Evaluation of the applicability of deep breathing test in the diagnosis of hypertension with white-coat effect in Chinese patients in primary care

Abstract Background Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data. Methods Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6–12 months follow-up prior to analysis. The fourth analysis used linear mixed modelling based on all available data. Results The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6–12 months follow-up (-4.06, 95% CI -6.30 to -1.82, p < 0.001) for patients with systolic BP below 135 at baseline. For the standardisation with matching and regression adjustment for propensity score analyses, systolic BP was significantly lower overall (− 5.96, 95% CI -8.36 to − 3.55 , p < 0.001) and (− 3.73, 95% CI− 5.34 to − 2.13, p < 0.001) respectively, even after assuming that − 5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -3.37 (95% CI -5.41 to -1.33 , p < 0.001) after 1 year. Conclusions The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

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Examining the Effectiveness of Telemonitoring with Routinely Acquired Blood Pressure Data in Primary Care: Challenges in the Statistical Analysis

10.21203/rs.3.rs-71464/v1 ◽

2020 ◽

Author(s):

Richard Parker ◽

Paul Padfield ◽

Janet Hanley ◽

Hilary Pinnock ◽

John Kennedy ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Statistical Analysis ◽

Cohort Analysis ◽

Random Coefficient ◽

White Coat ◽

White Coat Effect ◽

The Impact ◽

Analytical Approaches

Abstract BackgroundScale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data.MethodsThree different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, and “random coefficient modelling”. The first two methods standardised the groups so that all participants provided exactly two measurements at baseline and 6-12 months follow-up before using stratification or matched cohort analysis to compare the groups. The third analysis used linear mixed modelling based on all available data. ResultsThe standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6-12 months follow-up (-3.42, 95% CI -1.72 to -5.11, p<0.001). For the standardisation with matching analysis, systolic BP was also significantly lower (-5.96, 95% CI -3.55 to -8.36, p<0.001), even after assuming that -5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -4.68 (95% CI -3.12 to -6.24, p<0.001) after one year. ConclusionsThe three analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

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Ambulatory Blood Pressure Monitoring to Study White Coat Effect in Patients With Hypertension Followed in Primary Care

Revista Española de Cardiología (English Edition) ◽

10.1016/s1885-5857(06)60289-2 ◽

2004 ◽

Vol 57 (7) ◽

pp. 652-660

Author(s):

Francisco Villalba Alcalá ◽

José Lapetra Peralta ◽

Eduardo Mayoral Sánchez ◽

Antonio Espino Montoro ◽

Aurelio Cayuela Domínguez ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Ambulatory Blood Pressure Monitoring ◽

Ambulatory Blood Pressure ◽

Blood Pressure Monitoring ◽

White Coat ◽

Pressure Monitoring ◽

White Coat Effect

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DEEP BREATHING TEST IN DIFFERENTIAL DIAGNOSIS OF WHITE COAT HYPERTENSION

Journal of Hypertension ◽

10.1097/00004872-200406002-00076 ◽

2004 ◽

Vol 22 (Suppl. 2) ◽

pp. S25 ◽

Cited By ~ 1

Author(s):

J. M. Thalenberg ◽

R. M.S. Povoa ◽

M. T.N. Bombig ◽

G. A.C. Sa ◽

A. N. Attalah ◽

...

Keyword(s):

Differential Diagnosis ◽

White Coat ◽

White Coat Hypertension ◽

Deep Breathing ◽

Deep Breathing Test

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Examining the effectiveness of telemonitoring with routinely acquired blood pressure data in primary care: challenges in the statistical analysis

10.21203/rs.3.rs-71464/v2 ◽

2021 ◽

Author(s):

Richard Parker ◽

Paul Padfield ◽

Janet Hanley ◽

Hilary Pinnock ◽

John Kennedy ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Statistical Analysis ◽

Propensity Score ◽

Random Coefficient ◽

White Coat ◽

White Coat Effect ◽

Regression Adjustment ◽

The Impact

Abstract Background Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data. Methods Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6-12 months follow-up prior to analysis. . The fourth analysis used linear mixed modelling based on all available data. Results The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6-12 months follow-up (-3.42, 95% CI -1.72 to -5.11, p<0.001). For the standardisation with matching and regression adjustment for propensity score analyses systolic BP was also significantly lower (-5.96, 95% CI -3.55 to -8.36, p<0.001) and (-3.73, -5.34 to -2.13, p<0.001) respectively, even after assuming that -5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -4.68 (95% CI -3.12 to -6.24, p<0.001) after one year.Conclusions The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

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HBPM to refine the diagnosis of hypertension in a Family Health Care Unit in RJ, Brazil - LapARC

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.1118 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

T S Mello ◽

B G Botelho ◽

J V G Hollanda ◽

L A Antequera ◽

M A O Mourão ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Blood Pressure Monitoring ◽

