Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore

Contact time in GP Care: Descriptive patterns and a scoping review of the literature

BACKGROUND

Contact time in general practice (GP) refers to the duration a physician spends with a patient during an appointment. There are significant differences in contact times across OECD countries, raising questions about the influencing factors and potential consequences of these variations.

OBJECTIVE

To study the determinants and consequences of the length of consultations in GP care.

METHOD

We descriptively investigate differences in average appointment durations in GP care across OECD countries. We then conduct a scoping review of the literature encompassing 150 studies in seven topical clusters.

RESULTS

We identify considerable differences in contact times across countries and find evidence for substitution effects between the length of consultations and the number of consultations per year. There is also an association between reimbursement schemes and visit lengths. The review reveals consistent evidence for a few determinants, such as patient characteristics and physician experience, but mixed evidence on the effects of contact time on shared decision-making and health outcomes. The literature is dominated by correlational studies.

CONCLUSION

Descriptive comparisons show shorter contact times are substituted with more frequent visits, and fee-for-service payment systems result in longer contact times compared to capitation systems. For future health policy discussions, it is crucial to clarify which service delivery form is socially desired and economically sustainable.

Adherence to proper blood pressure measurements among interns at the university of Gondar specialized referral hospital

Introduction

Blood pressure is a lateral force exerted on the wall of arteries and is critical for the normal distribution of blood containing nutrients and oxygen to metabolic tissues. It is one of the vital signs often measured by interns, nurses, and physicians at doctor's offices, at bedside, and possibly at home. Accurate blood pressure measurement is essential for proper diagnosis and management of patients, especially those with hypertension. The aim of this cross-sectional survey study is to assess the practice of measuring blood pressure by interns.

Methods

This study was conducted in the form of a survey administered through face-to-face interviews. All the interns at the Univeristy of Gondar Specialized Referral Hospital were approached. The survey included questions about devices used, patient's information, and blood pressure measurement techniques. Epi-Data version 3.1 was used for data entry and exported to STATA 17 for data management and analysis. The Chi-square test was checked to assess the eligibility of variables for logistic regression. Finally, in the multivariable binary logistic regression analysis, variables with P-value < 0.05 were considered to be statistically significantly associated. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between blood pressure measurement and independent variables.

Result

The magnitude of appropriate measurement of blood pressure among interns was 10.1 (95% CI: 7.19, 13.9). A total of 318 interns participated in the current study. Of these study participants, 65.4% (208) were males. A increase in participants age (AOR: 1.48, 95% CI: 1.09, 2.01), being male interns (AOR: 5.51, 95% CI: 1.51, 8.97), and having patients who were familiar with the procedure (AOR: 2.95, 95% CI: 1.19, 7.03) were factors significantly associated with appropriate adherence to blood pressure measurement.

Conclusion and recommendation

Only 10% of six-year medical students (Interns) were successful in appropriately assessing blood pressure. Age, being male, and patient understanding were factors significantly associated to the adherence of blood pressure measurement. Considering the frequency of BP measurement and the impact of hypertension on morbidity and mortality, efforts are needed to maximize the quality of BP measurement by health professionals. This process should begin early during training and be consistent throughout their clinical practice, supplemented by ongoing education.

Barriers and facilitators to home blood pressure monitoring in women with pregnancies complicated by hypertensive disorders: a qualitative study

BACKGROUND/OBJECTIVE

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality in the US. Improved diagnosis and treatment of HDP may be achieved through home blood pressure monitoring (HBPM). However, there are challenges to effective HBPM during pregnancy. This qualitative study was conducted to explore patients' perspectives and experiences with HBPM.

METHODS

Pregnant or recently postpartum women with HDP (≥18 years) were recruited from an academic medical center to virtual focus groups from March to September 2023. The discussions centered on experiences with HDP and barriers and facilitators to HBPM. Qualitative thematic analysis was performed.

