Head-to-head comparison of the WHO STEPwise approach with immediate unattended and delayed unattended automated blood pressure measurements during household-based screening: a diagnostic accuracy study in Lesotho

Emmanuel Firima; Lefokotsane Retselisitsoe; Ikhetheleng Leisa; Molulela Manthabiseng; