Journal of Human Hypertension (2008) 22, 240–242 & 2008 Nature Publishing Group All rights reserved 0950-9240/08 $30.00 www.nature.com/jhh
RESEARCH LETTER
Are recommended indications for ambulatory blood pressure monitoring followed in clinical practice? Journal of Human Hypertension (2008) 22, 240–242; doi:10.1038/sj.jhh.1002299; published online 25 October 2007
The aim of this retrospective study was to assess the adherence to European recommendations when ambulatory blood pressure monitoring (ABPM) is used in clinical practice taking account of ordering physician’s qualification in two different periods of time, before and after publication of guidelines. There was no statistically significant difference between the periods in physicians’ compliance to guidelines. From our observations, physicians appear to be independent in making decisions about care for their patients. ABPM is increasingly used for the diagnosis and management of hypertension by general practitioners and specialists in both the USA and Europe. Its widespread use in clinical practice is questioned by some experts1,2 because of its cost, and the issue becomes critical when ABPM is also considered for extended indications that include all subjects with office blood pressure (OBP) between 130/85 and 160/ 95 mm Hg.3 This diagnostic uncertainty range appears to include a mix of populations consisting of prehypertensives (or high-normal BP subjects), masked hypertensives, white coat (or isolated office) hypertensives and true sustained hypertensives,3 that is all subjects in whom ABPM appears to have a role in clinical decision-making. Moreover, most evaluation studies of ABPM effectiveness in clinical management do not take account of real everyday practice, where ABPM is not always performed according to the indications of international guidelines.4,5 With this background, the aim of this retrospective study was to assess the use of ABPM in clinical practice, evaluating the compliance with European Society of Hypertension/European Society of Cardiology (ESH/ESC) recommendations, taking account of the ordering physician’s qualification (general practitioner or specialist) in two different periods of time, before and after the publication of the 2003 ESH/ESC guidelines.5 We studied 500 subjects who were referred for ABPM between February 2002 and October 2006 to our Unit of Preventive Cardiology located within a National Health Service (NHS) medical centre in Rome, Italy. All subjects were patients of the NHS
and gave their written informed consent for medical and scientific use of their personal data in an anonymous form. Ethical approval was not required because the study was considered ‘observational’ and not ‘experimental’ by the local Health Authority. We excluded 10 subjects (2%) from the analysis because of poor recording quality. In the remaining 490 subjects, 362 (73.9%) tests were ordered by general practitioners and 128 (26.1%) were ordered by specialists (mainly cardiologists and nephrologists). ABPM tests were compared in two periods of time: period I, from February 2002 to June 2004, that is before and up to 1 year after the publication, the dissemination and the Italian translation of the ESH/ ESC guidelines;5 and period II, from July 2004 to October 2006, when guidelines were supposed to have been accepted in clinical practice through compulsory meetings accredited for continuing medical education. Period I included the tests of 238 subjects (98 men, 140 women, age 60714 years) with 178 tests (74.8%) ordered by general practitioners and 60 tests (25.2%) ordered by specialists. Period II included the tests of 252 subjects (95 men, 157 women, age 60714 years) with 184 tests (73%) ordered by general practitioners and 68 tests (27%) ordered by specialists. There were no statistically significant differences between the periods in the distribution of gender, age and referring physician’s qualification. All ABPM tests were conducted by Spacelabs 90207 recorders (Redmond, WA, USA),6 set to take automatic readings every 15 min during daytime (that is waking period according to diaries) and every 20 min during the night (that is sleeping period according to diaries). All recordings were made on a working day and the following night, with no restriction on daily activities. A recording that produced less than 70% of the expected number of observations, because of a high number of artefacts, was considered a poor-quality test5 and omitted from subsequent analyses. Recommended indications for ABPM testing were defined, on the basis of the 2003 ESH/ESC guidelines,5 as newly diagnosed office hypertension (19.2%) without target organ damage, excluded by laboratory exams and ultrasound investigations, or diabetes (including suspected white coat hypertension and episodic hypertension), screening for masked hypertension in office normotensive subjects (6.7%) with high risk of cardiovascular disease (family history of cardiovascular
Research Letter 241
Table 1 Physicians’ compliance to recommended indications in two time periods Period Physician’s qualification Recommended indications Not recommended indications
I General practitioner
Specialist
P
General practitioner
Specialist
P
77/178 (43.3%) 101/178 (56.7%)
37/60 (61.7%) 23/60 (38.3%)
0.02
88/184 (47.8%) 96/184 (52.2%)
29/68 (42.6%) 39/68 (57.4%)
0.55
Period Physician’s qualification Recommended indications Not recommended indications
II
I vs II
I vs II
General practitioner
General practitioner
P
Specialist
Specialist
P
77/178 (43.3%) 101/178 (56.7%)
88/184 (47.8%) 96/184 (52.2%)
0.44
37/60 (61.7%) 23/60 (38.3%)
29/68 (42.6%) 39/68 (57.4%)
0.048
Period I from February 2002 to June 2004; period II from July 2004 and October 2006.
