Can blood pressure measurements taken in the physician’s office avoid the ‘white coat’ bias?

Abstract

Obtaining an accurate blood pressure (BP) reading is vital for diagnosing hypertension. However, BP measures taken in the physician's clinic (CBP) are subject to the 'white coat' bias. Measurements taken outside the office using ambulatory (ABP) and home (HBP) monitoring are superior predictors of cardiovascular diseases compared with CBP, but ABP remains underutilized because of the effort and expense involved. Unfortunately, HBP has limitations, including questionable device validity and patient compliance. Thus, it is important to identify feasible alternative techniques to measure BP in the office that will increase the accuracy of the diagnosis. Auscultatory BP was measured in 249 patients in a nonclinical setting by trained technicians (NCBP); on the following day, patients were taken to their physician (CBP). They were also given an HBP monitor, and a 36 h ABP monitoring. Because ABP is considered the gold standard for prediction of cardiovascular disease, these readings were used as the criterion in a statistical model in which CBP, HBP, and NCBP were entered as predictors. The level of agreement between measurements was estimated. Multiple regression analysis showed that HBP and NCBP (P < 0.001) explained 94 and 87% of the variance in systolic and diastolic ABP, respectively. The agreement between NCBP and ABP was greater than that between CBP and ABP or between HBP. When ABP monitoring and HBP monitoring are not options, the NCBP at the clinic can avoid the white coat bias and therefore improve diagnosis.