End-Digit Preference and the Quality of Blood Pressure Monitoring in Diabetic Adults

Abstract

OBJECTIVE -Although tight blood pressure (BP) control is proven to reduce diabetesrelated cardiovascular risk, it has been difficult to achieve in practice, perhaps in part because of low-quality monitoring data. We hypothesized that low-quality BP data, reflected in end-digit preference (EDP), remains common in primary care of diabetic adults.RESEARCH DESIGN AND METHODS -Data were abstracted from the charts of 404 adults with type 2 diabetes seen at 16 academically affiliated clinics from 1999 to 2001. Enddigits of systolic and diastolic BPs taken with nonautomated sphygmomanometers were extracted, and prevalence of EDP for zero was calculated. Associations between EDP and selected patient characteristics were determined using multiple logistic regressions.RESULTS -EDP was highly prevalent in the BP measurements taken by nonphysicians (4,333 BPs; 50% of systolic, 50% of diastolic readings ended in zero; P Ͻ 0.001) and physicians (1,347 BPs; 69% of systolic, 64% of diastolic readings ended in zero; P Ͻ 0.001). In multivariate analysis, nonphysicians showed greater EDP for systolic BP in older patients (odds ratio [OR] 1.07 per 5 years) and women (OR 1.36 vs. men) and for diastolic BP in African-Americans (OR 1.25 vs. whites; all P Ͻ 0.05); physicians showed greater EDP for diastolic BP in less obese patients (OR 0.97 per 5 kg/m 2 increment in BMI; P ϭ 0.02).CONCLUSIONS -Low-quality BP measurement is common in primary care of diabetic adults. Procedural and technological improvements to BP measurement deserve attention as part of an overall strategy to tighten BP control and reduce cardiovascular risk. Diabetes Care 30:1959-1963, 2007A lthough tight blood pressure (BP) control is proven to reduce diabetes-related cardiovascular risk in controlled trials (1-3), it has been difficult to achieve in general practice (4,5). One reason might be low-quality monitoring data: compared with A1C and lipids, which are stable day to day and are measured in laboratories with strict quality control standards, BP is quite variable and is measured by busy clinicians with little attention to standardization. A widely accepted indicator of low-quality BP measurement made with nonautomated sphygmomanometers is end-digit preference (EDP)-the occurrence of zeros as end digits more frequently than would be expected by chance alone. Earlier studies have found high prevalence of EDP in primary care (6,7) and specialty hypertension clinics (8). These studies have suggested that EDP might affect antihypertensive medication prescribing patterns (7) and that, in turn, the likelihood of EDP might be influenced by patient demographic characteristics (8).We therefore conducted a study to identify EDP and its correlates in a cohort of adults with type 2 diabetes in primary care. We hypothesized that EDP remains common, even in contemporary practice, and that EDP would be influenced by patient characteristics, including age, sex, race, and BMI. Chart abstraction was performed by two trained registered nurses and reviewed by two physicians. Abst...

ESCAPE-ancillary blood pressure measurement study

“…EDP is frequently observed and well documented both in clinical practice [2][3][4][5] and during research studies [6], particularly, when physicians use conventional auscultatory methods such as mercury or aneroid sphygmomanometers [3]. Depending on the studies [2][3][4][5][6], the reported frequency of multiples of 10 in systolic BP (SBP) measurements ranges from 50 to 90% with a mean value of 65% [7].…”

“…Depending on the studies [2][3][4][5][6], the reported frequency of multiples of 10 in systolic BP (SBP) measurements ranges from 50 to 90% with a mean value of 65% [7].…”

“…In addition, a mean pharmacological reduction of 2.2 mmHg in SBP leads to a significant reduction of 19% in the relative risk (RR) of myocardial infarction and 15% in the RR of stroke in a treated hypertensive population [11,12]. An underevaluation of SBP may lead to the inappropriate transfer of a patient from a population that should receive a treatment (or its adjustment) to a population that should not [5][6][7][8].…”

An Example of End-Digit Preference in Physiotherapy Practice

“…In contrast, end-digit preference is well documented in the medical literature, particularly as it applies to the measurement of blood pressure (BP). [1][2][3][6][7][8] Paralleling the prominence of BP measurement in the day-to-day practice of physicians is the regular assessment of range of motion (ROM) by physiotherapists. Given that both BP and ROM assessments require clinicians to read and record analogue values, it seems reasonable to conjecture that end-digit preference may affect ROM measurements; however, our literature searches (PubMed, CINAHL, EMBASE) combining the terms ''range of motion'' and ''end-digit'' failed to identify a single publication.…”

Reengineering the Physical Examination for the New Millennium?

“…Blood pressure provides a compelling example because physician measurement of this vital sign tends to be of low quality. 5 There is an increasing need for tight control of blood pressure to reduce cardiovascular complications; therefore, physicians risk suboptimal care by not using the technological advances for the collection of vital signs. 6 Because device engineering allows for progressive miniaturization, lower cost, and direct deposition of findings into the electronic medical record, should vital signs include an electrocardiographic assessment of rate and rhythm, an analysis of arterial pulse wave morphology, or other easily obtained noninvasive data?…”