Patient preferences for different methods of blood pressure measurement: is ethnicity relevant?

This is the author accepted manuscript. It is currently under an indefinite embargo pending publication by the Royal College of General Practitioners.$\textit{Background:}$ Ambulatory and/or home monitoring are recommended in the UK and North America for the diagnosis of hypertension but little is known about acceptability. $\textit{Aim:}$ To determine the acceptability of different methods of measuring blood pressure to people from different ethnic minority groups. $\textit{Design and setting:}$ Cross sectional study with focus groups in primary care. $\textit{Methods:}$ People with and without hypertension of different ethnicities were assessed for acceptability of clinic, home and ambulatory blood pressure measurement using completion rate, questionnaire and focus groups. $\textit{Results:}$ 770 participants were included comprising white British (n=300), South Asian (n=241) and African Caribbean (n=229). White British participants had significantly higher successful completion rates across all monitoring modalities compared to the other ethnic groups, especially for ambulatory monitoring: white British (277 completed, 92%[89-95%]) vs South Asian (171, 71%[65-76%], p<0.001 and African Caribbean (188, 82%[77-87%], p<0.001) respectively. There were significantly lower acceptability scores for minority ethnic participants across all monitoring methods compared to white British. Focus group results highlighted self-monitoring as most acceptable and ambulatory monitoring least without consistent differences by ethnicity. Clinic monitoring was seen as inconvenient and anxiety provoking but with the advantage of immediate professional input. $\textit{Conclusions:}$ Reduced acceptability and completion rates amongst minority ethnic groups raise important questions for the implementation and interpretation of blood pressure monitoring in general and ambulatory monitoring in particular. Selection of method for blood pressure monitoring should take into account clinical need and patient preference as well as consideration of potential cultural barriers to monitoring.National Institute for Health Research (Grant ID: PB-PG-1207-15042

Ethnicity and differences between clinic and ambulatory blood pressure measurements.

BACKGROUND: This study investigated the relationship of ethnicity to the differences between blood pressure (BP) measured in a clinic setting and by ambulatory blood pressure monitoring (ABPM) in individuals with a previous diagnosis of hypertension (HT) and without a previous diagnosis of hypertension (NHT). METHODS: A cross-sectional comparison of BP measurement was performed in 770 participants (white British (WB, 39%), South Asian (SA, 31%), and African Caribbean (AC, 30%)) in 28 primary care clinics in West Midlands, United Kingdom. Mean differences between daytime ABPM, standardized clinic (mean of 3 occasions), casual clinic (first reading on first occasion), and last routine BP taken at the general practitioner practice were compared in HT and NHT individuals. RESULTS: Daytime systolic and diastolic ABPM readings were similar to standardized clinic BP (systolic: 128 (SE 0.9) vs. 125 (SE 0.9) mm Hg (NHT) and 132 (SE 0.7) vs. 131 (SE 0.7) mm Hg (HT)) and were not associated with ethnicity to a clinically important extent. When BP was taken less carefully, differences emerged: casual clinic readings were higher than ABPM, particularly in the HT group where the systolic differences approached clinical relevance (131 (SE 1.2) vs. 129 (SE 1.0) mm Hg (NHT) and 139 (SE 0.9) vs. 133 (SE 0.7) mm Hg (HT)) and were larger in SA and AC hypertensive individuals (136 (SE 1.5) vs. 133 (SE 1.2) mm Hg (WB), 141 (SE 1.7) vs. 133 (SE 1.4) mm Hg (SA), and 142 (SE 1.6) vs. 134 (SE 1.3) mm Hg (AC); mean differences: 3 (0-7), P = 0.03 and 4 (1-7), P = 0.01, respectively). Differences were also observed for the last practice reading in SA and ACs. CONCLUSIONS: BP differences between ethnic groups where BP is carefully measured on multiple occasions are small and unlikely to alter clinical management. When BP is measured casually on a single occasion or in routine care, differences appear that could approach clinical relevance.This report presents independent research funded by the National Institute for Health Research (NIHR).The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of HealthThis is a pre-copyedited, author-produced PDF of an article accepted for publication in American Journal of Hypertension following peer review. The version of record, Am J Hypertens (2014) doi: 10.1093/ajh/hpu211, is available online at: http://ajh.oxfordjournals.org/content/early/2014/11/18/ajh.hpu211.long

