Blood Pressure Measurement Technique in Clinical Practice

Blood Pressure Measurement Technique in Clinical Practice | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Blood Pressure Measurement Technique in Clinical Practice Christian Delles, Dellaneira Setjiadi, Colin Geddes This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4635130/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Dec, 2024 Read the published version in Journal of Human Hypertension → Version 1 posted 10 You are reading this latest preprint version Abstract Blood pressure (BP) measurement is a common procedure conducted in various disciplines and widely available on clinical reports. The diagnosis and management of hypertension requires reliable measurement of BP in outpatient clinics. Published studies suggest the standardised method for BP measurement is difficult to apply in routine clinical practice. This study aimed to assess the current practice of BP measurement in outpatient clinics in relevant secondary care clinical specialties across the 15 separate hospital sites of the NHS Greater Glasgow and Clyde region (population 1.2 million) compared to the recommended standardised method. An online questionnaire was developed and disseminated to the supervising clinician of each of 268 regular outpatient clinics. The questionnaire focused on the standardised BP method (patient preparation, environment, and BP measurement technique). The questionnaire was returned for 110 clinics. 73 (66.4%) of the participating clinics measure BP routinely and these formed the basis for further analysis. 3 clinics (4.1%) apply all components of the standardised BP method. 5 (6.9%) clinics deliver advice to patients prior to clinic attendance on how to prepare for BP measurement. 61 (83.6%) of participating clinics have a dedicated quiet environment for BP measurement. 50 (68.5%) clinics always place the cuff on bare upper arm and 63.0% use a cuff size appropriate to upper arm circumference. In a wide range of secondary care out-patient clinic settings we found that BP measurement rarely adheres to the recommended standards. This has important implications for the quality of treatment decisions that are based on BP measurement. Health sciences/Health care/Diagnosis Health sciences/Diseases/Cardiovascular diseases/Hypertension/Renovascular hypertension Figures Figure 1 Summary What is known about the topic Blood pressure (BP) measurement is a common procedure conducted in various disciplines and widely available on clinical reports. The challenges in application of standardised method for BP measurement in routine clinical practice are often overlooked. What this study adds Description BP measurement techniques across NHS Greater Glasgow and Clyde (population 1.2 million). In a wide range of secondary care out-patient clinic settings, BP measurement rarely adheres to the recommended standards. Introduction Assessment of blood pressure (BP) is one of the most common measurements conducted in outpatient clinical settings particularly in cardiology, diabetes and endocrinology, nephrology and specialist hypertension clinics. Accurate BP measurements are crucial for diagnosis and management of hypertension ( 1 ). Contemporary guidelines including National Institute for Health and Care Excellence (NICE), Kidney Disease Improving Global Outcomes (KDIGO), European Society of Hypertension (ESH) guidelines ( 2 – 4 ) provide detailed guidance on accurate BP measurement. The randomised controlled trials referred to in these guidelines were all based on outpatient clinic BP (sometimes referred to as office BP) measured according to a standardised method. This standardised BP method involves 3 domains: patient preparation, environment and BP measurement technique.( 5 ) Non-standardised BP measurement can lead to over or under-estimation of BP of unpredictable magnitude and this will inevitably lead to sub-optimal treatment ( 6 ). For this reason, international guidelines emphasise that treatment of BP should be based on standardised office BP measurement. It is recognised that incorporation of all facets of standardised methodology into routine practice is challenging. The aim of this study was to determine if outpatient clinics in which BP is routinely measured adhere to the domains of standardised BP measurement. We also aimed to determine how ambulatory blood pressure measurement (ABPM) and home blood pressure monitoring (HBPM) are utilised in these clinics. In addition we determined if body mass index (BMI) is assessed at these clinics because of the notable association of overweight and obesity with hypertension ( 7 ). Subjects and Methods This is a descriptive cross-sectional study. Data collection was done through dissemination of an online questionnaire designed by Webropol (Helsinki, Finland). The questionnaire is a self-administered semi-structured questionnaire. A complete copy of the questionnaire and auto-generated results are available in the Data Supplement section. All regular secondary care outpatient clinics in the disciplines of cardiology, diabetes and endocrinology (D&E), general medicine (GM) and nephrology at 15 separate hospital or clinic sites were identified through the electronic patient management system. These were filtered manually to identify the outpatient clinics where it was anticipated that BP measurement is routine. The clinician responsible for a clinic was emailed and invited to complete the online questionnaire for that particular clinic. Therefore, each clinician might be invited to complete more than one questionnaire. The clinics were within National Health Service (NHS) Greater Glasgow and Clyde region, covering a mixed urban and rural population of approximately 1.2 million including seven hospitals with 15 separate outpatient clinic sites. Data analysis was done utilising Microsoft Excel Version 2310 (Microsoft, Redmont, WA, USA). Each question was extracted using automatic extraction by Webropol into an Excel file. Questions from the same domain were merged as appropriate. Ethical approval was granted by the Research Ethics Committee of the University of Glasgow’s College of Medical, Veterinary, and Life Sciences on 11th July 2023 (reference number 200220359). Results General Characteristics of Study Participants Completed questionnaires were received from the supervising clinician of 110 of the 268 surveyed clinics (41%). Table 1 shows general characteristics from these clinics. Participating clinics were divided into four groups i.e., cardiology, D&E, GM, and