Adult Population ◽

Home Monitoring ◽

Home Blood Pressure ◽

Neck Circumference ◽

White Coat ◽

Cross Sectional ◽

Diagnosis Of Hypertension

Abstract Background The new hypertension (HT) guidelines recommend the use of out-of-office blood pressure (BP) measures for its diagnosis however, in the scope of public health in Brazil, it is still based on office BP (OBP) for logistical and financial reasons. Furthermore, in our country, it is not yet clear whether the use of out-of-office BP would really be more reliable for the diagnosis. Objective To evaluate the importance of using Home Blood Pressure Monitoring (HBPM) in diagnosing HT in a young adult population in primary care in Brazil. Methods A cross-sectional population study enrolled adults between 20 and 50 years in a primary healthcare unit in Rio de Janeiro. Office BP was the mean value of 2 measures, while the HBPM followed a 7-day protocol. It was considered normal a Home BP < 135x85 mmHg and OBP <140x90 mmHg. Patients were classified into 4 phenotypes: normotension (controlled OBP and HBPM); white coat HT (uncontrolled OBP and controlled HBPM); masked HT (controlled OBP and uncontrolled HBPM) and sustained HT (uncontrolled OBP and HBPM). Results A total of 462 individuals were enrolled [38% males; mean age 36±9 years]. Sedentary lifestyle (43%), dyslipidemia (38%) and obesity (28%) were the main CV risk factors. OBP, the prevalence of HT was 13%, HBPM it was 19%, with low concordance between them (kappa=0.472). After HBPM, 17% changed the diagnosis, being 6% of them white-coat HT and 11% masked HT. The variables that were independently associated with HT diagnosed by OBP were male gender (OR 1.83,CI95%:1.01-3.33,p=0.04) and increased neck circumference (OR 3.77,CI95%:1.59-8.93,p=0.003), whilst by HBPM they were obesity (OR 2.18,CI95%:1.27-3.76,p=0.005) and increased neck circumference (OR 2.37,CI95%:1.05-5.33,p=0.04). Conclusions If the diagnosis was based only in the office BP values, 17% of the subjects would've had an erroneous diagnosis of hypertension, suggesting the importance of implementing out-of-office BP measurements in primary care. Key messages Home monitoring blood pressure corrected the diagnosis of hypertension of 17% of patients, allocating them correctly into white-coat HT and masked HT. Increased neck circumference was independently associated with the diagnosis of hypertension by both methods.

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Less White-Coat Effect Seen With Hyperaldosteronism

Internal Medicine News ◽

10.1016/s1097-8690(06)74645-5 ◽

2006 ◽

Vol 39 (24) ◽

pp. 24

Author(s):

Bruce Jancin

Keyword(s):

White Coat ◽

White Coat Effect

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Assessment of Functions of the Autonomic Nervous System in the Elderly with Different Comorbid Factors

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0040-1718854 ◽

2020 ◽

Author(s):

Sushma S. ◽

Medha Y Rao ◽

Shaikh Mohammed Aslam

Keyword(s):

Elderly Patients ◽

Predictive Value ◽

The Elderly ◽

Common Symptom ◽

Deep Breathing ◽

Isometric Handgrip ◽

Male Predominance ◽

Healthy Elderly ◽

Sensitivity Specificity ◽

Deep Breathing Test

Abstract Background Studies in healthy elderly patients have shown the prevalence of autonomic dysfunction (AD) in the range of 20 to 30%. However, there is paucity in data pertaining to AD in the elderly in the Indian context. Objective To assess the prevalence of AD in the elderly irrespective of their comorbidity status. Methods A total of 141 elderly patients with or without comorbidities/symptoms of AD were included. Demographic and clinical details of the patients were recorded. Autonomic function tests (AFTs) such as deep breathing test, Valsalva ratio, orthostatic heart rate (OHR), isometric handgrip test, and orthostatic blood pressure were performed based on Ewing’s battery of tests. The sensitivity, specificity, positive predictive value, negative predictive value, and the accuracy of AFTs were evaluated. Results Most patients (n = 85) were aged between 60 and 69 years, with a male predominance (58.87%). Hypertension and diabetes mellitus were the most common comorbidities. Postural hypotension was the most common symptom of AD. With advancing age, symptoms of AD manifested significantly more. Overall, 73.8% of patients had AD, of whom 45.4% had early AD. Number of AD symptoms, glycated hemoglobin (HbA1c) level, and comorbid factors (diabetes and hypertension) were significantly associated with the results of AFTs (p < 0.05). AFTs were highly significant with respect to the results obtained (p < 0.001). Deep breathing test, abnormal in majority of study patients, has a sensitivity of 93.3% and OHR has a specificity of 81.1% to determine AD. Conclusion The study concludes that age itself is an independent predictor of AD, which increases in severity if associated with comorbidities.

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