RESULTS

Among 20 participants, the mean age was 33.8 (SD 5.9) years, with 35% Hispanic and 35% Black/African-American. Facilitators to HBPM included understanding the parameters/purpose of HBPM, prior experience with healthcare/duration of hypertension, free access to HBPM equipment and decision support, creating a routine, external support/counseling (e.g., partner/healthcare/family), and technology support. Barriers to HBPM included uncertainty/lack of training about the HBPM process, accessing/using HBPM equipment, the belief that clinic monitoring was sufficient/achieving good control, and activation barriers to making HBPM a priority (e.g., fear of affirming the diagnosis, higher priorities/life stressors).

CONCLUSION

Many of the barriers to HBPM in pregnancy can be overcome through patient education/counseling, technology support, clinician/family reinforcement, and better access to validated blood pressure monitors. Given the importance of HBPM in improving outcomes for HDP, it is important for healthcare providers and policy makers to work to reduce barriers and amplify facilitators to HBPM for better adoption.

Exploring primary care physicians' challenges in using home blood pressure monitoring to manage hypertension in Singapore: a qualitative study

Objective

Hypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.

Method

A qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.

Results

PCPs identified variations in patients' HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.

Conclusion

Despite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP.

Current realities of home blood pressure monitoring from physicians' perspectives: results from Asia HBPM survey 2020

Uncontrolled hypertension is a significant problem in many parts of Asia. Effective management is essential to reduce the burden of hypertension. Home blood pressure monitoring (HBPM) is a promising tool that can aid in the diagnosis and management of hypertension. Experts from 11 countries/regions in Asia conceptualized a large-scale survey to examine the current realities of HBPM. A cross-sectional survey was conducted among health care professionals from China, India, Indonesia, Japan, Malaysia, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam between November 2019 and June 2021. Physicians' responses were summarized using descriptive statistics. A total of 7945 physicians participated in the survey. Among all respondents, 50.3% and 33.5% viewed HBPM as highly recognized by physicians and patients in their country/region, respectively. Lack of understanding of HBPM and concern with the accuracy and reliability of HBPM devices were identified as key barriers to HBPM recognition. Nearly all physicians (95.9%) reported recommending HBPM to their patients; however, they reported less than 50% of their patients measured home blood pressure (HBP). Among physicians who recommended HBPM, only 22.4% and 54.1% cited HBP diagnostic threshold values and timing of taking antihypertensive drugs that were consistent with available guidelines, respectively. The survey reveals that the recognition of HBPM as a valuable tool to diagnose and manage hypertension is suboptimal in most parts of Asia. Despite high recommendation of HBPM to hypertensive patients by physicians, there are considerable discrepancies between guidelines recommendations and practice realities. The recognition of HBPM as a valuable tool for the diagnosis and management of hypertension is suboptimal among both physicians and patients in Asia. A clear and consistent guidance for proper HBPM practice and use of validated and calibrated HBP monitors are among the top priorities to support the integration of HBPM into daily patient care. HBPM: home blood pressure monitoring, HBP: home blood pressure.

Awareness and recommendation of home blood pressure measurement among physicians in India: Results from Asia HBPM survey 2020

BACKGROUND

Awareness of hypertension and blood pressure (BP) control rates are still low in India. Home blood pressure monitoring (HBPM) is recognized as a valuable tool to diagnose and support hypertension treatment including the prevention of cardiovascular diseases(CVD) and target organ damage. We explored the prevailing knowledge and current recommendation of HBPM in daily practice by physicians in India.

MATERIALS AND METHODS

As part of Asia HBPM Survey 2020, a cross-sectional survey was conducted among healthcare providers from India between June 2020 to June 2021. The questionnaire consisted of 37 questions and sub-questions related to HBPM awareness and recommendations to patients.

RESULTS

A total of 832 physicians participated in the survey. Almost 83% were male, whereas age, specialty and workplace were well distributed. 31.3% of physicians instruct their patients to measure their BP before taking antihypertensive drugs, while around 30% of physicians gave no instructions. The reference value of hypertension diagnosis amongst the physicians was substantially low based on clinic BP (34.4%) and home BP (15.1%). Among physicians who manage hypertensive patients, nearly 88% recommend HBPM to their patients, however, only 34.9% of their patients own HBPM device and 30.4% of the patients measure their own BP at home.

CONCLUSION

The survey reveals that HBPM instructions to the patients are either lacking or not well aligned with the local hypertension guidelines which may have led to the low HBPM use among patients. Clear and practical educational material and sessions are needed to improve the understanding of HBPM amongst physicians.