renal. The D&E group made up 42.7% of the total participants with cardiology, GM and renal having 25.4%, 6.4%, and 25.4% respondents, respectively. Table 1 Characteristics of Clinics that Routinely Measure Blood Pressure How frequently is blood pressure measured at this clinic? n (%) At every visit 58 (79.4) Only at first visit/new patient 4 (5.5) Others Annual 4 (5.5) Ad hoc 4 (5.5) Separate screening session 2 (2.7) Not applicable Only single visit for each patient 1 (1.4) Total 73 (100) Clinic frequency Daily 1 (1.4) Twice per week 1 (1.4) Weekly 60 (82.2) Fortnightly 5 (6.8) Thrice per month 1 (1.4) Monthly 5 (6.8) Total 73 (100) Approximate number of patients attending each clinic 20 14 (19.2) Total 73 (100) Who takes BP measurement? Nurses 26 (35.6) Doctors 3 (4.1) Health care assistants 10 (13.7) Others Pharmacist 10 (13.7) Physiologist 1 (1.4) Transplant coordinator 1 (1.4) Doctor and nurses 4 (5.5) Nurses and health care assistant 17 (23.3) Doctor and health care assistant 1 (1.4) Total 73 (100) Nearly 70% of participating clinics routinely measure BP. Examples of clinics where BP is not routinely measured included highly specialised clinics e.g., clinics dedicated for echocardiography, osteoporosis, allergy, thyroid, virtual clinics and specific diabetes clinics where recent BP readings from primary care are routinely available. General Characteristics of outpatient clinics where BP is routinely measured (n = 73) Table 1 summarises characteristics of clinics that routinely measure BP (n = 73). Nearly 80% of these clinics measure BP at every visit. The vast majority run the clinics weekly (82.2%). Nearly half of the clinics have 10 to 20 patients in each visit (49.3%). Measurement of BP is predominantly done by nurses (35.6%), health care assistants (13.7%), and a combination of nurses and health care assistants (23.3%). In the clinics where the supervising clinician is a pharmacist (n = 10), nearly all BP measurement is taken by the pharmacists themselves. Standardised BP method (Patient preparation, environment, BP measurement technique) Table 2 summarises the responses in relation to the domains of standardised BP measurement in the 73 respondents where BP is routinely measured. Only 3 (4.1%) clinics adhered to all facets of the standardised BP method. These were all renal clinics. Table 2 Blood Pressure Measurement in Clinics. Patient preparation Advice on BP measurement preparation n (%) Yes - By mail/letter - By mail/letter AND at (preceding) clinic - By phone and at (preceding) clinic 1 (1.4) 3 (4.1) 1 (1.4) No 68 (93.1) Total 73 (100) Application of standardised resting period n (%) Always 24 (32.9) Never 33 (45.2) Sometimes 16 (21.9) Total 73 (100) Environment Dedicated quiet area without disturbance Yes 61 (83.6) No 12 (16.4) Total 73 (100) BP measurement technique Cuff is placed around patient’s bare upper arm Yes 50 (68.5) No 8 (11.0) Unknown 15 (20.5) Total 73 (100) The use of appropriate cuff size Yes 46 (63.0) No 9 (12.3) Unknown 18 (24.7) Total 73 (100) Measure BP on both arms at the first visit Yes 7 (9.6) No 58 (79.4) Unknown 8 (11.0) Total 73 (100) Table 3 Standing and Lying Blood Pressure Measurement Standing BP routine Indications (if applicable) n % Always 2 2.7 Never 28 38.4 Sometimes 43 58.9 Postural hypotension/orthostatic hypotension 35 (81.4%) Ad hoc based on doctor request 6 (13.9%) Others (endocrine reasons such as steroid replacement -- hypoadrenalism, phaeochromocytoma) 2 (4.6%) Total 73 100 Lying BP routine Always 2 2.7 Never 43 58.9 Sometimes 28 38.4 Postural hypotension/orthostatic hypotension 21 Ad hoc based on doctor request 3 Others (endocrine reasons, semi-recumbent) 2 Not specified 2 Total 73 100 Advice such as avoiding exercise, caffeine, and or tobacco consumption for 30 minutes prior to BP measurement, wearing clothing that allows easy access to bare upper arms are not provided by majority of the clinics (93.1%). Clinics that provide such advice send this information by mail or letter or give this advice at preceding clinics. The majority of respondents (n = 61 [83.6%]) reported having a dedicated quiet area without disturbance to measure BP. The advised standardised resting period is five minutes in a quiet area. Just over 30% of clinics apply this standardised resting period. With regard to BP measurement technique, 68.5% of participating clinics always place the cuff around the patient’s bare upper arm and 63.0% vary the cuff size according to the upper arm circumference. A large majority of clinics (79.4%) do not measure BP on both arms at the first visit. Reporting Techniques and Equipment Nearly one third of the participating clinics take more than one sitting BP measurement from the same arm (27.4%). If not reporting the average, various approaches are used to report BP measurement results, i.e., report all, the highest, exclude the first one if significantly higher, discard the first and choose the lowest, or the second measurement. Results from BP measurements are documented mostly in the electronic patient record (42.5%), both letter (non-auto-generated) and electronic patient record (26.0%), or non-auto-generated letter (24.6%). Complete data are presented in Table S1 of Data Supplement. 47.9% of respondents were able to report the types and brands of blood pressure equipment used in the clinics. The majority of clinics reported the use of an automated BP machine (71.4%) followed by a combined approach using automated machine and manual measurement with sphygmomanometer (20%). The remaining clinics use manual BP measurement (8.6%). Omron and Omicron are the two most common brands used by participating clinics. Other reported brands are Wellch Allyn, Mindray, Dinamap, and Criticare. Standing and Lying BP Nearly all participating clinics (98.6%) use sitting as the default position when measuring BP. Standing BP is always measured in two cardiology clinics (2.7%). Lying BP is always measured in two clinics (2.7%); one D&E and one GM clinic. Most clinics conduct standing and lying BP measurement in specific circumstances (58.9% and 38.4%, respectively). Suspicion of postural hypotension such as postural dizziness, collapse or syncope were the commonest reported indications for standing or lying BP measurement. HBPM and ABPM Nearly 70% of participating clinics reported that HBPM and/or ABPM are used in their clinics to complement clinic BP measurement. 