for seasonal fluctuations and patient demographic and clinical characteristics.ResultsThe study included 1 541 227 BP measurements from 225 504 unique patients during the entire study period, with 849 978 BP measurements from 165 137 patients (mean [SD] age, 47.1 [15.2] years; 58.2% female) during the manual measurement period and 691 249 measurements from 149 080 patients (mean [SD] age, 48.4 [15.3] years; 56.3% female) during the automated measurement period. With manual measurement, 32.8% of SBP terminal digits were 0 (20% was the expected value because nursing staff was instructed to record BP to the nearest even digit). This proportion decreased to 12.4% during the automated measurement period (expected value, 10%) when both even and odd digits were to be recorded. After automated measurement was implemented, the mean SBP estimated with statistical modeling increased by 5.09 mm Hg (95% CI, 4.98-5.19 mm Hg). Fewer BP values recorded during the automated than the manual measurement period were below 140/90 mm Hg (69.9% vs 84.3%; difference, -14.5%; 95% CI, -14.6% to -14.3%) and below 130/80 mm Hg (42.1% vs 60.0%; difference, -17.9%; 95% CI, -18.0% to -17.7%). The proportion of patients with a diagnosis of hypertension was 4.3 percentage points higher (23.4% vs 19.1%) during the automated measurement period.Conclusions and relevanceIn this quality improvement study, automated BP measurement was associated with decreased terminal digit preference and significantly higher mean BP levels. The method of BP measurement was also associated with the rate at which hypertension was diagnosed. These findings may have implications for pay-for-performance programs, which may create an incentive to record BP levels that meet a particular goal and a disincentive to adopt automated measurement of BP.

Project description:ImportanceAutomated office blood pressure (AOBP) measurement involves recording several blood pressure (BP) readings using a fully automated oscillometric sphygmomanometer with the patient resting alone in a quiet place. Although several studies have shown AOBP measurement to be more accurate than routine office BP measurement and not subject to a "white coat effect," the cumulative evidence has not yet been systematically reviewed.ObjectiveTo perform a systematic review and meta-analysis to examine the association between AOBP and office BP readings measured in routine clinical practice and in research studies, and ambulatory BP recorded during awake hours, as the latter is a standard for predicting future cardiovascular events.Data sourcesThe MEDLINE, Embase, and Cochrane Library were searched from 2003 to April 25, 2018.Study selectionStudies on systolic and diastolic BP measurement by AOBP in comparison with awake ambulatory BP, routine office BP, and research BP measurements were included if they contained 30 patients or more.Data extraction and synthesisStudy characteristics were abstracted independently and random effects meta-analyses and meta-regressions were conducted.Main outcomes and measuresPooled mean differences (95% CI) of systolic and diastolic BP between types of BP measurement.ResultsData were compiled from 31 articles comprising 9279 participants (4736 men and 4543 women). In samples with systolic AOBP of 130 mm Hg or more, routine office and research systolic BP readings were substantially higher than AOBP readings, with a pooled mean difference of 14.5 mm Hg (95% CI, 11.8-17.2 mm Hg; n = 9; I2 = 94.3%; P < .001) for routine office systolic BP readings and 7.0 mm Hg (95% CI, 4.9-9.1 mm Hg; n = 9; I2 = 85.7%; P < .001) for research systolic BP readings. Systolic awake ambulatory BP and AOBP readings were similar, with a pooled mean difference of 0.3 mm Hg (95% CI, -1.1 to 1.7 mm Hg; n = 19; I2 = 90%; P < .001).Conclusions and relevanceAutomated office blood pressure readings, only when recorded properly with the patient sitting alone in a quiet place, are more accurate than office BP readings in routine clinical practice and are similar to awake ambulatory BP readings, with mean AOBP being devoid of any white coat effect. There has been some reluctance among physicians to adopt this technique because of uncertainty about its advantages compared with more traditional methods of recording BP during an office visit. Based on the evidence, AOBP should now be the preferred method for recording BP in routine clinical practice.

Dataset Information

Manual or automated sphygmomanometer? A historical cohort to quantify measurement bias in blood pressure recording.

Publications

Manual or automated sphygmomanometer? A historical cohort to quantify measurement bias in blood pressure recording.

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