The Association Between 24-Hour Blood Pressure Profiles and Dementia

Midlife hypertension increases risk for dementia. Around one third of adults have diagnosed hypertension; however, many adults are undiagnosed, or remain hypertensive despite diagnosis or treatment. Since blood pressure (BP) follows a circadian rhythm, ambulatory BP monitoring allows for the assessment of BP over a 24-hour period and provides an important tool for improving the diagnosis and management of hypertension. The measurement of 24-hour BP profiles, especially nocturnal BP, demonstrate better predictive ability for cardiovascular disease and mortality than office measurement. However, few studies have examined 24-hour BP profiles with respect to dementia risk. This is an important topic since improvements in BP management could facilitate the primary prevention of vascular cognitive impairment and dementia. Therefore, this review discusses the evidence linking BP to dementia, with a focus on whether the implementation of 24-hour BP measurements can improve risk prediction and prevention strategies. Pathways linking nocturnal BP to dementia are also discussed as are risk reduction strategies. Overall, limited research suggests an association between 24-hour BP elevation and poorer cognition, cerebral small vessel disease, and dementia. However, most studies were cross-sectional. Further evidence is needed to substantiate 24-hour BP profiles, over and above office BP, as predictors of vascular cognitive impairment and incident dementia.

Professional qualifications of medical affairs pharmaceutical physicians and other internal stakeholders in the pharmaceutical industry

Background: Medical affairs pharmaceutical physicians (MAPPs) have unique value to pharmaceutical companies due to their accountability for activities that benefit regulators, payors, prescribers and patients. This study assessed whether MAPPs' specialist training and education in pharmaceutical medicine could account for this level of value by determining whether there was significant variation in education and training between MAPPs and other internal stakeholders of pharmaceutical companies. Methods: A systematic search of LinkedIn profiles from the 10 pharmaceutical companies by revenue was conducted between June and October 2021. Job title and type and year of undergraduate and postgraduate qualifications were extracted. A one-sided Mann-Whitney test assessed for differences in the total number of qualifications between MAPPs and other internal stakeholders involved in medical affairs using MAPPs as the reference group. Other internal stakeholders included medical affairs pharmacists (MAPharm), other medical affairs professionals (MAOth), and market access (MAcc), commercial (COmm) and sales professionals. Sub-group analysis determined differences in undergraduate and postgraduate education. Results: In total, 524 profiles were included. Compared to all other internal stakeholders, MAPPs had a significantly higher number of undergraduate (p < 0.001) and postgraduate (MAPharm, p = 0.003; MAOth, p = 0.004; MAcc, COmm and Sales, p < 0.001) qualifications. Additionally, MAPPs had a significantly longer time to industry than other internal stakeholders apart from MAPharm. Of those with clinical qualifications, MAPPs were almost twice as likely to have business qualifications. Conclusions: Of all internal stakeholders, MAPPs had the highest number of qualifications and the best match between expertise and the contextual demands of decision-makers in the pharmaceutical industry. Pharmaceutical companies in the UK can use these findings to clarify role boundaries and decision-making power based on the nature and level of expertise of each internal stakeholder.

Pilot cross-sectional study of foreign domestic workers supporting the basic healthcare needs of older persons in the community

OBJECTIVE

This pilot study aimed to determine the proportions, level of knowledge, anxiety and confidence of foreign domestic workers (FDWs) who were involved in supporting the healthcare needs of older persons with long-term non-communicable diseases.

DESIGN

The pilot study used a cross-sectional and descriptive design.FDWs who accompanied the older adults attending a primary healthcare setting in Singapore. 100 eligible FDWs' demographic data, knowledge and confidence level of caregiving in food preparation, medication supervision, exercise, blood pressure (BP), blood glucose (BG) monitoring and anxiety level assessed by the Generalised Anxiety Disorder-7 scale were recorded. Descriptive statistics were performed and presented. Items on confidence were regrouped into two groups of 'very' versus 'no/a little/moderate'. Knowledge scores and caregiving tasks were assessed with items on confidence using Mann-Whitney U test and χ² test, respectively.