21 (28.8%) use both HBPM and ABPM, 22 (30.1%) use only HBPM and 8 use only ABPM (11%). BMI More than half (54.8%) of the participating clinics routinely assess BMI in every visit. Several clinics indicated that BMI assessment is done only in certain circumstances such as new patients, imaging purposes (body surface area), or if there is an impression of substantial weight change. Complete data is presented in Table S2 of Data Supplement. Discussion This is the most comprehensive survey of outpatient clinic BP measurement practice in routine secondary care settings reported to date. Although guidelines describe the standardised BP method, there is no quality assurance system in place to ensure that recorded results have been performed by a standardised method unlike, for example, laboratory data. Our data confirmed previous reports that routine outpatient clinic BP measurement rarely adheres to the standardised method that was used in clinical trials of blood pressure treatment and is recommended in international guidelines, with only 4.1% of the surveyed clinics where BP is routinely measured adhering to all facets of the standardised method. This has important implications as all treatment decisions in the remaining clinics are potentially flawed by misinterpretation of the BP measurements taken in a non-standardised way. Previous studies indicate that the difference between non-standardised and standardised BP measurement for an individual patient is unpredictable and can be >40mmHg (8, 9). It is notable that 70% of the respondents use HBPM and ABPM to complement outpatient clinic BP measurement but treatment decisions based on these BP measurement techniques have less certainty than treatment decisions based on standardised BP measures (2-4). The lack of patient preparation by most of the clinics means that there is a risk of over-estimation of BP due to patients having consumed caffeine, exercised or have a sensation of a full bladder, while smoking tobacco or other inhalants might artificially lower BP. Failure by the majority of clinics to measure BP in a dedicated quiet area after at least 5 minutes of rest will lead to overestimation of BP. Failure to measure in both arms at the first visit to determine which arm has the higher BP and should be used for future clinic BP measurement may lead to falsely low BP readings in the future. Approximately 10% of patients with chronic conditions such as kidney disease have inter-arm BP difference of >10mmHg (10). Failure to ensure that BP is always taken on the bare arm with the correct cuff size for that arm leads to both over-estimation and under-estimation of BP (11). Previous studies that have explored barriers to standardised method being used for routine BP measurement at clinics reported time pressure (busy clinics), pressured maintain clinician workflow and limited resources including clinic layouts as important factors (12, 13). These factor were likely prominent explanations for the lack of adherence in the clinics we surveyed although this was not the focus of our study. Our survey, in a health service for a population of 1.2 million with hundreds of patients attending clinics every week where BP measurement and related treatment decisions are routine, indicates that the lack of adherence to standardised BP method means that patients are having inadequate treatment of BP and, at this scale, this has major resource implications related to consequences of both under and over-treatment of BP. It is likely that investment to ensure standardised BP measurement was applied at all these clinics would be trivial compared to these consequences and therefore would be highly cost-effective (14, 15). Our study had strengths and limitations. This is a large survey covering several secondary care specialities across all secondary care sites in a defined health service area. The survey return rate of 41% is relatively high for surveys of this kind and resulted in 73 responses of clinics where BP is routinely measured. It is unlikely that our survey missed many clinics where BP is routinely measured as we targeted specialties where BP management is a major focus of care. It seems likely that the clinics that did not respond were either equally or less likely to adhere to the standardised method. The fact that the survey was performed in a single health service area means that the result might not be generalizable. This seems unlikely as there are reports in the literature of the challenges of implementing the standardised method and discussion at national and international meetings indicates this is a widespread issue. We described adherence to the standardised method but did not explore the barriers. Future studies should explore these barriers including clinician education, patient education real estate infrastructure, staffing resource and equipment and lead to studies of how to implement the necessary changes. This might need novel solutions e.g., if resources are limited it would be better to measure BP by the standardised method every alternate visit for regular attendees than by the non-standardised method every visit. A similar study should also be done in primary care where a large proportion of blood pressure management is conducted in the UK. Our comprehensive survey demonstrated very low adherence to all facets of the standardised BP method in secondary care clinics where BP measurement is routine. This has important implications for the quality of treatment decisions. Clinicians should pay close attention to how BP is being measured before making treatment decisions. We believe that greater priority should be given to the quality of BP measurement in outpatient settings in a similar way to quality controls relating to other routine clinical measurements such as laboratory measures. Declarations Data Availability Statement Data are available from the corresponding author on reasonable request. Acknowledgements This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 954798 (“MINDSHIFT”). CD is also supported by the British Heart Foundation (Centre of Research Excellence, reference RE/18/6/34217). Author Contributions DS contributed to questionnaire design, ethical approval, data extraction and analysis as well as manuscript writing. CG and CD provided feedback on questionnaire design and manuscript writing. CG provided list of clinics for dissemination. CD helped on ethical approval process. Funding DS is funded by the European Commission’s Horizon 2020 Framework Programme (No. 954798). CD is supported by the British Heart Foundation (Centre of Research Excellence, reference RE/18/6/34217). Ethical Approval Ethical approval was granted by the Research Ethics Committee of the University of Glasgow’s College of Medical, Veterinary, and Life Sciences on 11 th July 2023 (reference number 200220359). Competing Interest Authors have nothing to disclose. References Muntner P, Einhorn PT, Cushman WC, Whelton PK, Bello NA, Drawz PE, et al. Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel. Journal of the American College of Cardiology. 2019;73(3):317-35. Cheung A, Chang T, Cushman W, Furth S, Hou F, Ix J, et al. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney International. 2021;99:S1-S87. NICE. Hypertension in adults: diagnosis and management [NICE guideline [NG136]]. 2022 [updated 18 March 2022; cited 2023 10 November]. Available from: https://www.nice.org.uk/guidance/ng136/chapter/Recommendations#measuring-blood-pressure. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal. 2018;39(33):3021-104. Wijayaratne D. Standardised Office Blood Pressure Measurement 2021 [Available from: https://www.nephjc.com/news/2021/6/8/kdigo-and-bp-one-target-many-visual-abstracts. Elias MF, Goodell AL. Human Errors in Automated Office Blood Pressure Measurement. Hypertension. 2021;77(1):6-15. Shihab HM, Meoni LA, Chu AY, Wang NY, Ford DE, Liang KY, et al. Body mass index and risk of incident hypertension over the life course: the Johns Hopkins Precursors Study. Circulation. 2012;126(25):2983-9. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697-716. Cheng RZ, Bhalla V, Chang TI. Comparison of routine and automated office blood pressure measurement. Blood Press Monit. 2019;24(4):174-8. Clark CE, Taylor RS, Shore AC, Campbell JL. Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis. Br J Gen Pract. 2016;66(652):e838-e47. Palatini P, Asmar R. Cuff challenges in blood pressure measurement. J Clin Hypertens (Greenwich). 2018;20(7):1100-3. Hwang KO, Aigbe A, Ju HH, Jackson VC, Sedlock EW. Barriers to Accurate Blood Pressure Measurement in the Medical Office. J Prim Care Community Health. 2018;9:2150132718816929. Fonseca-Reyes S, Forsyth-MacQuarrie AM, García de Alba-García JE. Simultaneous blood pressure measurement in both arms in hypertensive and nonhypertensive adult patients. Blood Press Monit. 2012;17(4):149-54. McVicker JT. Blood pressure measurement--does anyone do it right?: An assessment of the reliability of equipment in use and the measurement techniques of clinicians. J Fam Plann Reprod Health Care. 2001;27(3):163-4. Sharman JE, Ordunez P, Brady T, Parati G, Stergiou G, Whelton PK, et al. The urgency to regulate validation of automated blood pressure measuring devices: a policy statement and call to action from the world hypertension league. J Hum Hypertens. 2023;37(2):155-9. Additional Declarations There is NO conflict of interest to disclose. 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cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003ch2\u003e\u003cstrong\u003eWhat is known about the topic\u003c/strong\u003e\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003eBlood pressure (BP) measurement is a common procedure conducted in various disciplines and widely available on clinical reports.\u003c/li\u003e\n \u003cli\u003eThe challenges in application of standardised method for BP measurement in routine clinical practice are often overlooked.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003ch2\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003eDescription BP measurement techniques across NHS Greater Glasgow and Clyde (population 1.2 million).\u003c/li\u003e\n \u003cli\u003eIn a wide range of secondary care out-patient clinic settings, BP measurement rarely adheres to the recommended standards.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Introduction","content":"\u003cp\u003eAssessment of blood pressure (BP) is one of the most common measurements conducted in outpatient clinical settings particularly in cardiology, diabetes and endocrinology, nephrology and specialist hypertension clinics. Accurate BP measurements are crucial for diagnosis and management of hypertension (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Contemporary guidelines including National Institute for Health and Care Excellence (NICE), Kidney Disease Improving Global Outcomes (KDIGO), European Society of Hypertension (ESH) guidelines (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) provide detailed guidance on accurate BP measurement. The randomised controlled trials referred to in these guidelines were all based on outpatient clinic BP (sometimes referred to as office BP) measured according to a standardised method. This standardised BP method involves 3 domains: patient preparation, environment and BP measurement technique.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNon-standardised BP measurement can lead to over or under-estimation of BP of unpredictable magnitude and this will inevitably lead to sub-optimal treatment (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). For this reason, international guidelines emphasise that treatment of BP should be based on standardised office BP measurement. It is recognised that incorporation of all facets of standardised methodology into routine practice is challenging. The aim of this study was to determine if outpatient clinics in which BP is routinely measured adhere to the domains of standardised BP measurement. We also aimed to determine how ambulatory blood pressure measurement (ABPM) and home blood pressure monitoring (HBPM) are utilised in these clinics. In addition we determined if body mass index (BMI) is assessed at these clinics because of the notable association of overweight and obesity with hypertension (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"Subjects and Methods","content":"\u003cp\u003eThis is a descriptive cross-sectional study. Data collection was done through dissemination of an online questionnaire designed by Webropol (Helsinki, Finland). The questionnaire is a self-administered semi-structured questionnaire. A complete copy of the questionnaire and auto-generated results are available in the Data Supplement section. All regular secondary care outpatient clinics in the disciplines of cardiology, diabetes and endocrinology (D\u0026amp;E), general medicine (GM) and nephrology at 15 separate hospital or clinic sites were identified through the electronic patient management system. These were filtered manually to identify the outpatient clinics where it was anticipated that BP measurement is routine. The clinician responsible for a clinic was emailed and invited to complete the online questionnaire for that particular clinic. Therefore, each clinician might be invited to complete more than one questionnaire. The clinics were within National Health Service (NHS) Greater Glasgow and Clyde region, covering a mixed urban and rural population of approximately 1.2\u0026nbsp;million including seven hospitals with 15 separate outpatient clinic sites.