Association of an Automated Blood Pressure Measurement Quality Improvement Program With Terminal Digit Preference and Recorded Mean Blood Pressure in 11 Clinics.

Importance: Terminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording. Objective: To evaluate whether converting from manual BP measurement with aneroid sphygmomanometers to automated BP measurement was associated with terminal digit preference, mean levels of recorded BP, and the rate at which hypertension was diagnosed. Design, Setting, and Participants: This quality improvement study was conducted from May 9, 2021, to March 24, 2022, using interrupted time series analysis of medical record data from 11 primary care clinics in a single health care system from April 2008 to April 2015. The study population was patients aged 18 to 75 years who had their BP measured and recorded at least once during the study period. Exposures: Manual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015. Main Outcomes and Measures: The main outcome was the distribution of terminal digits and mean systolic BP (SBP) values obtained during 4 years of manual measurement vs 3 years of automated measurement, assessed using a generalized linear mixed regression model with a random intercept for clinic and adjusted for seasonal fluctuations and patient demographic and clinical characteristics. Results: The study included 1 541 227 BP measurements from 225 504 unique patients during the entire study period, with 849 978 BP measurements from 165 137 patients (mean [SD] age, 47.1 [15.2] years; 58.2% female) during the manual measurement period and 691 249 measurements from 149 080 patients (mean [SD] age, 48.4 [15.3] years; 56.3% female) during the automated measurement period. With manual measurement, 32.8% of SBP terminal digits were 0 (20% was the expected value because nursing staff was instructed to record BP to the nearest even digit). This proportion decreased to 12.4% during the automated measurement period (expected value, 10%) when both even and odd digits were to be recorded. After automated measurement was implemented, the mean SBP estimated with statistical modeling increased by 5.09 mm Hg (95% CI, 4.98-5.19 mm Hg). Fewer BP values recorded during the automated than the manual measurement period were below 140/90 mm Hg (69.9% vs 84.3%; difference, -14.5%; 95% CI, -14.6% to -14.3%) and below 130/80 mm Hg (42.1% vs 60.0%; difference, -17.9%; 95% CI, -18.0% to -17.7%). The proportion of patients with a diagnosis of hypertension was 4.3 percentage points higher (23.4% vs 19.1%) during the automated measurement period. Conclusions and Relevance: In this quality improvement study, automated BP measurement was associated with decreased terminal digit preference and significantly higher mean BP levels. The method of BP measurement was also associated with the rate at which hypertension was diagnosed. These findings may have implications for pay-for-performance programs, which may create an incentive to record BP levels that meet a particular goal and a disincentive to adopt automated measurement of BP.

Diabetes: how are we diagnosing and initially managing it?

PURPOSE: We undertook this study to examine the symptoms, clinical events, and types of health care encounters that preceded the diagnosis of diabetes mellitus in adults, and to examine changes in glycemic control and cardiovascular risk factors in the first year after a diabetes diagnosis. METHODS: We conducted a historical cohort study of patients in a large multispecialty medical group in Minnesota. Among 55,121 adults who were continuously enrolled in the health plan and receiving care at the study medical group from January 1, 1993, to December 31, 1996, we identified 504 who received a new diagnosis of diabetes in 1995 or 1996. Our main outcome measures were the type of symptoms at diagnosis; the clinical circumstances and type of encounter that led to diabetes diagnosis; and changes in glycemic control (assessed by hemoglobin A1c [HbA1c] value), low-density lipoprotein cholesterol level, blood pressure (BP), aspirin use, and body weight in the first year after diagnosis, ascertained from a detailed review of medical records. RESULTS: Almost one third (32.3%) of adults with newly diagnosed diabetes had symptoms of hyperglycemia at initial diagnosis. Compared with patients who did not have hyperglycemia symptoms at diagnosis, those who did were younger and more often male, and had lower comorbidity scores and higher HbA1c values (9.9% vs 8.1%) at diagnosis (P <.01 for each comparison). In the 12 months after diagnosis, the group as a whole had significant improvements (P <.001) in HbA1c values (from 8.8% to 7.1%), systolic blood pressure (137.5 to 133.2 mm Hg), diastolic blood pressure (80.7 to 77.3 mm Hg), weight (207.7 to 201.1 lb), and aspirin use (15.3% to 26.1%). Improvements were seen in all patient subgroups, including those defined by symptoms at diagnosis and by visit type at diagnosis. CONCLUSIONS: Primary care practices may improve detection of undiagnosed diabetes in primary care and improve 1-year outcomes by being vigilant for symptoms of diabetes, by evaluating those at high risk for this disorder, and by instituting appropriate treatments at the time of diagnosis.

Household composition and risk of fatal child maltreatment.

OBJECTIVE: Approximately 2000 children die annually in the United States from maltreatment. Although maternal and child risk factors for child abuse have been identified, the role of household composition has not been well-established. Our objective was to evaluate household composition as a risk factor for fatal child maltreatment. METHODOLOGY: Population-based, case-control study using data from the Missouri Child Fatality Review Panel system, 1992-1994. Households were categorized based on adult residents' relationship to the deceased child. Cases were all maltreatment injury deaths among children <5 years old. Controls were randomly selected from natural-cause deaths during the same period and frequency-matched to cases on age. The main outcome measure was maltreatment death. RESULTS: Children residing in households with adults unrelated to them were 8 times more likely to die of maltreatment than children in households with 2 biological parents (adjusted odds ratio [aOR]: 8.8; 95% confidence interval [CI]: 3.6-21.5). Risk of maltreatment death also was elevated for children residing with step, foster, or adoptive parents (aOR: 4.7; 95% CI: 1.6-12.0), and in households with other adult relatives present (aOR: 2.2; 95% CI: 1.1-4.5). Risk of maltreatment death was not increased for children living with only 1 biological parent (aOR: 1.1; 95% CI: 0.8-2.0). CONCLUSIONS: Children living in households with 1 or more male adults that are not related to them are at increased risk for maltreatment injury death. This risk is not elevated for children living with a single parent, as long as no other adults live in the home.