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Observational Study
. 2018 Jun 27:361:k2478.
doi: 10.1136/bmj.k2478.

Prospective external validation of the Predicting Out-of-OFfice Blood Pressure (PROOF-BP) strategy for triaging ambulatory monitoring in the diagnosis and management of hypertension: observational cohort study

James P Sheppard  1 , Una Martin  2 , Paramjit Gill  3 , Richard Stevens  4 , Fd Richard Hobbs  4 , Jonathan Mant  5 , Marshall Godwin  6 , Janet Hanley  7 , Brian McKinstry  8 , Martin Myers  9 , David Nunan  4 , Richard J McManus  4 ; PROOF-BP investigators
Affiliations
Observational Study

Prospective external validation of the Predicting Out-of-OFfice Blood Pressure (PROOF-BP) strategy for triaging ambulatory monitoring in the diagnosis and management of hypertension: observational cohort study

James P Sheppard et al. BMJ. .

Erratum in

Abstract

Objective: To prospectively validate the Predicting Out-of-OFfice Blood Pressure (PROOF-BP) algorithm to triage patients with suspected high blood pressure for ambulatory blood pressure monitoring (ABPM) in routine clinical practice.

Design: Prospective observational cohort study.

Setting: 10 primary care practices and one hospital in the UK.

Participants: 887 consecutive patients aged 18 years or more referred for ABPM in routine clinical practice. All underwent ABPM and had the PROOF-BP applied.

Main outcome measures: The main outcome was the proportion of participants whose hypertensive status was correctly classified using the triaging strategy compared with the reference standard of daytime ABPM. Secondary outcomes were the sensitivity, specificity, and area under the receiver operator characteristic curve (AUROC) for detecting hypertension.

Results: The mean age of participants was 52.8 (16.2) years. The triaging strategy correctly classified hypertensive status in 801 of the 887 participants (90%, 95% confidence interval 88% to 92%) and had a sensitivity of 97% (95% confidence interval 96% to 98%) and specificity of 76% (95% confidence interval 71% to 81%) for hypertension. The AUROC was 0.86 (95% confidence interval 0.84 to 0.89). Use of triaging, rather than uniform referral for ABPM in routine practice, would have resulted in 435 patients (49%, 46% to 52%) being referred for ABPM and the remainder managed on the basis of their clinic measurements. Of these, 69 (8%, 6% to 10%) would have received treatment deemed unnecessary had they received ABPM.

Conclusions: In a population of patients referred for ABPM, this new triaging approach accurately classified hypertensive status for most, with half the utilisation of ABPM compared with usual care. This triaging strategy can therefore be recommended for diagnosis or management of hypertension in patients where ABPM is being considered, particularly in settings with limited resources.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the MRC and NIHR for the submitted work; support from Omron, outside the submitted work; no financial relationships with any other organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Patient recruitment flow diagram
Fig 2
Fig 2
Post hoc analyses examining sensitivity and specificity of PROOF-BP triaging strategy for hypertension, by subgroups. CKD=chronic kidney disease; CVD=cardiovascular disease
Fig 3
Fig 3
Proportion of patients correctly classified with hypertension using PROOF-BP triaging strategy, by subgroups. CKD=chronic kidney disease; CVD=cardiovascular disease
Fig 4
Fig 4
Proportion of patients referred for ambulatory blood pressure monitoring (ABPM) using PROOF-BP triaging strategy, by subgroups. CKD=chronic kidney disease; CVD=cardiovascular disease
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