This article regarding the prevalence of Emergency Department visits opens in quite the disarming fashion, noting, casually, the anecdotal impression of increased visits for elevated blood pressure detected by a home machine. That’s a nice way of saying “Every. Damn. Day.”
So, how often are these “worried well” ending up in our Emergency Department? According to these authors – we don’t know. We don’t know because yes, a little over 40% of those visiting the ED with a primary diagnosis of “hypertension” were the result of home blood pressure readings, but 37% of their cohort was “not documented”. It is difficult to interpret the source of the “not documented” – were they in the ED for another symptom? Or was there some other referral source? It’s unfortunately impossible to say. Regardless, this 40% self-referral due to home blood pressure readings dwarfs that of those who detected an elevated blood pressure at a pharmacy (8%) or MD office (13%). So, even if precision is lacking in these data, the proportion is substantial – and probably fits with our anecdotal sense.
Median blood pressure from the referring source, when available, generally exceeded the ED measurement – which was a median of 182/97 in triage. Interestingly, a 41% of patients received some sort of medication for blood pressure control while in the ED. Another 7% of patients necessitated admission – which is where this article sort of starts to get muddy. The overall intent seems to be to describe this influx of aforementioned “worried well” due to home blood pressure monitors, but a 7% admission rate is hardly trivial – and actually 78% of patients complained of some potentially related or important concurrent symptom. The most common somatic complaints were headache (38%), dizziness (30%), and chest pain (16%). This isn’t exactly a cohort of “asymptomatic hypertension”, and shouldn’t be perceived as a proxy for potentially unnecessary ED utilization.
Of course, there is the chicken and egg paradox with these symptoms – are they somatization of anxiety from the elevated blood pressure or true pathology? Considering the relative paucity of admissions from this fairly symptomatic cohort, it does not appear treating clinicians generally considered the elevated blood pressure related to important end-organ dysfunction. Then, there are the obvious limitations to their chart review and the generalization challenges from this regional catchment area in Canada. Many words later, at the least, there is one reasonable takeaway regarding ED patients with home blood pressure monitors – it is true, they’re everywhere!
“The Characteristics and Outcomes of Patients Who Make an Emergency Department Visit for Hypertension After Use of a Home or Pharmacy Blood Pressure Device”
https://www.ncbi.nlm.nih.gov/pubmed/30037583
I learned about this first hand from my mother, bless her (hypochondriacal) heart. When she got anxious or stressed, she would start taking frequent BP measurements, and then I’d get a call. It only stopped when I hid her machine. So now when the CC is “concern for BP”, I ask screening questions for anxiety and depression, with virtually 100% positive response rate. Anecdotal, I know, but I almost never give these folks anything for their BP. Don’t feed the bears!
Time for a new RCT:
Patients are issued home BP monitors that are either accurate, or 50% reduced toward the normal range. All are, of course, blinded.
See if any patient-oriented cardiovascular or renovascular outcomes change. Secondary outcomes are ED visits, polypharmacy complications, and costs.
On another topic I’d like to hear your take on: the study that showed a fever recorded in the ED (a better word IMO would be “recognized”) improved survival in sepsis. When I’m confronted with a patient (especially elderly) that has nonspecific symptoms and a normal oral triage temp, I take my own rectal temp (to avoid RN eye rolls). This is anecdotal, but the yield on this “test” is around 30%, ie a third of the time they actually have a fever. Which means they get their antibiotics right away. So I’m convinced core temps are a best practice. I’ve been trying for >10 years to find someone to collaborate on studying this. Any interest?
Design: observational study. Inclusion: all patients >60 with a normal oral temp who consent to a rectal temp. Rectal Temps would probably need to be taken by MD as RN’s don’t like them so won’t be very convincing.
Outcome variable: % of time the oral temp is falsely normal.
This could eventually lead to an RCT to look at whether rectal temp improves survival (if time to atbx is the main determinant, I’m prettty convinced it will).