RESULTS

The FDWs were from Indonesia (60%), Philippines (23%) and Myanmar (14%). Their mean age was 33 years with an average of 5.8 years working experience; 62% self-reported previous caregiver training for elderly. The mean age of care-recipients was 81 years. Knowledge of FDWs on BP and BG monitoring was low (<50% answered correctly). Among the 55 FDWs who were required to perform BP monitoring, 45.5% lack confidence. Similarly, 40% of the 30 FDWs were not confident in performing BG monitoring. Those with very high confidence levels had higher knowledge on BP and BG monitoring. Of those who were involved in medication supervision (n=86), 36% lacked confidence. The majority of the FDWs (96%) were not affected by anxiety in managing these healthcare tasks for older persons.

CONCLUSION

More than half of the FDWs supported healthcare needs of older persons but they had inadequate knowledge and lacked confidence in performing the healthcare-related tasks.

Development and Validation of the Medical Affairs Pharmaceutical Physician Value (MAPPval) Instrument

BACKGROUND

A pilot study conducted in 2020 suggested that Medical Affairs Pharmaceutical Physicians (MAPPs) may be inherently undervalued within the pharmaceutical industry and vulnerable to replacement by less qualified roles. There are currently no standardized metrics to measure MAPP performance, thus it is necessary to measure the value of MAPPs to employers and clarify the need for their specific skills.

OBJECTIVES

The first aim of this study was to identify a list of indicators to produce an MAPP value measurement tool, and the second aim was to determine its discriminant validity by showing that the 'MAPPval instrument' differentiated the MAPP role from other internal stakeholders (regulatory affairs, market access, commercial, and patient advocacy) in terms of accountability for pharmaceutical company activities and level of engagement with external stakeholders.

METHODS

MAPPs were recruited using convenience sampling via professional networks and completed a qualitative online survey to identify a list of key role indicators using a consensus method known as the Jandhyala method. Responses were coded and scored, and aggregated responses were presented to participants in a Consensus Round. Participants rated their agreement with each item on a 5-point Likert scale, from strongly agree to strongly disagree. Indicators that reached a consensus index of > 50% (CI ≥ 0.51) were retained in the final MAPP performance instrument. Participants' retrospectively self-reported professional activities over a period of 12 months were used to validate the measure. A two-proportion z-test and Mann-Whitney tests were used to determine discriminant validity by showing whether the value of the MAPP role as defined by the instrument was significantly different from that of other internal stakeholders in terms of their accountability for and external stakeholder benefit from each MAPP activity.

RESULTS

In total, 11 MAPPs participated in the Jandhyala method, which generated 22 unique MAPP value indicators. Payor-targeted activities and journal publications had the two highest awareness indexes (1.00 and 0.98, respectively). The retrospective study confirmed the MAPPval instrument's validity. MAPPs were the only internal stakeholder classified as accountable for at least one activity that benefited all four stakeholders. They were classified as accountable for activities that influenced significantly more external stakeholders than other internal stakeholders, even when activities influenced fewer than four external stakeholders. MAPPs were also accountable for significantly more activities recorded over the 12-month period than regulatory affairs, market access, commercial, and patient advocacy.

CONCLUSIONS

This study generated and validated the first measure of MAPP value to pharmaceutical companies. MAPPs have unique value to pharmaceutical companies compared with other roles in terms of their accountability for activities that influence regulators, payors, prescribers, and patients. Through their accountability for pharmaceutical company activities and influence of external stakeholders, MAPPs play a key role in medicine adoption.

Knowledge, perception and practice of Québec nurses for ambulatory and clinic blood pressure measurement methods: are we there yet?

BACKGROUND

Guidelines regarding blood pressure measurement (BPM) methods, namely home (HBPM), ambulatory (ABPM), office (OBPM) and automated (AOBP) are published by Hypertension Canada and rely on accurate measurement technique. Nurses commonly perform BPM but their knowledge, perception and practice considering all methods is understudied. This study is the first to establish the picture of Québec nurses working in primary care settings concerning the four BPM methods.

METHODS

All nurses licensed to practice in primary care in Québec were targeted in our survey. Data were collected using a validated and pretested investigator-initiated questionnaire in English and French. A personalized e-mail invitation, and two reminders, including a link to a secured platform was sent in December 2019. A certificate of ethics was issued by UQTR.

