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Simplified hypertension screening methods across 60 countries: An observational study

['Rodrigo M. Carrillo-Larco', 'Department Of Epidemiology', 'Biostatistics', 'School Of Public Health', 'Imperial College London', 'London', 'United Kingdom', 'Cronicas Centre Of Excellence In Chronic Diseases', 'Universidad Peruana Cayetano Heredia', 'Lima']

Date: 2022-04

Main findings

Leveraging 60 national surveys, we documented concordance between hypertension diagnosis based on the average of the last 2 of 3 BP measurements (standard approach) and 9 simplified approaches (e.g., second BP measurement if the first was above a threshold). The proportion of missed cases was lowest when using the second BP reading if the first BP measurement was 130–145/80–95 mm Hg, followed by using the second BP only. Notably, the former simplified approach would require a second BP measurement in some people only, reducing the total number of BP measurements, and therefore time and resources used, which could allow more people to be screened. We observed differences between countries within world regions. Also, we quantified the absolute cardiovascular risk in the missed hypertension group. In many countries, the mean cardiovascular risk was not different between the missed hypertension and consistent hypertension groups, yet the mean cardiovascular risk in the missed group was slightly lower than that in the consistent hypertension group.

Altogether, this research shows that simplified BP screening approaches may be sensible and could increase the number of people screened for hypertension, particularly in LMICs where screening for hypertension is still limited [4]. However, it would seem reasonable not to have a one-size-fits-all simplified approach. Although physicians may have reasonable concerns about missing hypertension cases with the simplified approaches, our findings suggest that missed cases may have slightly lower absolute cardiovascular risk than their peers with hypertension. Also, cardiovascular risk was positively associated with missed hypertension for only some simplified approaches. Future work with prospective cohorts should confirm this observation before simplified approaches are strongly recommended.

Across all countries, the proportion of missed hypertension in our study was similar to the proportion reported for simplified screening approaches in the US [14]: 10.2% versus 9.6% [14] for the first BP record, 5.8% versus 4.9% [14] for the second BP record, 7.3% versus 7.2% [14] for the average of the first and second BP records, and 7.4% versus 5.2% [14] for the second BP record if the first was ≥130/80 mm Hg. Conversely, our proportions of over-diagnosis were more than 2 times the proportions in the US: 14.4% versus 4.3% [14] for the first BP record, 5.8% versus 2.0% for the second BP record, 7.4% versus 2.0% for the average of the first 2 BP records, and 5.1% versus 2.0% [14] for the second BP record when the first was ≥130/80 [14]. The similar proportions for missed hypertension may suggest that the simplified BP screening approaches are sensible and little biased by measurement protocols. The higher over-diagnosis found in our study could be owing to different BP measurement protocols between the STEPS surveys and the US national health survey [10,14]. Arguably, over-diagnosis would not be an unfavourable outcome, particularly when antihypertensive treatment is initiated at lower BP thresholds (provided the patient has other indications like history of cardiovascular disease or high cardiovascular risk) [7,9].

The results highlight that some of the 9 simplified approaches may lead to little misdiagnosis and are not associated with higher overall cardiovascular risk; however, we cautiously believe that further validation of these simplified approaches is warranted. Large prospective studies are needed to study the long-term cardiovascular outcomes for each simplified approach. Nevertheless, we would cautiously suggest considering 2 simplified approaches: (i) using only the second BP measurement and (ii) using the second BP reading if the first BP measurement is 130–145/80–95 mm Hg. If deemed necessary by local experts, these 2 simplified approaches could be implemented in screening programmes. Also, these 2 simplified approaches could be subject of further in-country validation analyses.

The WHO STEPS protocol [10], like other similar guidelines, recommends waiting 3 minutes between BP measurements. If there are 3 measurements (standard), and we assume that each measurement takes seconds, then measuring BP in 1 person could take at least 6 minutes. This would be equivalent to measuring BP in 10 people per hour. However, if a simplified approach is implemented, whereby, for example, only 2 measurements are required, the time invested to measure BP in 1 person would be approximately 3 minutes. In other words, we could measure BP in 20 people per hour, substantially increasing the number of individuals who could be screened for hypertension. The simplified approaches could save 50% of the time needed to measure BP in 1 person compared to current and standard guidelines.

Therefore, the potential applications of our work target several relevant scenarios. First, our work could influence May Measurement Month [12,13]. This is a global hypertension screening programme conducted yearly, and since 2016 it has covered more than 100 countries, benefiting over 1,000,000 people. This programme follows the 3-measurement protocol. Our work could inform future May Measurement Month campaigns by motivating discussion on whether fewer BP measurements could be taken, to maximise resources while reaching a much larger population. Second, our work could also influence future research and large health surveys. In addition to being used in the WHO STEPS surveys themselves, the WHO STEPS survey protocol has influenced other population-based health surveys worldwide, which would also take 3 BP measurements. Our work could spark interest in discussing whether 3 BP measurements are needed, or whether taking fewer measurements is a reasonable option to save resources that could be used to measure other relevant health variables. Third, in some clinics there may be a lack of sphygmomanometers or a shortage of personnel, limiting the number of people who can be screened for hypertension. Our work could deliver pragmatic approaches to optimise the protocols for BP measurement, to maximise the number of people who can be screened.

Our results showed large variability across countries within world regions. While simplified BP screening approaches may be a sensible and pragmatic alternative for screening large populations, a one-size-fits-all simplified approach may not be possible. Countries may need to find the optimal trade-off between the number of BP measurements and hypertension cases missed. Health organisations could set protocols for each country to define simplified BP screening approaches, so that these can be used in massive screening programmes [12,13].

Ten-year cardiovascular risk was positively associated with missed hypertension cases depending on the simplified approach used. Based on this, our results do not support relying on the first BP measurement only, for example. Conversely, our work may support using the second BP measurement or the average of the first 2 measurements, because 10-year cardiovascular risk was not associated with misdiagnosis amongst cases missed by these simplified approaches. The regression coefficients for absolute cardiovascular risk in some of the models, depending on the simplified approach, did not reach statistical significance. We would argue that this signalled groups of missed cases in which cardiovascular risk was not (truly) associated with misdiagnosis. Given the large sample size included in the models, the results most likely show strong associations (or lack of association) than unstable results. Nevertheless, residual confounding could still be a possibility, even though we included the relevant and potential confounders that were available. Our results must be further validated with larger samples and, more importantly, with prospective cohort studies to examine the mid- and long-term cardiovascular outcomes of the missed and consistent hypertension groups [19].

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[1] Url: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003975

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