Brief online certification course for measuring blood pressure with an automated blood pressure device. A free new resource to support World Hypertension Day Oct 17, 2020

Abstract

Detection, diagnosis, and treatment of hypertension require accurate blood pressure assessment. However, in clinical practice, lack of training in or nonadherence to measurement recommendations, lack of patient preparation, unsuitable environments where blood pressure is measured, and inaccurate and inappropriate equipment are widespread and commonly lead to inaccurate blood pressure readings. This has led to calls to require regular training and certification for people assessing blood pressure. Hence, the Pan American Health Organization in collaboration with Resolve to Save Lives, the World Hypertension League, Lancet Commission on Hypertension Group, and Hypertension Canada has developed a free brief training and certification course in blood pressure measurement. The course is available at www. The release of the online certification course is timed to help support World Hypertension Day. This year World Hypertension Day has been delayed to October 17 due to the COVID‐19 pandemic. For 2020, the World Hypertension League calls on all health care professionals, health care professional organizations, and indeed all of society, to assess the blood pressure of all adults, measure blood pressure accurately, and achieve blood pressure control in those with hypertension.

1. INTRODUCTION

Increased blood pressure (BP) is the single leading modifiable risk factor for death in the world (1). Hypertension, the clinical manifestation of increased BP, is both preventable and treatable. ¹ A major impediment to the clinical management (diagnosis, treatment, and follow‐up) of hypertension is inaccurate BP assessment. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ This is primarily a result of lack of training or lack of compliance in measuring BP properly, performing measurement in inappropriate environments, inadequate preparation of the person whose BP is being measured, and inaccurate or inappropriate (unvalidated) equipment. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ These issues can be partially resolved by training the personnel involved in a standardized approach to BP measurement. ⁶ There have been increasing calls to require regular training and certification of all personnel involved in BP measurement.

There is a lack of programs to train and certify observers and, to our knowledge, currently no easily accessible “online” programs where those measuring BP could be trained and certified. ⁶ In an effort to address this gap and in responding to countries increasing demand, the Pan American Health Organization, in the context of the ongoing HEARTS in the Americas Initiative (HEARTS in the Americas. https://www.paho.org/en/hearts‐americas , accessed May 7, 2020), mobilized to develop a brief online training and certification program for BP measurement in adults. The course was developed in collaboration with the World Hypertension League, Lancet Commission on Hypertension Group, Resolve to Save Lives, and Hypertension Canada and has no cost for users.

In keeping with current recommendations that automated and semi‐automated devices with an upper arm cuff be used for BP measurement in adults, the certification program exclusively addresses these automated BP measurements. ² , ⁴ , ⁶ The certificates of completion have a validity of 6 months in keeping with data that regular retraining and certification are necessary to maintain BP measurement skills, even in a epidemiological BP survey context. ⁹ The program includes a brief video on accurate BP assessment, covering patient preparation, appropriate environment for BP assessment, measurement technique, and use of accurate and appropriate equipment. Following the video is a true/false knowledge and attitude test, where all questions must be correctly answered before a course certificate can be obtained. There is also a module that briefly discusses the questions and answers to facilitate learning and reinforcement of knowledge gained. The total time to watch the video and take the test is estimated to be under 20 minutes. The program is available at https://bit.ly/PAHOVC‐Blood‐Pressure‐Measurement in English, Spanish, Portuguese, and French, (with links to Italian and Chinese) and the program is designed to be easily translated into other languages. Intended for health care personnel, including non‐professional health workers, particularly at the primary health care level, the course is also suited to health science students and health literate people who measure BP at home or who are involved in programs that assess BP. The course is available to be translated and reposted by credible health and scientific organizations with credit being provided to the developing organizations and members as well as indicating support by the translating and reposting organization.

