# Patients' acceptance of less blood pressure measurement in consultation: a cross-sectional study in general practice

Amélie Richard, Jeromine Trefond, Céline Lambert, Guillaume Balandreaud, Hélène Vaillant-Roussel

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Amélie Richard, Jeromine Trefond, Céline Lambert, Guillaume Balandreaud, Hélène Vaillant-Roussel.

Patients' acceptance of less blood pressure measurement in consultation: a cross-sectional study in general practice. Family Practice, 2023, 40 (1), pp.55-60. 10.1093/fampra/cmac059. hal-04880417

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# Patients' acceptance of less blood pressure measurement in consultation: a cross-sectional study in general practice

Amélie Richard<fnref n="1" />,<fnref n="2" />,<fnref n="3" />,* ID, Jeromine Trefond<fnref n="1" />,<fnref n="2" />, Céline Lambert<fnref n="4" />, Guillaume Balandreaud<fnref n="1" />, Hélène Vaillant-Roussel<fnref n="1" />,<fnref n="2" />,<fnref n="5" />

**Purpose:** Blood pressure (BP) is measured at almost every general practitioner (GP) consultation in the region of Auvergne, France. A 2018 qualitative study shows that GPs measure BP to satisfy patients, whereas patients declare themselves indifferent to the absence of the measurement. The objective was to validate the results of a qualitative study, to quantitatively assess patient satisfaction when BP is not measured, and to study the factors associated with the degree of patient satisfaction.

**Methods:** This was a quantitative observational study conducted using self-questionnaires among patients in medical practices in Auvergne.

**Results:** Four hundred and ninety-two questionnaires were evaluated in 20 medical practices. Sixty percent of patients had indifferent or favorable feelings in the absence of BP measurement. In bivariate analysis, young age, male sex, absence of pathology, and low frequency of visits were associated with indifferent or favorable feelings in the absence of BP measurement. In multivariable analysis, a history of hypertension and psychiatric history were associated with unfavorable feelings. The intraclass correlation coefficient for practice-related variability was 5.6%. Patients' susceptibility to having particularly favorable or unfavorable feelings could be related to their GP (physician effect).

**Conclusion:** The hypothesis put forward in the qualitative study is confirmed: the majority of patients are in favor of or indifferent to the absence of BP measurement in general practice. General practice could be more efficient by measuring BP less frequently and better.

**Key words:** blood pressure determination, physician–patient relations, general practice

## Introduction

The measurement of blood pressure (BP) is performed almost systematically in general medical consultations, as a kind of ritual.<fnref n="1" />,<fnref n="2" /> Despite the frequency of this procedure, hypertension is still insufficiently detected, with one of 2 hypertensive people unaware of their condition.<fnref n="3" /> Factors distort the results of BP measurement.<fnref n="4" />⁻⁶ Four of 5 measurements have at least one methodological bias.⁶ From a medicolegal point of view, the general practitioner (GP) must limit his or her actions to what is necessary for the quality and effectiveness of care.⁷ In 2018, the European societies of cardiology and hypertension advocated measurement every 5 years for optimal BP, every 3 years for normal BP, and every year for high normal BP.⁸ A qualitative study in 2018 was interested in the feelings of GPs and patients in the absence of BP measurement. The GPs performed this procedure in response to a supposed request from patients. Paradoxically, most patients felt indifferent or positive about the absence of measurement.⁹ Our objective was to quantitatively verify the results of the qualitative study: are patients indifferent to their BP not being measured in the consultation?

## Methods

The article presented here follows the updated guideline for reporting Strengthening the Reporting of Observational studies in Epidemiology (STROBE).¹⁰

### Type of study and sampling

A quantitative observational cross-sectional study was conducted using a patient satisfaction self-questionnaire from November 2019 to January 2020. Twenty GPs were randomly selected among those registered with the Council of the Order in the French region of Auvergne in 2019, respecting the proportion of GPs per department (there are 4 departments in Auvergne). Another GP from the same department was randomly selected if a GP refused to participate or in the absence of a response within 3 weeks after the telephone call (after at least 2 reminders within this period) or if a GP practiced an activity other than general practice (angiology, occupational medicine, medical expertise, spa doctors, hospital doctors). Questionnaires and an explanatory poster were placed in the waiting rooms of these practices for recruitment. Patients were asked to imagine and remember consultations they had

<footnote n="1">¹Department of General Practice, Clermont Auvergne University, Clermont-Ferrand, France</footnote>

<footnote n="2">²Research Unit ACCePPT, Clermont Auvergne University, Clermont-Ferrand, France</footnote>

<footnote n="3">³Maison de Santé Pluriprofessionnelle des Batignolles (MSP), Joze, France</footnote>

<footnote n="4">⁴Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France</footnote>

<footnote n="5">⁵DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France</footnote>

<footnote>*Corresponding author: Department of General Practice, UFR Medicine and Medical Professions, University of Clermont Auvergne, 28 Place Henri Dunant, 63000 Clermont-Ferrand, France. Email: Amelie.richard@uca.fr</footnote>
## Key message

* General practitioners measure blood pressure (BP) to satisfy patients.

* Four of 5 BP measurements have at least one methodological bias.

* Quantitative observational study was conducted using self-questionnaires among patients.

* Majority of patients are in favor of or indifferent to the absence of BP measurement.

* General practice could be more efficient by measuring BP less frequently and better.

experienced. The waiting room was shared by several GPs. A sealed ballot box allowed for anonymous collection.

## Questionnaire

It was developed from bibliographic data (Supplementary Appendix 1).⁹,¹¹ The question was "How do you feel if your GP does not take your blood pressure during a consultation?." Patients' memories were called upon for 2 types of consultations: for an acute reason or for a chronic reason. It was validated by a panel of experts, CL, AR, HVR, and GB, and tested on 20 patients in a multiprofessional health center before its diffusion.

## Primary objective, inclusion criteria, and exclusion criteria

The primary objective was to determine the rate of indifferent, favorable, or unfavorable patients in the absence of BP measurement. The secondary objective was to identify the factors associated with the different feelings.

All GP practices in Auvergne could take part in the study. If more than one GP was recruited from the same practice, all were randomized to the same group as the first recruited.

For the patients, the inclusion criteria were adult patients consulting a GP from an included practice, regardless of their reason for consultation and their treating physician. The exclusion criteria were the inability to read, write, or understand a questionnaire. Illegible questionnaires and patients coming to see another health professional in the practice (physiotherapy, osteopathy) were excluded, as the practices could combine several health care activities.

## Statistical analysis

This cross-sectional study conducted on a sample should make it possible to generalize the results to the entire target population. A margin of error on the estimate (reliability of the sample) is defined to calculate the number of patients needed, in addition to the expected proportion of indifferent patients in the absence of BP measurement. Considering an expected proportion of 70% (according to the qualitative study), the inclusion of at least 323 patients (resp. 505) made it possible to obtain a precision of ±5% (resp. ±4%). Thus, the inclusion of at least 400 patients was a good compromise regarding the reliability and feasibility of the study. Considering that approximately 20 patients per GP could be included, 20 GPs were randomly selected to obtain a sample of 400 patients.

Statistical analysis was performed using Stata software (version 15; StataCorp, College Station, TX). All tests were 2-sided, with a Type I error set at 0.05. Categorical data are expressed as the number of patients and associated percentages, and age is expressed as the mean ± standard deviation. The rate of patients with an indifferent or positive perception

of the absence of BP measurement during a consultation was expressed with a 95% confidence interval (CI). Factors associated with a negative perception were studied using generalized linear mixed models with a logit link function. In these models, medical practice was considered a random effect. The ratio of the between-cluster variance to the total variance, called the "intraclass correlation coefficient" (ICC), was calculated to measure how individuals within a cluster (medical practice) are similar to one another. A multivariable analysis was performed considering the covariates according to the bivariate results and clinical relevance. The results are expressed as odds ratios (ORs) and 95% CIs.