Measurement of blood pressure for the diagnosis and management of hypertension in different ethnic groups: one size fits all.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease and prevalence varies by ethnic group. The diagnosis and management of blood pressure are informed by guidelines largely based on data from white populations. This study addressed whether accuracy of blood pressure measurement in terms of diagnosis of hypertension varies by ethnicity by comparing two measurement modalities (clinic blood pressure and home monitoring) with a reference standard of ambulatory BP monitoring in three ethnic groups. METHODS: Cross-sectional population study (June 2010 - December 2012) with patients (40-75 years) of white British, South Asian and African Caribbean background with and without a previous diagnosis of hypertension recruited from 28 primary care practices. The study compared the test performance of clinic BP (using various protocols) and home-monitoring (1 week) with a reference standard of mean daytime ambulatory measurements using a threshold of 140/90 mmHg for clinic and 135/85 mmHg for out of office measurement. RESULTS: A total of 551 participants had complete data of whom 246 were white British, 147 South Asian and 158 African Caribbean. No consistent difference in accuracy of methods of blood pressure measurement was observed between ethnic groups with or without a prior diagnosis of hypertension: for people without hypertension, clinic measurement using three different methodologies had high specificity (75-97%) but variable sensitivity (33-65%) whereas home monitoring had sensitivity of 68-88% and specificity of 64-80%. For people with hypertension, detection of a raised blood pressure using clinic measurements had sensitivities of 34-69% with specificity of 73-92% and home monitoring had sensitivity (81-88%) and specificity (55-65%). CONCLUSIONS: For people without hypertension, ABPM remains the choice for diagnosing hypertension compared to the other modes of BP measurement regardless of ethnicity. Differences in accuracy of home monitoring and clinic monitoring (higher sensitivity of the former; higher specificity of the latter) were also not affected by ethnicity

Influence of ethnicity on acceptability of method of blood pressure monitoring: a cross-sectional study in primary care.

BACKGROUND: Ambulatory and/or home monitoring are recommended in the UK and the US for the diagnosis of hypertension but little is known about their acceptability. AIM: To determine the acceptability of different methods of measuring blood pressure to people from different minority ethnic groups. DESIGN AND SETTING: Cross-sectional study with focus groups in primary care in the West Midlands. METHOD: People of different ethnicities with and without hypertension were assessed for acceptability of clinic, home, and ambulatory blood pressure measurement using completion rate, questionnaire, and focus groups. RESULTS: A total of 770 participants were included, who were white British (n = 300), South Asian (n = 241), and African Caribbean (n = 229). White British participants had significantly higher successful completion rates across all monitoring modalities compared with the other ethnic groups, especially for ambulatory monitoring: white British (n = 277, 92% [95% confidence interval [CI] = 89% to 95%]) versus South Asian (n = 171, 71% [95% CI = 65% to 76%], P<0.001) and African Caribbean (n = 188, 82% [95% CI = 77% to 87%], P<0.001), respectively. There were significantly lower acceptability scores for minority ethnic participants across all monitoring methods compared with white British participants. Focus group results highlighted self-monitoring as most acceptable and ambulatory monitoring least acceptable without consistent differences by ethnicity. Clinic monitoring was seen as inconvenient and anxiety provoking but with the advantage of immediate professional input. CONCLUSION: Reduced acceptability and completion rates among minority ethnic groups raise important questions for the implementation and interpretation of blood pressure monitoring. Selection of method of blood pressure monitoring should take into account clinical need, patient preference, and potential cultural barriers to monitoring

Interarm Difference in Systolic Blood Pressure in Different Ethnic Groups and Relationship to the "White Coat Effect": A Cross-Sectional Study.

BACKGROUND: Interarm differences (IADs) ≥10 mm Hg in systolic blood pressure (BP) are associated with greater incidence of cardiovascular disease. The effect of ethnicity and the white coat effect (WCE) on significant systolic IADs (ssIADs) are not well understood. METHODS: Differences in BP by ethnicity for different methods of BP measurement were examined in 770 people (300 White British, 241 South Asian, 229 African-Caribbean). Repeated clinic measurements were obtained simultaneously in the right and left arm using 2 BPTru monitors and comparisons made between the first reading, mean of second and third and mean of second to sixth readings for patients with, and without known hypertension. All patients had ambulatory BP monitoring (ABPM). WCE was defined as systolic clinic BP ≥10 mm Hg higher than daytime ABPM. RESULTS: No significant differences were seen in the prevalence of ssIAD between ethnicities whichever combinations of BP measurement were used and regardless of hypertensive status. ssIADs fell between the 1st measurement (161, 22%), 2nd/3rd (113, 16%), and 2nd-6th (78, 11%) (1st vs. 2nd/3rd and 2nd-6th, P < 0.001). Hypertensives with a WCE were more likely to have ssIADs on 1st, (odds ratio [OR] 1.73 (95% confidence interval 1.04-2.86); 2nd/3rd, (OR 3.05 (1.68-5.53); and 2nd-6th measurements, (OR 2.58 (1.22-5.44). Nonhypertensive participants with a WCE were more likely to have a ssIAD on their first measurement (OR 3.82 (1.77 to -8.25) only. CONCLUSIONS: ssIAD prevalence does not vary with ethnicity regardless of hypertensive status but is affected by the number of readings, suggesting the influence of WCE. Multiple readings should be used to confirm ssIADs

Results and lessons from the spironolactone to prevent cardiovascular events in early stage chronic kidney disease (STOP-CKD) randomised controlled trial

Objectives To determine whether low-dose spironolactone can safely lower arterial stiffness in patients with chronic kidney disease stage 3 in the primary care setting. Design A multicentre, prospective, randomised, placebo-controlled, double-blinded study. Setting 11 primary care centres in South Birmingham, England. Participants Adult patients with stage 3 chronic kidney disease. Main exclusion criteria were diagnosis of diabetes mellitus, chronic heart failure, atrial fibrillation, severe hypertension, systolic blood pressure <120 mm Hg or baseline serum potassium ≥5 mmol/L. Intervention Eligible participants were randomised to receive either spironolactone 25 mg once daily, or matching placebo for an intended period of 40 weeks. Outcome measures The primary end point was the change in arterial stiffness as measured by pulse wave velocity. Secondary outcome measures included the rate of hyperkalaemia, deterioration of renal function, barriers to participation and expected recruitment rates to a potential future hard end point study. Results From the 11 practices serving a population of 112 462, there were 1598 (1.4%) patients identified as being eligible and were invited to participate. Of these, 134 (8.4%) attended the screening visit of which only 16 (1.0%) were eligible for randomisation. The main reasons for exclusion were low systolic blood pressure (<120 mm Hg: 40 patients) and high estimated glomerular filtration rate (≥60 mL/min/1.73 m2: 38 patients). The trial was considered unfeasible and was terminated early. Conclusions We highlight some of the challenges in undertaking research in primary care including patient participation in trials. This study not only challenged our preconceptions, but also provided important learning for future research in this large and important group of patient

TRIALS STUDY PROTOCOL Open Access

to prevent cardiovascular events in early-stage chronic kidney disease (STOP-CKD): study protocol for a randomized controlled pilot tria

Additional file 1: of Measurement of blood pressure for the diagnosis and management of hypertension in different ethnic groups: one size fits all

Diagnostic output of raw data at different BP thresholds. (DOCX 19 kb