RESULTS

A total of 453 nurses participated in the study. Median age was 40 ± 11 years, and 92% were women. The overall score on BPM methods knowledge was slightly below 50% (46% ± 23). The perception was mostly positive, with an overall score above 50% (73% ± 8). In practice, HBPM was recommended by 47% of nurses, and ABPM by 18%. Although AOBP is the preferred method in Canada, only 25% of the nurses use it, including the 57% that use an oscillometric device and 11% that use manual auscultation.

CONCLUSION

Nurses working in primary care play a central role in BPM. Our results highlight that overall knowledge and practice are suboptimal. Resources should, therefore, be allocated to ensure that initial training and continuing education are addressed.

Advances in Non-Invasive Blood Pressure Monitoring

This paper reviews recent advances in non-invasive blood pressure monitoring and highlights the added value of a novel algorithm-based blood pressure sensor which uses machine-learning techniques to extract blood pressure values from the shape of the pulse waveform. We report results from preliminary studies on a range of patient populations and discuss the accuracy and limitations of this capacitive-based technology and its potential application in hospitals and communities.

Knowledge, perception and practice of health professionals regarding blood pressure measurement methods: a scoping review

OBJECTIVE

Guideline-concordant performance of accurate blood pressure measurement (BPM), whether the modality is home (HBPM), ambulatory (ABPM), automated (AOBP) or office (OBPM), is dependent on proper technique. Knowledge, perception and practice of health professionals for BPM is crucial and has been partly studied, but a thorough review has never been reported. A scoping review of global studies was conducted to synthesize published data on this topic.

METHODS

An Arksey and O'Malley methodological framework was used. Keywords were identified and extraction was completed to April 2019 using CINAHL and MEDLINE. Studies were classified as positive for knowledge, perception and practice if the majority (>50%) of reported responses were favourable, and negative otherwise. If specific results were not reported, the author's conclusions were used to classified.

RESULTS

Seventy-two studies were identified: 25 HBPM, 14 ABPM, two AOBP, 40 OBPM. For knowledge, the percentage of negative studies were higher for HBPM (40%) and OBPM (68%) and lower for ABPM (14%) regarding BPM techniques. For perception, the number of negative studies were lower for HBPM (20%) and ABPM (7%) regarding usefulness of BPM methods in hypertension management. For practice, the number of negative studies were higher for HBPM (48%), ABPM (71%), OBPM (73%) and AOBP (50%) regarding implementation of hypertension guidelines.

CONCLUSION

The results of this scoping review demonstrate adequate perception of BPM but suboptimal knowledge and practice. Education is still needed to improve knowledge and practice. Future efforts should focus on improving what we know and what we do when measuring BP.

Asian management of hypertension: Current status, home blood pressure, and specific concerns in Singapore

Despite reductions in hypertension prevalence and improvements in control rates in recent years, almost one-third of all deaths in Singapore are due to cardiovascular disease and that proportion is growing. Ischemic heart disease is the most common cause of cardiovascular death, ahead of stroke. Local data suggest that awareness and support for home blood pressure monitoring (HBPM) is good, but there are reservations about the accuracy of HBPM devices and physicians cited a lack of time and resources to educate patients about HBPM. In addition, there was a knowledge gap around use of HBPM for evaluating treatment response. This is consistent with the emphasis of using HBPM for the diagnosis, rather than monitoring, of hypertension in the Singapore hypertension guidelines. In the absence of specific HBPM thresholds and targets, it is suggested that HOPE Asia Network consensus documents provide the most locally relevant guidance of the use of HBPM. Calcium channel blockers and angiotensin receptor blockers are the most commonly used antihypertensive agents in Singapore, and monotherapy was relatively uncommon (24%) of patients. Overall, more needs to be done in detecting and managing hypertension in Singapore to address rates of cardiovascular disease and cardiovascular disease mortality. Use of HBPM needs to be encouraged to improve adherence to treatment and optimize BP targets according to Asian perspectives and data.

