Screening for High Blood Pressure in Adults
Note: This is a draft Research Plan. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF.
The final Research Plan will be used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center. The resulting Evidence Report will form the basis of the USPSTF Recommendation Statement on this topic.
This draft Research Plan is available for comment from June 20 until July 17, 2013 at 5:00 p.m., ET. You may wish to read the entire Research Plan before you comment.
I. Proposed Analytic Framework
Abbreviations: ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CHD = coronary heart disease; CVD = cardiovascular disease; HF = heart failure; ESKD = end-stage kidney disease; HBPM = home blood pressure monitoring.
II. Proposed Key Questions to Be Systematically Reviewed
- Does screening for high blood pressure reduce cardiovascular disease and mortality in adults age 18 years or older?
- What is the best way to screen for high blood pressure in adults in the primary care setting*?
- How accurate (i.e., sensitivity, specificity, predictive value) are clinic-based blood pressure measurement methods (e.g., manual vs. automated) in diagnosing hypertension within a single visit?
- What screening protocol characteristics within a single encounter (e.g., sitting quietly for 5 minutes, number of readings) define the best diagnostic accuracy?
- What is the best way to confirm hypertension in adults who initially screen positive for high blood pressure?
- How well do home and ambulatory blood pressure monitoring methods predict cardiovascular events compared with clinic-based blood pressure measurement methods? What confirmation protocol characteristics define the best prediction of cardiovascular events? Which methods and associated protocols best predict cardiovascular events?
- How accurate are other noninvasive blood pressure measurement methods in establishing or confirming the diagnosis of hypertension compared with these best methods and associated protocols? Does diagnostic accuracy vary by protocol characteristics (i.e., characteristics not reviewed in Key Question 2b, such as the number of visits)?
- Does changing the measurement method from that used during the initial screening improve diagnostic accuracy for some specific patient subgroups (e.g., those with suspected white coat hypertension)?
- What is the clinically appropriate rescreening interval for patients who have previously been screened and found to have normal blood pressure?
- What is the shortest interval in which clinically significant, diagnosed hypertension may develop?
- Does the rescreening interval vary by patient characteristics (e.g., age, sex, race/ethnicity, cardiovascular risk, blood pressure level, screening history)?
- What are the adverse effects of screening for high blood pressure in adults?
*For this review, eligible primary care settings must have personnel trained in blood pressure measurement, established blood pressure measurement protocols, and ongoing documentation procedures for each (e.g., internal medicine, family practice, obstetrics/gynecology, school- and military-based health clinics, pharmacies, retail and mobile clinics, dental offices).
III. Proposed Contextual Questions
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
- What is the diagnostic accuracy of automated and nonautomated blood pressure measurement instruments in the community setting (e.g., grocery store and pharmacy kiosks, community health fairs) that are not associated with an attendant, trained personnel, or established procedures? What are the characteristics of patients for whom these automated kiosks may be acceptable (e.g., non-obese patients)?
- Is there a valid protocol for identifying patients who are likely to have white coat hypertension?
IV. Proposed Research Approach
The Proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Report. Criteria are overarching as well as specific to each of the key questions (KQs).