\u003c/p\u003e \u003cp\u003eData analysis was done utilising Microsoft Excel Version 2310 (Microsoft, Redmont, WA, USA). Each question was extracted using automatic extraction by Webropol into an Excel file. Questions from the same domain were merged as appropriate. Ethical approval was granted by the Research Ethics Committee of the University of Glasgow\u0026rsquo;s College of Medical, Veterinary, and Life Sciences on 11th July 2023 (reference number 200220359).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Characteristics of Study Participants\u003c/h2\u003e \u003cp\u003eCompleted questionnaires were received from the supervising clinician of 110 of the 268 surveyed clinics (41%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows general characteristics from these clinics. Participating clinics were divided into four groups i.e., cardiology, D\u0026amp;E, GM, and renal. The D\u0026amp;E group made up 42.7% of the total participants with cardiology, GM and renal having 25.4%, 6.4%, and 25.4% respondents, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Clinics that Routinely Measure Blood Pressure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHow frequently is blood pressure measured at this clinic?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAt every visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (79.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOnly at first visit/new patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnnual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAd hoc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeparate screening session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly single visit for each patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinic frequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTwice per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWeekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (82.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFortnightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eThrice per month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMonthly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximate number of patients attending each clinic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (31.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e10\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (49.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWho takes BP measurement?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (35.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDoctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHealth care assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransplant coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDoctor and nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNurses and health care assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (23.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDoctor and health care assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNearly 70% of participating clinics routinely measure BP. Examples of clinics where BP is not routinely measured included highly specialised clinics e.g., clinics dedicated for echocardiography, osteoporosis, allergy, thyroid, virtual clinics and specific diabetes clinics where recent BP readings from primary care are routinely available.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Characteristics of outpatient clinics where BP is routinely measured (n\u0026thinsp;=\u0026thinsp;73)\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises characteristics of clinics that routinely measure BP (n\u0026thinsp;=\u0026thinsp;73). Nearly 80% of these clinics measure BP at every visit. The vast majority run the clinics weekly (82.2%). Nearly half of the clinics have 10 to 20 patients in each visit (49.3%). Measurement of BP is predominantly done by nurses (35.6%), health care assistants (13.7%), and a combination of nurses and health care assistants (23.3%). In the clinics where the supervising clinician is a pharmacist (n\u0026thinsp;=\u0026thinsp;10), nearly all BP measurement is taken by the pharmacists themselves.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStandardised BP method (Patient preparation, environment, BP measurement technique)\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarises the responses in relation to the domains of standardised BP measurement in the 73 respondents where BP is routinely measured. Only 3 (4.1%) clinics adhered to all facets of the standardised BP method. These were all renal clinics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood Pressure Measurement in Clinics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003ePatient preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvice on BP measurement preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003e- By mail/letter\u003c/p\u003e \u003cp\u003e- By mail/letter AND at (preceding) clinic\u003c/p\u003e \u003cp\u003e- By phone and at (preceding) clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (93.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eApplication of standardised resting period\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (32.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (45.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (21.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eEnvironment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDedicated quiet area without disturbance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (83.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"14\" rowspan=\"15\"\u003e \u003cp\u003e\u003cb\u003eBP measurement\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003etechnique\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCuff is placed around patient\u0026rsquo;s bare upper arm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (68.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eThe use of appropriate cuff size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (63.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (12.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (24.