## Results

### Sample

During the inclusion phase, it was necessary to randomly select 33 general practices to obtain the required sample of 20 general practices (Supplementary Appendix 2 and Table 1). Indeed, 13 were excluded: 2 with special practice, 2 retired, 1 refusal, and 8 unreachable. Among the 20 general practices finally included in the study (Supplementary Appendix 2), 17

<table><caption>Table 1. Patient characteristics.</caption><thead><tr><th></th><th>Total (n = 492)</th></tr></thead><tbody><tr><td>Age (years)</td><td>53.2 ± 16.5</td></tr><tr><td>Age ≥ 65 years</td><td>139 (28.3)</td></tr><tr><td>Female sex</td><td>344 (69.9)</td></tr><tr><td>Medical antecedents</td><td>318 (64.6)</td></tr><tr><td>High blood pressure</td><td>136 (27.6)</td></tr><tr><td>Psychiatric problems</td><td>33 (6.7)</td></tr><tr><td>Chronic treatments</td><td>313 (63.6)</td></tr><tr><td>Antihypertensive</td><td>153 (31.1)</td></tr><tr><td>Psychotropic drugs</td><td>41 (8.3)</td></tr><tr><td>Frequency of consultation</td><td></td></tr><tr><td>1–2 per year</td><td>120 (24.4)</td></tr><tr><td>3–5 per year</td><td>261 (53.0)</td></tr><tr><td>At least 6 times a year</td><td>111 (22.6)</td></tr><tr><td>Urban living environment<sup>a</sup></td><td>253 (51.4)</td></tr><tr><td>Level of education</td><td></td></tr><tr><td>No diploma</td><td>34 (6.9)</td></tr><tr><td>Grade 9</td><td>111 (22.6)</td></tr><tr><td>High school diploma</td><td>108 (21.9)</td></tr><tr><td>Higher education</td><td>239 (48.6)</td></tr></tbody></table>

Data are presented as number of patients (column percentages) or mean ± standard deviation.

<sup>a</sup>Place of living was urban for more 2,000 residents.
were group practices. The 3 places that did not return any questionnaires were a group practice in Clermont Ferrand (the capital of the Auvergne), a general practitioner in isolated practice in Aulnat (a small commune in the Puy de Dôme), and a group practice in Saint-Paulien (in the rural department of the Haute Loire). The questionnaires were moved and were not in evidence in the waiting room, so no questionnaires were completed. One thousand questionnaires were distributed with an expected 50% response rate. The response rate varied depending on the medical practice, and 3 practices did not return any questionnaire. Of the 495 questionnaires returned, 3 were excluded on the basis of age. The characteristics of the patients are detailed in Table 1. The mean age was $53.2 \pm 16.5$ years, and 69.9% were women.

## Univariate analysis

Of the 492 questionnaires included, in response to question 1 (context of an acute condition), 59.8% of patients were indifferent or in favor of not measuring BP (95% CI: 55.2–64.2%) (Table 2). In response to question 2 (context of a chronic reason), of 286 patients, 52.4% were indifferent or in favor of not measuring BP (95% CI: 46.5–58.4%).

Whatever the reason for the consultation (acute or chronic), 93% of the "indifferent feelers" trusted their GP, 91% of the "positive feelers" expected to be listened to and that the measure would be available, and 94% of the "negative feelers" thought that the measure should be automatic.

Most practices had an equal amount of unfavorable feedback, between 35% and 50%. Three practices were less than 30%, and 3 were more than 55%, all of which were solo practices. The susceptibility of patients to having a particularly negative or positive feeling could be related to the habit of their GP, so a "doctor effect" is possible. In this study, the ICC was 5.6%.