disease, smoking, diabetes, hypercholesterolaemia and target organ damage), hypertension in pregnancy (3.5%), hypotension or hypotensive symptoms associated with antihypertensive medications (3.7%), evaluation of drug-resistant hypertension (defined as failure to achieve goal OBP despite standard triple therapy) (14.0%). Not recommended indications were defined as untreated Grade 2 hypertension (13.1%) and 24-h BP control in non-resistant treated hypertensives (39.8%). ABPM tests of periods I and II were compared by w2 tests to assess statistical differences in compliance with European recommendations according to the ordering physician’s qualification. Logistic regression was used to investigate the difference between the two periods and the difference between the two groups of physicians and the interaction between them. In period I, there was a statistically significant difference between general practitioners and specialists in their compliance with guidelines (P ¼ 0.02), while no difference was found in period II. There was no statistical difference between periods in general practitioners’ compliance to guidelines (P ¼ 0.44), but specialists in period II had a worse adherence to recommended indications than specialists in period I (P ¼ 0.048) (Table 1). There was no statistical difference between periods in overall physicians’ adherence to guidelines (P ¼ 0.81). These results were confirmed by logistic regression, which also confirmed the significance of the interaction between periods and physicians. Our report is the largest study, to the best of our knowledge, to assess the impact of indications for ABPM in everyday clinical practice. A smaller study7 described the indications for ABPM in a primary-care setting of USA and found that 42.4% of the sessions did not follow the guidelines for both treated and untreated subjects. In the literature, some studies1,3,8 address the issue of ‘making ABPM available to many, if not all, hypertensive patients’ to improve the accuracy of the diagnosis of isolated office or white
coat hypertension, a situation where BP-lowering drugs are not apparently needed.1 How is this trend perceived in clinical practice? European countries like Italy, where ABPM testing can be ordered both in primary and secondary care without indication limits to NHS coverage, represent a valid setting to evaluate this issue. In this specific context, which could not be applied to different health systems, our study showed that 52.9% of the total indications for ABPM did not follow the European guidelines5 and even 1 year after the publication and the cultural dissemination of the 2003 ESH/ESC guidelines,5 there was no progress in the adherence to the recommended indications by physicians, independent of their qualification. ABPM has become the gold standard for relating BP to future fatal and non-fatal cardiovascular disease, when compared to OBP.9 It is not then surprising that physicians rely more on this accurate information for making decisions about
What is known about this topic K ABPM is increasingly used for the diagnosis and management of hypertension by general practitioners and specialists in both the USA and Europe. Its widespread use in clinical practice is questioned. 5 K In the 2003 ESH/ESC guidelines, ABPM is considered of additional clinical value, when considerable variability of OBP is found over the same or different visits, high OBP is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home and resistance to drug treatment is suspected. What this study adds K How are ABPM guidelines perceived in clinical practice? From our data, physicians appear to be independent in making decisions about care for their patients. In particular, specialists (presumed to have expertise) relied less on guidelines. K Physicians rely more on ABPM information for making decisions about management of those patients with high OBP and some with lower pressures but suspected of being higher during ordinary life exposures.
Journal of Human Hypertension
Research Letter 242
management of those patients with high OBP and some with lower pressures but suspected of being higher during ordinary life exposures. In particular, both referring physicians relied on ABPM recordings in the management of treated hypertension (53.9% of all indications). The predictable consequence of extending indications for ABPM is an increase in the NHS costs. Thus, alternative BP measurement methods, less expensive than ABPM, should be considered: accurate clinic readings and home BP recordings.2
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3
4
Conflict of interest The authors do not have any conflict of interest and did not receive any financial support for this work. G Pannarale1, R Licitra1, V Basso1, D Mutone1, F Mirabelli1, L Gianturco1, A Pergolini1, A Madeo1, JF Osborn2 and C Gaudio1 1 Department of Cardiology, Unit of Preventive Cardiology, Sapienza University, Rome, Italy and 2 Department of Public Health Sciences, Sapienza University, Rome, Italy E-mail:
[email protected] Published online 25 October 2007
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Journal of Human Hypertension
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