Implementation of home blood pressure monitoring among French GPs: A long and winding road

BACKGROUND

To explore the perception of home blood pressure monitoring (HBPM) by general practitioners (GPs) in everyday practice in order to identify facilitators and barriers to its implementation in daily practice.

METHODS

A qualitative study comprising the conduct of six focus groups between October 2016 and February 2017, gathering 41 general practitioners in primary care practice in Lorraine (North Eastern France), with thematic and comprehensive analysis.

RESULTS

The first reasons given by GPs to explain their difficulties with HBPM (Home Blood Pressure Monitoring) implementation were the usual lack of time, material and human resources. However, all of these motives masked other substantial limiting factors including insufficient knowledge regarding HBPM, poor adherence to recommendations on HBPM and fear of losing their medical authority. GPs admitted that HBPM use could enhance patient observance and decrease therapeutic inertia. Despite this observation, most GPs used HBPM only at the time of diagnosis and rarely for follow-up. One explanation for GP reluctance towards HBPM may be, along with guidelines regarding hypertension, HBPM is perceived as being a binding framework and being difficult to implement. This barrier was more predominantly observed among aging GPs than in young GPs and was less frequent when GPs practiced in multidisciplinary health centers because the logistical barrier was no longer present.

DISCUSSION

In order to improve HBPM implementation in everyday practice in France, it is necessary to focus on GP training and patient education. We must also end "medical power" in hypertension management and turn to multidisciplinary care including nurses, pharmacists and patients.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Connecting Home-Based Self-Monitoring of Blood Pressure Data Into Electronic Health Records for Hypertension Care: A Qualitative Inquiry With Primary Care Providers

Background

There is a lack of research on how to best incorporate home-based self-measured blood pressure (SMBP) measurements, combined with other patient-generated health data (PGHD), into electronic health record (EHR) systems in a way that promotes primary care workflow without burdening the primary care team with irrelevant or superfluous data.

Objective

The purpose of this study was to explore the perspectives of primary care providers in utilizing SMBP measurements and integrating SMBP data into the clinical workflow for the management of hypertension in the primary care setting.

Methods

A total of 13 primary care physicians were interviewed in total; 5 in individual interviews and 8 in a focus group. The interview questions were centered on (1) the value of SMBP in hypertension care, (2) needs of viewing SMBP and desired visual display, (3) desired alert algorithm and critical values, (4) needs for other PGHD, and (5) workflow of primary care team in utilizing SMBP. The interviews were audiotaped and transcribed verbatim, and a thematic analysis was performed to extract overarching themes.

Results

The primary care experience of the 13 providers ranged from 5 to 35 years. The following themes emerged from the individual and focus group interviews: (1) ways to utilize SMBP measurements in primary care, (2) preferred visual display of SMBP, (3) patient condition determines preferred scheduling of patient SMBP measurements and provider’s preferred frequency of viewing SMBP data, (4) effect of patient condition on alert parameters, (5) location to receive critical value alerts, (6) primary recipient of critical value alerts, and (7) the need of additional PGHD (eg, emotional stressors, food diary, and medication adherence) to provide context of SMBP values.

Conclusions

The perspectives of primary care providers need to be incorporated into the design of a built-in interface in the EHR to incorporate SMBP and other PGHD. Future usability evaluation should be conducted with mock-up interfaces to solicit opinions on the optimal alert frequency and mechanism to best fit the workflow in the primary care setting. Future studies should examine how the utilization of a built-in interface that fully integrates SMBP measurements and PGHD into EHR systems can support patient self-management and thus, improve patient outcomes.

The potential role of testosterone in hypertension and target organ damage in hypertensive postmenopausal women

Objective: The aim of this study was to confirm the potential role of testosterone in hypertension and target organ damage (TOD) in hypertensive postmenopausal women.

Methods: A matched group study was conducted. One hundred sixty-one hypertensive postmenopausal women between 45 and 65 years of age were enrolled as group 1. Another 161 age-matched hypertensive men were enrolled as group 2. Ambulatory blood pressure monitoring, echocardiographic imaging, vascular function, sex hormones and clinical characteristics were evaluated. Quantitative data were analyzed using independent Student’s t-test and multiple regression analysis.