<table><caption>**Table 2.** Patient perception results in different consultation contexts.</caption><thead><tr><th></th><th>Acute condition context (n = 492)</th><th>Chronic condition context (n = 286)</th></tr></thead><tbody><tr><td>Negative perception</td><td>198 (40.2)</td><td>136 (47.6)</td></tr><tr><td>Systematic measurement</td><td>186/197 (94.4)</td><td>121/136 (89.0)</td></tr><tr><td>Consultation for nothing</td><td>21/197 (10.7)</td><td>16/136 (11.8)</td></tr><tr><td>Other</td><td>9/197 (4.6)</td><td>13/136 (9.6)</td></tr><tr><td>Indifferent perception</td><td>283 (57.5)</td><td>139 (48.6)</td></tr><tr><td>Confidence in the treating physician</td><td>262/281 (93.2)</td><td>131/139 (94.2)</td></tr><tr><td>Knowledge of usual blood pressure</td><td>51/281 (18.2)</td><td>25/139 (18.0)</td></tr><tr><td>No blood pressure symptoms</td><td>36/281 (12.8)</td><td>18/139 (12.9)</td></tr><tr><td>Other</td><td>21/281 (7.5)</td><td>9/139 (6.5)</td></tr><tr><td>Positive perception</td><td>11 (2.2)</td><td>11 (3.8)</td></tr><tr><td>Other expectation</td><td>10/11 (90.9)</td><td>9/11 (81.8)</td></tr><tr><td>Examination focused on symptoms</td><td>7/11 (63.6)</td><td>0/11 (0.0)</td></tr><tr><td>Other</td><td>1/10 (10.0)</td><td>2/11 (18.2)</td></tr></tbody></table>

Data are presented as number of patients (column percentages).

## Bivariate analysis

The consultations for acute conditions were significantly associated with indifferent/positive feelings: younger age, male sex, absence of medical history, chronic treatment, hypertension, antihypertensive treatment, psychiatric problems, psychotropic treatment, and a lower frequency of consultation (Table 3). The consultations for chronic conditions were significantly associated with indifferent/positive feelings: younger age, absence of medical history, chronic treatment, hypertension, and antihypertensive treatment. One element appeared in the context of the chronic pattern: living in a rural area was associated with indifferent or positive feelings.

## Multivariable analysis in case of consultation for acute conditions

A history of hypertension was significantly associated with negative feelings (OR = 1.86, 95% CI: 1.08–3.20), as was a psychiatric history (OR = 2.73, 95% CI: 1.20–6.24), independent of other factors included in the model (age, sex, and number of consultations per year) (Fig. 1).

## Discussion

### Main result

Patients are mostly indifferent to the lack of BP measurement during consultation.

### Strengths and weaknesses

This is an original topic that is little treated in the literature. Information bias was limited by the use of a sealed ballot box and the absence of GP involvement. The neutrality of the questionnaire limited the satisfaction bias so as not to influence the answers. The voluntary recruitment of patients was in the waiting rooms. The sample was representative of the French population of general practice patients, compared with that found in the ECOGEN study: 35.66% over 60 years old, 58.26% women.¹²

## Findings in the context of existing literature

Almost 60% of patients felt indifferent/positive in the absence of BP measurement. The GP's perception of the patient's expectations is the main determinant for dispensing a prescription during a consultation.¹³ However, the expectations perceived by the GP and the real expectations of the patient can be discordant, as in this case concerning the measurement of BP.⁹ It is in the GP's interest to communicate well with the patient to better understand the patient's expectations.¹⁴ The shared medical decision allows the patient to be involved and the GP to better understand the patient's expectations.¹⁵ This approach also applies to screening procedures, such as measuring BP.¹⁶

Younger patients and men were open to not measuring BP. Younger patients are less concerned about their BP. Men place less emphasis on prevention and consult their GP less often than women.¹⁷⁻²⁰ High BP is more frequent in men²¹ and less well controlled³ than in women.

Patients with a history of hypertension are aware of BP risk. Several studies have shown that awareness of disease risk depends on personal history.²²,²³ However, these patients are certainly not aware of the optimal and validated conditions for BP measurement, including the 10-min resting time. People with a psychiatric history, as well as people with
<table><caption>**Table 3.** Factors associated with patients' perception of the absence of blood pressure measurement during a consultation in general practice in the context of acute and chronic conditions.</caption><thead><tr><th rowspan="2"></th><th colspan="3">Acute conditions</th><th colspan="3">Chronic conditions</th></tr><tr><th>Indifferent or positive perception (n = 294)</th><th>Negative perception (n = 198)</th><th>P</th><th>Indifferent or positive perception (n = 150)</th><th>Negative perception (n = 136)</th><th>P</th></tr></thead><tbody><tr><td>Age (years)</td><td>51.7 ± 16.9</td><td>55.4 ± 15.7</td><td>0.006</td><td>55.8 ± 15.8</td><td>61.9 ± 12.6</td><td>&lt;0.001</td></tr><tr><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>&lt;65 years</td><td>217 (61.5)</td><td>136 (38.5)</td><td>0.13</td><td>100 (57.5)</td><td>74 (42.5)</td><td>0.017</td></tr><tr><td>≥65 years</td><td>77 (55.4)</td><td>62 (44.6)</td><td></td><td>50 (44.6)</td><td>62 (55.4)</td><td></td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>191 (55.5)</td><td>153 (44.5)</td><td>0.006</td><td>102 (52.0)</td><td>94 (48.0)</td><td>0.88</td></tr><tr><td>Male</td><td>103 (69.6)</td><td>45 (30.4)</td><td></td><td>48 (53.3)</td><td>42 (46.7)</td><td></td></tr><tr><td>Medical antecedents</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>117 (67.2)</td><td>57 (32.8)</td><td>0.012</td><td>12 (85.7)</td><td>2 (14.3)</td><td>0.014</td></tr><tr><td>Yes</td><td>177 (55.7)</td><td>141 (44.3)</td><td></td><td>138 (50.7)</td><td>134 (49.3)</td><td></td></tr><tr><td>High blood pressure</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>226 (63.5)</td><td>130 (36.5)</td><td>0.003</td><td>103 (62.8)</td><td>61 (37.2)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>68 (50.0)</td><td>68 (50.0)</td><td></td><td>47 (38.5)</td><td>75 (61.5)</td><td></td></tr><tr><td>Psychiatric problems</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>282 (61.4)</td><td>177 (38.6)</td><td>0.008</td><td>134 (52.3)</td><td>122 (47.7)</td><td>0.86</td></tr><tr><td>Yes</td><td>12 (36.4)</td><td>21 (63.6)</td><td></td><td>16 (53.3)</td><td>14 (46.7)</td><td></td></tr><tr><td>Chronic treatments</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>120 (67.0)</td><td>59 (33.0)</td><td>0.017</td><td>10 (90.9)</td><td>1 (9.1)</td><td>0.025</td></tr><tr><td>Yes</td><td>174 (55.6)</td><td>139 (44.4)</td><td></td><td>140 (50.9)</td><td>135 (49.1)</td><td></td></tr><tr><td>Antihypertensive</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>216 (63.7)</td><td>123 (36.3)</td><td>0.007</td><td>97 (64.7)</td><td>53 (35.3)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>78 (51.0)</td><td>75 (49.0)</td><td></td><td>53 (39.0)</td><td>83 (61.0)</td><td></td></tr><tr><td>Psychotropic drugs</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>276 (61.2)</td><td>175 (38.8)</td><td>0.040</td><td>130 (52.2)</td><td>119 (47.8)</td><td>0.89</td></tr><tr><td>Yes</td><td>18 (43.9)</td><td>23 (56.1)</td><td></td><td>20 (54.1)</td><td>17 (45.9)</td><td></td></tr><tr><td>Frequency of consultation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>1-2 per year</td><td>82 (68.3)</td><td>38 (31.7)</td><td>0.019</td><td>16 (55.2)</td><td>13 (44.8)</td><td>0.91</td></tr><tr><td>3-5 per year</td><td>156 (59.8)</td><td>105 (40.2)</td><td></td><td>90 (52.0)</td><td>83 (48.0)</td><td></td></tr><tr><td>At least 6 times a year</td><td>56 (50.5)</td><td>55 (49.5)</td><td></td><td>44 (52.4)</td><td>40 (47.6)</td><td></td></tr><tr><td>Place of residence<sup>a</sup></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Urban</td><td>146 (57.7)</td><td>107 (42.3)</td><td>0.11</td><td>69 (46.3)</td><td>80 (53.7)</td><td>0.045</td></tr><tr><td>Rural</td><td>148 (61.9)</td><td>91 (38.1)</td><td></td><td>81 (59.1)</td><td>56 (40.9)</td><td></td></tr><tr><td>Level of education</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No diploma</td><td>21 (61.8)</td><td>13 (38.2)</td><td>0.60</td><td>15 (55.6)</td><td>12 (44.4)</td><td>0.33</td></tr><tr><td>Grade 9</td><td>64 (57.7)</td><td>47 (42.3)</td><td></td><td>44 (57.9)</td><td>32 (42.1)</td><td></td></tr><tr><td>High school diploma</td><td>70 (64.8)</td><td>38 (35.2)</td><td></td><td>37 (57.8)</td><td>27 (42.2)</td><td></td></tr><tr><td>Higher education</td><td>139 (58.2)</td><td>100 (41.8)</td><td></td><td>54 (45.4)</td><td>65 (54.6)</td><td></td></tr></tbody></table>