|Aim||KQs 1, 2, 4, 5: Screening for high blood pressure in a primary care setting (alone or as part of a clinical examination)
KQ 3: Measuring blood pressure to confirm diagnosis of hypertension
|Measurement of short-term diet-, exercise-, or drug-induced blood pressure changes; measurement of blood pressure as part of a disease management program for heart failure or weight loss|
|Population||KQs 1, 2, 5: Adults age 18 years or older
KQ 3: Adults age 18 years or older with at least one elevated blood pressure measurement (as defined by study) identified by clinic-based screening
KQ 4a: Adults age 18 years or older whose previous clinic-based blood pressure screening was normal or not in the treatable range, or for whom an initial diagnosis of hypertension was not confirmed
|Pregnant women, children (age <18 years), inpatients, institutionalized persons, patients with underlying causes of high blood pressure
KQs 1, 2, 3b, 3c, 4, 5:
|Intervention||KQs 1, 2, 4, 5: Clinic-based, noninvasive blood pressure measurement using any commonly used device or screening protocol during a single encounter
KQ 3: Any clinic-based blood pressure measurement confirmed by another clinic-based, home, or ambulatory blood pressure measurement (with any device or measurement protocol). For all ambulatory devices, average 24- or 48-hour, daytime, and nighttime blood pressure measurements are acceptable
|Wrist and finger monitors|
|Comparator||KQs 1, 5: No blood pressure screening
KQ 2: A different clinic-based, noninvasive blood pressure measurement using any device or protocol (e.g., manual vs. automated)
KQ 3: Any clinic-based blood pressure measurement confirmed by another clinic-based, home, or ambulatory blood pressure measurement (with any device or protocol)
KQ 4a: Time interval for rescreening using the same method
|KQs 2, 3: Within-class comparative effectiveness of devices (e.g., automated vs. automated) with identical screening protocols|
KQs 2, 3b: Sensitivity, specificity, positive and negative predictive value (or comparable statistics or data that allow calculation of such), concordance for hypertension
KQ 3a: Measures of association of blood pressure and fatal or nonfatal cardiovascular events (as listed above), such as risk ratio or hazard ratio
KQ 4a: Change in blood pressure classification (i.e., normal to diagnosis of hypertension) when rescreened at different time intervals (e.g., 1 year, 5 years, 10 years)
|KQs 1, 3: Cardiovascular symptoms (e.g., palpitations), angina pectoris (chest pain), revascularization, carotid intima-media thickness, patient satisfaction, quality of life
KQs 2, 3b: Studies that do not provide enough data to create 2×2 tables or calculate sensitivity and specificity
KQ 3a: Studies that do not define composite cardiovascular disease outcomes; composite cardiovascular outcomes that contain excluded outcomes (as listed above)
KQ 4a: Studies that report only average change in blood pressure for the entire population
|Timing of outcome assessment||No restrictions||No restrictions|
|Setting||KQs 1, 2, 4, 5: Eligible primary care settings must have personnel trained in blood pressure measurement, established blood pressure measurement protocols, and ongoing documentation procedures for each (e.g., internal medicine, family practice, obstetrics/gynecology, school- and military-based health clinics, pharmacies, retail and mobile clinics, dental offices)
KQ 3: Primary care settings (see above for definition), home
|Emergency departments, acute health care settings, school classrooms, worksites, inpatient/residential facilities, correctional facilities|
|Study design||KQ 1: Randomized, controlled trials (RCTs) or controlled clinical trials (CCTs)
KQ 2: Diagnostic accuracy studies, RCTs, CCTs, cohort studies
KQ 3: Diagnostic accuracy studies, RCTs, CCTs, cohort studies, case-control studies
KQ 4a: Longitudinal cohort studies
KQ 5: RCTs, CCTs, cohort studies
|Before-after studies, time series, case series, case reports|
|Country||Studies in countries rated as “very high” on the Human Development Index: Andorra, Argentina, Australia, Austria, Barbados, Belgium, Brunei Darussalam, Canada, Chile, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Poland, Portugal, Qatar, Seychelles, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Arab Emirates, United Kingdom, United States||Studies in countries rated below “very high” on the Human Development Index|
|Literature search dates||KQs 1, 5: January 2003 to present (which includes carrying forward any studies included in the previous USPSTF systematic review)
KQs 2, 3: January 1992 to present. The rationale is based on that of Verberk and colleagues (1); 1992 was chosen because the first protocol with guidelines for validation of blood pressure monitoring devices was published in 1990, and a lag time of 2 years was added to allow the guidelines to be fully implemented.
KQ 4: January 1965 to present. The rationale is that this is a new KQ that has never been addressed in a USPSTF systematic review
|Language||English only||Other languages than English|
|Study quality||Fair or good||Poor, according to design-specific USPSTF criteria|
AHRQ Publication No. 13-05194-EF-5
Current as of June 2013
U.S. Preventive Services Task Force. Screening for High Blood Pressure in Adults: Draft Research Plan. AHRQ Publication No. 13-05194-EF-5. http://www.uspreventiveservicestaskforce.org/draftresplan3.htm