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMeasure BP on both arms at the first visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (79.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStanding and Lying Blood Pressure Measurement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStanding BP routine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndications (if applicable)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostural hypotension/orthostatic hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (81.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAd hoc based on doctor request\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (13.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers (endocrine reasons such as steroid replacement -- hypoadrenalism, phaeochromocytoma)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLying BP routine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostural hypotension/orthostatic hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAd hoc based on doctor request\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers (endocrine reasons, semi-recumbent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdvice such as avoiding exercise, caffeine, and or tobacco consumption for 30 minutes prior to BP measurement, wearing clothing that allows easy access to bare upper arms are not provided by majority of the clinics (93.1%). Clinics that provide such advice send this information by mail or letter or give this advice at preceding clinics.\u003c/p\u003e \u003cp\u003eThe majority of respondents (n\u0026thinsp;=\u0026thinsp;61 [83.6%]) reported having a dedicated quiet area without disturbance to measure BP. The advised standardised resting period is five minutes in a quiet area. Just over 30% of clinics apply this standardised resting period. With regard to BP measurement technique, 68.5% of participating clinics always place the cuff around the patient\u0026rsquo;s bare upper arm and 63.0% vary the cuff size according to the upper arm circumference. A large majority of clinics (79.4%) do not measure BP on both arms at the first visit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eReporting Techniques and Equipment\u003c/h2\u003e \u003cp\u003eNearly one third of the participating clinics take more than one sitting BP measurement from the same arm (27.4%). If not reporting the average, various approaches are used to report BP measurement results, i.e., report all, the highest, exclude the first one if significantly higher, discard the first and choose the lowest, or the second measurement.\u003c/p\u003e \u003cp\u003eResults from BP measurements are documented mostly in the electronic patient record (42.5%), both letter (non-auto-generated) and electronic patient record (26.0%), or non-auto-generated letter (24.6%). Complete data are presented in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e of Data Supplement.\u003c/p\u003e \u003cp\u003e47.9% of respondents were able to report the types and brands of blood pressure equipment used in the clinics. The majority of clinics reported the use of an automated BP machine (71.4%) followed by a combined approach using automated machine and manual measurement with sphygmomanometer (20%). The remaining clinics use manual BP measurement (8.6%). Omron and Omicron are the two most common brands used by participating clinics. Other reported brands are Wellch Allyn, Mindray, Dinamap, and Criticare.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStanding and Lying BP\u003c/h2\u003e \u003cp\u003eNearly all participating clinics (98.6%) use sitting as the default position when measuring BP. Standing BP is always measured in two cardiology clinics (2.7%). Lying BP is always measured in two clinics (2.7%); one D\u0026amp;E and one GM clinic.\u003c/p\u003e \u003cp\u003eMost clinics conduct standing and lying BP measurement in specific circumstances (58.9% and 38.4%, respectively). Suspicion of postural hypotension such as postural dizziness, collapse or syncope were the commonest reported indications for standing or lying BP measurement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eHBPM and ABPM\u003c/h2\u003e \u003cp\u003eNearly 70% of participating clinics reported that HBPM and/or ABPM are used in their clinics to complement clinic BP measurement. 21 (28.8%) use both HBPM and ABPM, 22 (30.1%) use only HBPM and 8 use only ABPM (11%).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eBMI\u003c/h2\u003e \u003cp\u003eMore than half (54.8%) of the participating clinics routinely assess BMI in every visit. Several clinics indicated that BMI assessment is done only in certain circumstances such as new patients, imaging purposes (body surface area), or if there is an impression of substantial weight change. Complete data is presented in Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e of Data Supplement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the most comprehensive survey of outpatient clinic BP measurement practice in routine secondary care settings reported to date. Although guidelines describe the standardised BP method, there is no quality assurance system in place to ensure that recorded results have been performed by a standardised method unlike, for example, laboratory data. Our data confirmed previous reports that routine outpatient clinic BP measurement rarely adheres to the standardised method that was used in clinical trials of blood pressure treatment and is recommended in international guidelines, with only 4.1% of the surveyed clinics where BP is routinely measured adhering to all facets of the standardised method. \u0026nbsp;This has important implications as all treatment decisions in the remaining clinics are potentially flawed by misinterpretation of the BP measurements taken in a non-standardised way. Previous studies indicate that the difference between non-standardised and standardised BP measurement for an individual patient is unpredictable and can be \u0026gt;40mmHg\u0026nbsp;(8, 9). It is notable that 70% of the respondents use HBPM and ABPM to complement outpatient clinic BP measurement but treatment decisions based on these BP measurement techniques have less certainty than treatment decisions based on standardised BP measures\u0026nbsp;(2-4). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe lack of patient preparation by most of the clinics means that there is a risk of over-estimation of BP due to patients having consumed caffeine, exercised or have a sensation of a full bladder, while smoking tobacco or other inhalants might artificially lower BP. \u0026nbsp;Failure by the majority of clinics to measure BP in a dedicated quiet area after at least 5 minutes of rest will lead to overestimation of BP. \u0026nbsp;Failure to measure in both arms at the first visit to determine which arm has the higher BP and should be used for future clinic BP measurement may lead to falsely low BP readings in the future. \u0026nbsp; Approximately 10% of patients with chronic conditions such as kidney disease have inter-arm BP difference of \u0026gt;10mmHg\u0026nbsp;(10). Failure to ensure that BP is always taken on the bare arm with the correct cuff size for that arm leads to both over-estimation and under-estimation of BP\u0026nbsp;(11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious studies that have explored barriers to standardised method being used for routine BP measurement at clinics reported time pressure (busy clinics), pressured maintain clinician workflow and limited resources including clinic layouts as important factors\u0026nbsp;(12, 13). \u0026nbsp; These factor were likely prominent explanations for the lack of adherence in the clinics we surveyed although this was not the focus of our study. \u0026nbsp;Our survey, in a health service for a population of 1.2 million with hundreds of patients attending clinics every week where BP measurement and related treatment decisions are routine, indicates that the lack of adherence to standardised BP method means that patients are having inadequate treatment of BP and, at this scale, this has major resource implications related to consequences of both under and over-treatment of BP. \u0026nbsp;It is likely that investment to ensure standardised BP measurement was applied at all these clinics would be trivial compared to these consequences and therefore would be highly cost-effective\u0026nbsp;(14, 15). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study had strengths and limitations. This is a large survey covering several secondary care specialities across all secondary care sites in a defined health service area. \u0026nbsp; The survey return rate of 41% is relatively high for surveys of this kind and resulted in 73 responses of clinics where BP is routinely measured. It is unlikely that our survey missed many clinics where BP is routinely measured as we targeted specialties where BP management is a major focus of care. \u0026nbsp;It seems likely that the clinics that did not respond were either equally or less likely to adhere to the standardised method. \u0026nbsp; The fact that the survey was performed in a single health service area means that the result might not be generalizable. \u0026nbsp; This seems unlikely as there are reports in the literature of the challenges of implementing the standardised method and discussion at national and international meetings indicates this is a widespread issue. \u0026nbsp;We described adherence to the standardised method but did not explore the barriers. Future studies should explore these barriers including clinician education, patient education real estate infrastructure, staffing resource and equipment and lead to studies of how to implement the necessary changes. \u0026nbsp;This might need novel solutions e.g., if resources are limited it would be better to measure BP by the standardised method every alternate visit for regular attendees than by the non-standardised method every visit. A similar study should also be done in primary care where a large proportion of blood pressure management is conducted in the UK.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur comprehensive survey demonstrated very low adherence to all facets of the standardised BP method in secondary care clinics where BP measurement is routine. \u0026nbsp; This has important implications for the quality of treatment decisions. \u0026nbsp;Clinicians should pay close attention to how BP is being measured before making treatment decisions. We believe that greater priority should be given to the quality of BP measurement in outpatient settings in a similar way to quality controls relating to other routine clinical measurements such as laboratory measures. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eData are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project has received funding from the European Union\u0026rsquo;s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 954798 (\u0026ldquo;MINDSHIFT\u0026rdquo;). CD is also supported by the British Heart Foundation (Centre of Research Excellence, reference RE/18/6/34217).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDS contributed to questionnaire design, ethical approval, data extraction and analysis as well as manuscript writing. CG and CD provided feedback on questionnaire design and manuscript writing. CG provided list of clinics for dissemination. CD helped on ethical approval process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDS is funded by the European Commission\u0026rsquo;s Horizon 2020 Framework Programme (No. 954798). CD is supported by the British Heart Foundation (Centre of Research Excellence, reference RE/18/6/34217).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Research Ethics Committee of the University of Glasgow\u0026rsquo;s College of Medical, Veterinary, and Life Sciences on 11\u003csup\u003eth\u003c/sup\u003e July 2023 (reference number 200220359).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have nothing to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMuntner P, Einhorn PT, Cushman WC, Whelton PK, Bello NA, Drawz PE, et al. Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel. Journal of the American College of Cardiology. 2019;73(3):317-35.\u003c/li\u003e\n\u003cli\u003eCheung A, Chang T, Cushman W, Furth S, Hou F, Ix J, et al. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney International. 2021;99:S1-S87.\u003c/li\u003e\n\u003cli\u003eNICE. Hypertension in adults: diagnosis and management [NICE guideline [NG136]]. 2022 [updated 18 March 2022; cited 2023 10 November]. Available from: https://www.nice.org.uk/guidance/ng136/chapter/Recommendations#measuring-blood-pressure.\u003c/li\u003e\n\u003cli\u003eWilliams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal. 2018;39(33):3021-104.\u003c/li\u003e\n\u003cli\u003eWijayaratne D. Standardised Office Blood Pressure Measurement 2021 [Available from: https://www.nephjc.com/news/2021/6/8/kdigo-and-bp-one-target-many-visual-abstracts.