title: Predicting Out-of-Office Blood Pressure in the Clinic (PROOF-BP): Derivation and Validation of a Tool to Improve the Accuracy of Blood Pressure Measurement in Clinical Practice.
abstract: Patients often have lower (white coat effect) or higher (masked effect) ambulatory/home blood pressure readings compared with clinic measurements, resulting in misdiagnosis of hypertension. The present study assessed whether blood pressure and patient characteristics from a single clinic visit can accurately predict the difference between ambulatory/home and clinic blood pressure readings (the home-clinic difference). A linear regression model predicting the home-clinic blood pressure difference was derived in 2 data sets measuring automated clinic and ambulatory/home blood pressure (n=991) using candidate predictors identified from a literature review. The model was validated in 4 further data sets (n=1172) using area under the receiver operator characteristic curve analysis. A masked effect was associated with male sex, a positive clinic blood pressure change (difference between consecutive measurements during a single visit), and a diagnosis of hypertension. Increasing age, clinic blood pressure level, and pulse pressure were associated with a white coat effect. The model showed good calibration across data sets (Pearson correlation, 0.48-0.80) and performed well-predicting ambulatory hypertension (area under the receiver operator characteristic curve, 0.75; 95% confidence interval, 0.72-0.79 [systolic]; 0.87; 0.85-0.89 [diastolic]). Used as a triaging tool for ambulatory monitoring, the model improved classification of a patient's blood pressure status compared with other guideline recommended approaches (93% [92% to 95%] classified correctly; United States, 73% [70% to 75%]; Canada, 74% [71% to 77%]; United Kingdom, 78% [76% to 81%]). This study demonstrates that patient characteristics from a single clinic visit can accurately predict a patient's ambulatory blood pressure. Usage of this prediction tool for triaging of ambulatory monitoring could result in more accurate diagnosis of hypertension and hence more appropriate treatment.
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.). james.sheppard@phc.ox.ac.uk.
authors.forename: James P
authors.initials: JP
authors.lastname: Sheppard
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Richard
authors.initials: R
authors.lastname: Stevens
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Paramjit
authors.initials: P
authors.lastname: Gill
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Una
authors.initials: U
authors.lastname: Martin
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Marshall
authors.initials: M
authors.lastname: Godwin
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Janet
authors.initials: J
authors.lastname: Hanley
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Carl
authors.initials: C
authors.lastname: Heneghan
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: F D Richard
authors.initials: FD
authors.lastname: Hobbs
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mant
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Brian
authors.initials: B
authors.lastname: McKinstry
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Martin
authors.initials: M
authors.lastname: Myers
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: David
authors.initials: D
authors.lastname: Nunan
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Alison
authors.initials: A
authors.lastname: Ward
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Bryan
authors.initials: B
authors.lastname: Williams
authors.affiliation: From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (J.P.S., R.S., C.H., F.D.R.H., D.N., A.W., R.J.M.); Institute of Applied Health Research, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (P.G., U.M.); Family Practice Unit, Memorial University of Newfoundland, St John's, Newfoundland, NL, Canada (M.G.); Health Services Research Unit, Edinburgh Napier University, Edinburgh, United Kingdom (J.H.); Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (J.M.); Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (B.M.); Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada (M.M.); and Institute of Cardiovascular Science, University College London, London, United Kingdom (B.W.).
authors.forename: Richard J
authors.initials: RJ
authors.lastname: McManus
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001795:Blood Pressure Determination / Q000379:methods*; D018660:Blood Pressure Monitoring, Ambulatory / Q000379:methods*; D002170:Canada; D002940:Circadian Rhythm; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D059468:Masked Hypertension / Q000175:diagnosis*; D008875:Middle Aged; D009819:Office Visits; D011237:Predictive Value of Tests; D012372:ROC Curve; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D006113:United Kingdom; D014481:United States; D059466:White Coat Hypertension / Q000175:diagnosis*
keywords: ambulatory blood pressure monitoring; hypertension; masked hypertension; white coat hypertension