Flipping the Visit: Impact of Blood Pressure Remeasurement after the Visit
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Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; 2Veterans Affairs Connecticut Health Care System (11ACSL), West Haven, CT, USA.
K E Y W O R D S : H y p er t e ns i on ; B l o o d p re s su r e m e a s u r em en t ; Overtreatment. J Gen Intern Med DOI: 10.1007/s11606-019-05359-y © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
INTRODUCTION
Hypertension is one of the most common conditions managed in primary care and is a major risk factor for cardiovascular morbidity and mortality. With the release of the 2017 ACC/ AHA hypertension guidelines with new thresholds for diagnosis, the age-standardized prevalence of hypertension increased from 29% (JNC7 guidelines) to 45.5% in 2015– 2016.1, 2 While hypertension remains one of the most impactful conditions primary care physicians manage, overtreatment can adversely affect patients. In a cohort of over 300,000 elderly patients newly treated for hypertension, there was a 43% increased risk of hip fracture occurring within 45 days following treatment initiation.3 In addition, low daytime systolic BP (< 128 mmHg) has been shown to be independently associated with greater progression of cognitive decline in a cohort of elderly patients with baseline cognitive impairment.4 Accurate assessment of BP is imperative to avoid overtreatment, especially in the elderly population. It is well known that many factors affect BP measurement, including talking, smoking, mental stress, and measurement in the inappropriate position and over clothing.5 Many of these factors exist just prior to an office visit and can be eliminated if the BP is assessed following the visit. We undertook this quality improvement initiative to determine the impact of BP reassessment after a clinic visit in a select population of male veterans.
METHODS
The West Haven Veterans Affairs medical center takes care of approximately 14,000 veterans, half of whom receive primary care in the Firm A clinic. In this clinic, vital signs are checked Received July 22, 2019 Revised August 8, 2019 Accepted September 12, 2019
prior to the visit and entered into the electronic medical record. The primary care provider can repeat the BP if the initial BP is elevated. For patients with elevated repeat BPs (defined as systolic > 140), we established a protocol whereby these patients could have their BP rechecked after the visit. The repeat BPs were performed in the appropriate position with the correct cuff size over bare skin while using an electronic monitor set on a 5min timer. The patient was asked to empty his/her bladder and abstain from using a cell phone during the repeat check. Repeat BPs were performed in a quiet room with the lights dimmed. The repeat BP was recorded and compared with the initial BP.
RESULTS
Fifty-eight patients had repeat BPs obtained following their primary care visit. All patients were male with a mean age of 72.3 (range 34–96). Forty-three pa
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