Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore

Abstract

PurposeOut-of-office blood pressure (BP) measurements (home blood pressure monitoring [HBPM] and ambulatory blood pressure monitoring [ABPM]) provide important additional information for effective hypertension detection and management decisions. Therefore, out-of-office BP measurement is now recommended by several international guidelines. This study evaluated the practice and uptake of HBPM and ABPM among physicians from Singapore.Materials and methodsA sample of physicians from Singapore was surveyed between 8 September and 5 October 2016. Those included were in public or private practice had been practicing for ≥3 years, directly cared for patients ≥70% of the time, and treated ≥30 patients for hypertension per month. The questionnaire covered six main categories: general BP management, BP variability (BPV) awareness/diagnosis, HBPM, ABPM, BPV management, and associated training needs.ResultsSixty physicians (30 general practitioners, 20 cardiologists, and 10 nephrologists) were included (77% male, 85% aged 31–60 years, and mean 22-year practice). Physicians recommended HBPM and ABPM to 81% and 27% of hypertensive patients, respectively. HBPM was most often used to monitor antihypertensive therapy (88% of physicians) and 97% thought that ABPM was useful for providing information on BPV. HBPM instructions often differed from current guideline recommendations in terms of frequency, number of measurements, and timing. The proportion of consultation time devoted to discussing HBPM and BPV was one-quarter or less for 73% of physicians, and only 55% said that they had the ability to provide education on HBPM and BPV. Patient inertia, poor patient compliance, lack of medical consultation time, and poor patient access to a BP machine were the most common challenges for implementing out-of-office BP monitoring.ConclusionAlthough physicians from Singapore do recommend out-of-office BP measurement to patients with hypertension, this survey identified several important gaps in knowledge and clinical practice.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

“…A survey conducted in Singapore showed that although nearly three‐quarters of physicians who responded said they would recommend ABPM to their patients, only 27% of patients overall were actually given a recommendation for ABPM . The most commonly cited indications for ABPM were diagnosis of resistant hypertension, confirmation of hypertension, evaluation of antihypertensive efficacy, and determination of BPV.…”

“…The most commonly cited indications for ABPM were diagnosis of resistant hypertension, confirmation of hypertension, evaluation of antihypertensive efficacy, and determination of BPV. Lack of medical consultation time, no access to a suitable device, patient inertia, poor patient compliance, and lack of suitable education materials were cited as challenges to the implementation of out‐of‐office BP measurement (including ABPM) …”

Asian management of hypertension: Current status, home blood pressure, and specific concerns in Singapore

“…Monitoring of morning home BP using home BP monitoring (HBPM) will likely be necessary to facilitate achievement of lower BP targets. However, recent local survey data showed that Singaporean physicians had reservations about the accuracy of HBPM devices and cited limited time and resources in their clinical practice to educate their patients about using HBPM . Although most clinicians would recommend HBPM, there seems to be a knowledge gap in how to do HBPM and evaluating treatment response; there was also no consensus in home BP targets .…”

“…However, recent local survey data showed that Singaporean physicians had reservations about the accuracy of HBPM devices and cited limited time and resources in their clinical practice to educate their patients about using HBPM . Although most clinicians would recommend HBPM, there seems to be a knowledge gap in how to do HBPM and evaluating treatment response; there was also no consensus in home BP targets . This is not unexpected because the Singapore hypertension guidelines mostly emphasize use of HBPM for the diagnosis of hypertension rather than for evaluating BP control and guiding changes in antihypertensive therapy.…”

Guidance on home blood pressure monitoring: A statement of the HOPE Asia Network

“…Out‐of‐office measurement of blood pressure (BP), including ambulatory and home BP monitoring (ABPM and HBPM, respectively), is recognized internationally as an important tool to facilitate effective detection and management of hypertension, and to monitor BP variability . Deficits in knowledge about out‐of‐office BP measurement and gaps in clinical practice among general practitioners and specialists have recently been identified in Singapore . This is likely to reflect the situation elsewhere in Asia, highlighting the need for accessible, key evidence‐based information for physicians.…”