Determination of ambulatory blood pressure control in treated patients with controlled office blood pressures.

Office blood pressure measurement is the standard for assessing blood pressure control. Many patients, however, take their antihypertensive medication in the morning, so they are likely to have their office blood pressure measured during the maximal antihypertensive effect. It is therefore unknown whether patients deemed by office blood pressure to be controlled do in fact have 24h blood pressure control. The objectives of this study were to determine blood pressure control, including blood pressure control while the patients were awake and during the first 6 hours after awakening, by ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients deemed by office blood pressure measurements to be controlled. A total of 103 patients on a stable antihypertensive regimen and deemed to be controlled in terms of office blood pressure values (mean office blood pressure <140/90mmHg) were enrolled. Patients were stratified by cardiovascular risk status and the number of antihypertensive medications that they were taking. Seventy-eight out of 103 participants successfully completed ABPM. The mean ambulatory blood pressure was greater than 135/85mmHg and 140/90mmHg while awake for 37% (95% confidence interval [CI] 26-48%) and 23% (95% CI 14-32%) of all patients respectively. Forty-eight per cent (95% CI 33-63%) of patients taking monotherapy versus 25% (95% CI 11-39%) of patients on multiple antihypertensive medications were uncontrolled (P=0.039) using 135/85mmHg as the reference value. Thirty-one per cent (95% CI, 17-44%) of patients on monotherapy versus 14% (95% CI 3-25%) of patients on multiple antihypertensive medication were uncontrolled (P=0.064) using 140/90mmHg instead. These results demonstrate that a high number of patients deemed by office blood pressure to be under control do not have adequate blood pressure control based on ABPM.

Reliability of self-reported blood pressure measurements.

BACKGROUND: Home blood pressure (BP) monitoring improves BP control, but it is unknown whether patients accurately report home BP readings to their physician. This study compared self-reported with electronically stored home BP and heart rate (HR) readings and evaluated this agreement in patients with controlled vs. uncontrolled hypertension. METHODS: A single-blind, randomized clinical trial was conducted in an ambulatory managed care population. Subjects were identified by hypertension-related codes from the International Classification of Diseases, Ninth Revision (401.0, 401.1, and 401.9). Subjects recorded systolic BP (SBP), diastolic BP (DBP), and HR 3 times daily for 1 week by means of a digital BP monitor. Subjects were unaware that the monitor electronically stored results. RESULTS: Thirty subjects were enrolled (29 complete data sets); their mean age (+/-SD) was 56+/-9 years, and 15 (52%) were women. Sixty-eight percent of subject-recorded SBP, DBP, and HR measurements were identical to electronically stored results. Twenty percent of recorded SBPs and 17% of recorded DBPs differed from stored SBP and DBP by more than 10 mm Hg. Erroneous reporting was evident in 9% of uncontrolled vs 4% of controlled SBPs (P<.001). Similarly, 21% of uncontrolled and 4% of controlled DBPs were erroneously reported (P<.001). In cases where the stored HR exceeded 100 beats/min, 43% of HR readings were recorded as 100 beats/min or less (P<.001). CONCLUSIONS: Most self-reported BP and HR readings were identical to electronically stored measurements. However, erroneous reporting occurred significantly more often in cases of uncontrolled BP and HR, which may misguide physicians in the optimal treatment of their patients with hypertension.

Comparison of two home blood pressure monitors with a mercury sphygmomanometer in an ambulatory population.

We performed a randomized, single-visit, crossover study to compare the precision of a digital monitor and an aneroid monitor relative to a desktop mercury sphygmomanometer (DMS). Three blood pressure measurements per patient, one per device, were taken over 25 minutes. Of 99 patients, 95 had complete blood pressure data. Systolic blood pressures measured with the digital monitor were significantly different from those with the DMS (p<0.01). Thirty-four percent of systolic and 48% of diastolic pressures measured with the digital monitor were within +/- 5 mm Hg of the DMS. The aneroid monitor performed significantly better than the digital monitor, with 54% of systolic (p<0.01) and 58% of diastolic blood pressures within +/- 5 mm Hg of the DMS standard. Health care providers are encouraged to supervise patients' initial use of a home blood pressure monitor and calibrate readings against a standard mercury sphygmomanometer.

Cost-effectiveness comparison of sequential ofloxacin versus standard switch therapy.

OBJECTIVE: To compare the cost-effectiveness of sequential intravenous-to-oral ofloxacin versus intravenous-to-oral standard switch therapy for the treatment of patients with sepsis who are hospitalized with bacterial infections. DESIGN: Cost-effectiveness analysis from a provider perspective, including resources important to an integrated healthcare network, of a randomized, open-label, controlled, clinical trial. SETTING: Millard Fillmore Health System, Buffalo, NY. PATIENTS: Hospitalized adults requiring parenteral antibiotics for a complicated urinary tract infection, lower respiratory tract infection, or skin and soft tissue infection. INTERVENTIONS: Sequential intravenous-to-oral ofloxacin or standard intravenous-to-oral switch antibiotics. OUTCOME MEASURES: Clinical outcomes and direct costs associated with hospitalization, primary physician services, specialist physician services, and outpatient care. RESULTS: Eighty-two of 89 patients randomized into the two treatment groups were evaluable. Standard switch therapy failed with 12 patients versus 10 patients receiving ofloxacin. Complete economic data were available for 74 patients. Sequential ofloxacin therapy resulted in a 1-day-shorter antibiotic-related hospitalization without evidence of recurrent infection during the posttherapy follow-up evaluations. An average cost savings of $399 per patient was achieved in the sequential ofloxacin group. Although this difference did not attain statistical significance (probably due to the large variance), it is an economically significant finding. The cost-effectiveness ratios were $5735 per successful outcome for the standard switch therapy group versus $5126 per successful outcome in the sequential ofloxacin group. CONCLUSIONS: Sequential ofloxacin was as effective and consistently less expensive than standard switch antibiotics in the initial evaluation and in the sensitivity analysis of room cost and drug acquisition cost. Standard switch therapy would have to be greater than 25% more effective than sequential ofloxacin therapy to change the economic decision.