It is acknowledged that there are limitations to this online course. A major limitation is in having a high proportion of health care professionals take the course voluntarily or preferably as a requirement. The course will be promoted by the supporting organizations all of which are active in population hypertension control programs. The table outlines the suggested actions that organizations and individuals can take to assist in disseminating the course and enhancing BP measurement. The course has not been tested in a randomized controlled trial to assess the impact of achieving certification on improving the accuracy of BP assessment. The usefulness of the course will be evaluated by assessing use of the course and through a brief evaluation questionnaire to those who have taken the course. The course does not allow for direct observation or interaction with trainers to more thoroughly ensure that recommendations for BP measurement are well understood and properly followed. There are very few hypertension control programs that have developed more extensive in‐person BP measurement and certification programs. ⁹ , ¹⁰ , ¹¹ , ¹² Further, our course does not address manual BP assessment, which is largely poorly performed, technically more difficult, and currently not recommended for routine clinical practice except in children to confirm a hypertension diagnosis. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ Typical certification programs for manual measurement take most of a day and require in‐person training, highly trained educators, and auditory testing. ⁹ , ¹¹ , ¹² The online certification course is also not well suited to individuals with low health literacy who may not understand the terminology used. In‐person training and certification courses more tailored to the audience may achieve superior outcomes. Further, the course is designed for assessment of BP in adults. In children, recommendations still favor manual measurement over automated measurement. ¹⁸ The current course can be viewed as a feasible early step that allows modest training and testing, without cost, and minimum inconvenience to those taking the course.

We hope our course enhances global efforts to engage health care professionals in accurate BP measurement and, at the very least, be an advance over the current situation in which ongoing training and assessment of BP measurement are rare.

A strong and solid call to action for hypertension control was released by the World Hypertension League and partners in 2019. ¹ Notably, increased BP is estimated to have resulted in preventable deaths and disability‐adjusted life years (DALY) of more than 10.4 million and 217 million, respectively, in 2017, with increasing numbers each year. ¹ Such figures mean that hypertension is a global crisis with pandemic proportions that needs a commensurate and coordinated global response to its immense health and socioeconomic burden. For instance, the current COVID‐19 pandemic, which has been particularly lethal in those with cardiovascular disease, has totaled 0.25 million deaths by May 6, 2020 (https://ourworldindata.org/covid‐deaths#what‐is‐the‐total‐number‐of‐confirmed‐deaths, accessed May 6, 2020), and at the time of writing this commentary, the global response has cost trillions of dollars (https://www.theglobeandmail.com/business/article‐can‐the‐world‐afford‐the‐cost‐of‐fighting‐covid‐19/, accessed May 7, 2020). In contrast, hypertension control has not yet found the same level of global responsiveness despite it having some of the strongest evidence for benefit in all of clinical science. Achieving high rates of hypertension control has immense and rapid benefit in reducing cardiovascular deaths and disability. Sadly, after decades of sustained decline in cardiovascular deaths and disability, in several countries the rates of decline have been markedly attenuated or even reversed to increases. ¹ , ¹⁹

The release of the free and brief online certification course for measuring BP with an automated device is timed to help support World Hypertension Day. This year World Hypertension Day has been delayed to October 17 due to the COVID‐19 pandemic. For 2020, the World Hypertension League calls on all health care professionals, health care professional organizations, and indeed all of society, to assess the BP of all adults and children, measure BP accurately, and achieve BP control in those with hypertension.

CONFLICT OF INTEREST

none.

AUTHOR CONTRIBUTIONS

NC, TK, PO, YARM, XHZ, RTT, LC, and JES. GF: honoraria for lectures by Omron HealthCare and Sanofi. RP is co‐founder and CEO of mmHg Inc, a digital health and telemonitoring company. RTT: Investigator‐initiated research grants from Merck and Sanofi and consulting work for Shoppers Drug Mart and Emergis Biosolutions.

NRCC drafted the manuscript which was reviewed and revised by the other co‐authors.

2.

Table 1.

Some interventions that health organizations and health care providers can undertake to encourage uptake of training and certification for blood pressure assessment

Disseminate the URL for the certification course to those who assess blood pressure with a focus on primary care.

Translate the certification course as needed for the local population.

Publish availability of the brief course via website, email, newsletters, letters to editors, and commentaries.

Develop more extensive online and/or in‐person training and certification courses.

Require health care workers to be certified (where feasible) and retain certification to assess blood pressure.

Encourage governmental, accreditation, and self‐regulating professional organizations to regulate a requirement for training and certification for accurate blood pressure assessment.

Take the brief course and provide feedback for enhancing the course to PAHO and the WHL.

Campbell NRC, Khalsa T, Ordunez P, et al. Brief online certification course for measuring blood pressure with an automated blood pressure device. A free new resource to support World Hypertension Day Oct 17, 2020. J Clin Hypertens. 2020;22:1754–1756. 10.1111/jch.14017