Results: The mean and load level of blood pressure were lower in women than in men (P<0.05), except for the mean level and load of the nocturnal systolic blood pressure (SBP) (123.77±15.72 mmHg vs 126.35±15.64 mmHg, and 50.43±30.31% vs 55.35±28.51%, P>0.05). However, the carotid-femoral pulse wave velocity (cf-PWV) in women was higher than that in men (9.68±2.23 m/s vs 8.03±2.82 m/s, P<0.05). The ratio of the early diastolic mitral peak flow velocity to early diastolic mitral annular velocity (E/Em) was obviously impaired (13.06±3.53 vs 12.05±3.68, P<0.05) in women. Furthermore, in women, a positive correlation was found between testosterone and cf-PWV (γ=0.157, P=0.046), and Cf-PWV was positively related to the mean level of nighttime SBP (γ=0.210, P=0.008). Moreover, nocturnal SBP was a risk factor for E/Em (γ=0.156, P=0.048, P<0.05).

Conclusion: Testosterone may play a role in the correlation between hypertension and TOD in hypertensive postmenopausal women.

Clinical Trial number: This research study was registered under the ClinicalTrials.gov PRS Website (NCT03451747).

Emergency Department-Provided Home Blood Pressure Devices Can Help Detect Undiagnosed Hypertension

INTRODUCTION

Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear.

AIM

In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP.

METHODS

From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge.

RESULTS

Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4-59)]. Participants' median age was 40 years-old (IQR 34-48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up.

CONCLUSIONS

For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.

Evolving role of pharmaceutical physicians in medical evidence and education

The role of pharmaceutical physicians who are the experts working in pharmaceutical companies has progressed over the last few decades, from supervising research and development (R&D) studies and/or providing support to marketing teams to serving an independent critical function. In this review, we focus on pharmaceutical physicians serving medical affairs functions in the pharmaceutical industry. Historically, members of the medical affairs team mainly provided a bridge between commercial teams and the R&D sector and between the organization and external stakeholders. Such teams may even have been managed by other departments, with an emphasis on acquiring and generating data for regulatory purposes. In recent years, the role of medical affairs has broadened due to a change in focus and the increasingly stringent regulatory landscape. Strict regulations require the detachment of commercial from medical activities within pharmaceutical organizations. This change provides an opportunity for a different type of partnership, allowing scientifically minded and medically driven initiatives. This article summarizes the key role of pharmaceutical industry-based physicians in medical affairs and discusses the emerging and evolving role of medical affairs for value creation in evidence generation and medical education.

Understanding short-term blood-pressure-variability phenotypes: from concept to clinical practice

Clinic blood pressure (BP) is recognized as the gold standard for the screening, diagnosis, and management of hypertension. However, optimal diagnosis and successful management of hypertension cannot be achieved exclusively by a handful of conventionally acquired BP readings. It is critical to estimate the magnitude of BP variability by estimating and quantifying each individual patient's specific BP variations. Short-term BP variability or exaggerated circadian BP variations that occur within a day are associated with increased cardiovascular events, mortality and target-organ damage. Popular concepts of BP variability, including "white-coat hypertension" and "masked hypertension", are well recognized in clinical practice. However, nocturnal hypertension, morning surge, and morning hypertension are also important phenotypes of short-term BP variability that warrant attention, especially in the primary-care setting. In this review, we try to theorize and explain these phenotypes to ensure they are better understood and recognized in day-to-day clinical practice.

Guidance on home blood pressure monitoring: A statement of the HOPE Asia Network

Hypertension is an important modifiable cardiovascular risk factor and a leading cause of death throughout Asia. Effective prevention and control of hypertension in the region remain a significant challenge despite the availability of several regional and international guidelines. Out-of-office measurement of blood pressure (BP), including home BP monitoring (HBPM), is an important hypertension management tool. Home BP is better than office BP for predicting cardiovascular risk and HBPM should be considered for all patients with office BP ≥ 130/85 mm Hg. It is important that HBPM is undertaken using a validated device and patients are educated about how to perform HBPM correctly. During antihypertensive therapy, monitoring of home BP control and variability is essential, especially in the morning. This is because HBPM can facilitate the choice of individualized optimal therapy. The evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for HBPM in Asia.