Data are presented as number of patients (row percentages) or mean ± standard deviation. Significant P-values in bold are less than 0.05.

frequent consultations, are opposed to the lack of measurement. This reflects possible anxiety with a related search for reassurance. A recent study showed a statistical link between the frequency of consultation and the presence of psychosomatic disorders.²⁴

Patients who have always seen their GP measure BP cannot imagine a consultation without this procedure. Each

physician, according to his or her habits and representations, has a responsibility for the habits and representations of his or her patients. A “doctor effect” is possible.

Frequent measurement of BP in the office leads to an overestimation of the white coat effect, and nonoptimal measurement conditions lead to ignoring high figures with a diagnostic and therapeutic delay.²⁵⁻²⁷ The GP could carry out

<footnote><sup>a</sup>Place of residence was urban for more 2,000 residents.</footnote>
<figure><img src="image_2.png" /><figcaption>**Fig. 1.** Multivariable analysis of factors associated with patients' negative perception of the absence of blood pressure measurement during a consultation in general practice in the context of acute reason.</figcaption></figure>

this measurement in optimal conditions during a dedicated time by analyzing the values obtained. Patients are ready to accept the absence of systematic measurement. This gesture would no longer be a ritual of each consultation but rather a procedure carried out with care. Choosing to measure BP less often and but with greater care would make it possible to fight therapeutic inertia in the detection, follow-up, and control of hypertension.²⁸,²⁹

## Conclusion

The hypothesis put forward in the qualitative study was confirmed: the majority of patients were in favor of or indifferent to not measuring BP in general practice. General practice could be more efficient by measuring BP less often and, at the same time, measuring BP with greater care.

## Supplementary material

Supplementary data are available at *Family Practice* online.
Supplementary Appendix 1. Questionnaire.

Supplementary Appendix 2. Characteristics of the medical practices included in the study.

## Funding

The study was funded by departmental resources.

## Ethical considerations

The study was declared to the Commission Nationale de l'Informatique et des Libertés (CNIL) on 24/10/2019. The opinion of the Committee of Protection of Persons (CPP) South-East VI on 27/11/2019 (no. 2019/CE56) was favorable.

## Conflict of interest

None declared.

## Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

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