\u003c/li\u003e\n\u003cli\u003eElias MF, Goodell AL. Human Errors in Automated Office Blood Pressure Measurement. Hypertension. 2021;77(1):6-15.\u003c/li\u003e\n\u003cli\u003eShihab HM, Meoni LA, Chu AY, Wang NY, Ford DE, Liang KY, et al. Body mass index and risk of incident hypertension over the life course: the Johns Hopkins Precursors Study. Circulation. 2012;126(25):2983-9.\u003c/li\u003e\n\u003cli\u003ePickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697-716.\u003c/li\u003e\n\u003cli\u003eCheng RZ, Bhalla V, Chang TI. Comparison of routine and automated office blood pressure measurement. Blood Press Monit. 2019;24(4):174-8.\u003c/li\u003e\n\u003cli\u003eClark CE, Taylor RS, Shore AC, Campbell JL. Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis. Br J Gen Pract. 2016;66(652):e838-e47.\u003c/li\u003e\n\u003cli\u003ePalatini P, Asmar R. Cuff challenges in blood pressure measurement. J Clin Hypertens (Greenwich). 2018;20(7):1100-3.\u003c/li\u003e\n\u003cli\u003eHwang KO, Aigbe A, Ju HH, Jackson VC, Sedlock EW. Barriers to Accurate Blood Pressure Measurement in the Medical Office. J Prim Care Community Health. 2018;9:2150132718816929.\u003c/li\u003e\n\u003cli\u003eFonseca-Reyes S, Forsyth-MacQuarrie AM, Garc\u0026iacute;a de Alba-Garc\u0026iacute;a JE. Simultaneous blood pressure measurement in both arms in hypertensive and nonhypertensive adult patients. Blood Press Monit. 2012;17(4):149-54.\u003c/li\u003e\n\u003cli\u003eMcVicker JT. Blood pressure measurement--does anyone do it right?: An assessment of the reliability of equipment in use and the measurement techniques of clinicians. J Fam Plann Reprod Health Care. 2001;27(3):163-4.\u003c/li\u003e\n\u003cli\u003eSharman JE, Ordunez P, Brady T, Parati G, Stergiou G, Whelton PK, et al. The urgency to regulate validation of automated blood pressure measuring devices: a policy statement and call to action from the world hypertension league. J Hum Hypertens. 2023;37(2):155-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-human-hypertension","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jhh","sideBox":"Learn more about [Journal of Human Hypertension](http://www.nature.com/jhh/)","snPcode":"41371","submissionUrl":"https://mts-jhh.nature.com/cgi-bin/main.plex","title":"Journal of Human Hypertension","twitterHandle":"@jhhypertension","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4635130/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4635130/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBlood pressure (BP) measurement is a common procedure conducted in various disciplines and widely available on clinical reports. The diagnosis and management of hypertension requires reliable measurement of BP in outpatient clinics. Published studies suggest the standardised method for BP measurement is difficult to apply in routine clinical practice.\u003c/p\u003e\n\u003cp\u003eThis study aimed to assess the current practice of BP measurement in outpatient clinics in relevant secondary care clinical specialties across the 15 separate hospital sites of the NHS Greater Glasgow and Clyde region (population 1.2 million) compared to the recommended standardised method.\u003c/p\u003e\n\u003cp\u003eAn online questionnaire was developed and disseminated to the supervising clinician of each of 268 regular outpatient clinics. The questionnaire focused on the standardised BP method (patient preparation, environment, and BP measurement technique).\u003c/p\u003e\n\u003cp\u003eThe questionnaire was returned for 110 clinics. 73 (66.4%) of the participating clinics measure BP routinely and these formed the basis for further analysis. 3 clinics (4.1%) apply all components of the standardised BP method. 5 (6.9%) clinics deliver advice to patients prior to clinic attendance on how to prepare for BP measurement. 61 (83.6%) of participating clinics have a dedicated quiet environment for BP measurement. 50 (68.5%) clinics always place the cuff on bare upper arm and 63.0% use a cuff size appropriate to upper arm circumference.\u003c/p\u003e\n\u003cp\u003eIn a wide range of secondary care out-patient clinic settings we found that BP measurement rarely adheres to the recommended standards. This has important implications for the quality of treatment decisions that are based on BP measurement.\u003c/p\u003e","manuscriptTitle":"Blood Pressure Measurement Technique in Clinical Practice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 18:32:23","doi":"10.21203/rs.3.rs-4635130/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-10-08T11:49:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-10-07T14:22:24+00:00","index":1,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-09-26T10:21:34+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-09-26T10:08:00+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-09-19T14:24:38+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2024-07-04T18:26:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-03T02:23:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-27T11:20:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Human Hypertension","date":"2024-06-26T10:32:34+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2024-06-26T08:40:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-human-hypertension","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jhh","sideBox":"Learn more about [Journal of Human Hypertension](http://www.nature.com/jhh/)","snPcode":"41371","submissionUrl":"https://mts-jhh.nature.com/cgi-bin/main.plex","title":"Journal of Human Hypertension","twitterHandle":"@jhhypertension","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2b074e84-574d-414b-9a2b-36adbda59958","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34144393,"name":"Health sciences/Health care/Diagnosis"},{"id":34144394,"name":"Health sciences/Diseases/Cardiovascular diseases/Hypertension/Renovascular hypertension"}],"tags":[],"updatedAt":"2024-12-06T08:05:35+00:00","versionOfRecord":{"articleIdentity":"rs-4635130","link":"https://doi.org/10.1038/s41371-024-00984-5","journal":{"identity":"journal-of-human-hypertension","isVorOnly":false,"title":"Journal of Human Hypertension"},"publishedOn":"2024-12-05 05:00:00","publishedOnDateReadable":"December 5th, 2024"},"versionCreatedAt":"2024-07-29 18:32:23","video":"","vorDoi":"10.1038/s41371-024-00984-5","vorDoiUrl":"https://doi.org/10.1038/s41371-024-00984-5","workflowStages":[]},"version":"v1","identity":"rs-4635130","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4635130","identity":"rs-4635130","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}