title: Comparison of agreement between different measures of blood pressure in primary care and daytime ambulatory blood pressure.
abstract: OBJECTIVE
  To assess alternatives to measuring ambulatory pressure, which best predicts response to treatment and adverse outcome.
  
  
  METHODS
  Three general practices in England.
  
  
  METHODS
  Validation study.
  
  
  METHODS
  Patients with newly diagnosed high or borderline high blood pressure; patients receiving treatment for hypertension but with poor control.
  
  
  METHODS
  Overall agreement with ambulatory pressure; prediction of high ambulatory pressure (>135/85 mm Hg) and treatment thresholds.
  
  
  RESULTS
  Readings made by doctors were much higher than ambulatory systolic pressure (difference 18.9 mm Hg, 95% confidence interval 16.1 to 21.7), as were recent readings made in the clinic outside research settings (19.9 mm Hg,17.6 to 22.1). This applied equally to treated patients with poor control (doctor v ambulatory 21.4 mm Hg, 17.3 to 25.4). Doctors' and recent clinic readings ranked systolic pressure poorly compared with ambulatory pressure and other measurements (doctor r=0.46; clinic 0.47; repeated readings by nurse 0.60; repeated self measurement 0.73; home readings 0.75) and were not specific at predicting high blood pressure (doctor 26%; recent clinic 15%; nurse 72%; patient in surgery 81%; home 60%), with poor likelihood ratios for a positive test (doctor 1.2; clinic 1.1; nurse 2.1, patient in surgery 4.7; home 2.2). Nor were doctor or recent clinic measures specific in predicting treatment thresholds.
  
  
  CONCLUSIONS
  The "white coat" effect is important in diagnosing and assessing control of hypertension in primary care and is not a research artefact. If ambulatory or home measurements are not available, repeated measurements by the nurse or patient should result in considerably less unnecessary monitoring, initiation, or changing of treatment. It is time to stop using high blood pressure readings documented by general practitioners to make treatment decisions.
authors.affiliation: Community Clinical Sciences Division (Primary Medical Care Group), Faculty of Medicine, Health and Biological Sciences, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST, UK. psl3@soton.ac.uk
authors.forename: Paul
authors.initials: P
authors.lastname: Little
authors.forename: Jane
authors.initials: J
authors.lastname: Barnett
authors.forename: Lucy
authors.initials: L
authors.lastname: Barnsley
authors.forename: Jean
authors.initials: J
authors.lastname: Marjoram
authors.forename: Alex
authors.initials: A
authors.lastname: Fitzgerald-Barron
authors.forename: David
authors.initials: D
authors.lastname: Mant
mesh_terms: D001795:Blood Pressure Determination / Q000379:methods / Q000592:standards*; D018660:Blood Pressure Monitoring, Ambulatory / Q000592:standards; D005260:Female; D006699:Home Care Services; D006801:Humans; D006973:Hypertension / Q000175:diagnosis* / Q000451:nursing / Q000628:therapy; D008297:Male; D012016:Reference Values; D012648:Self Care; D012680:Sensitivity and Specificity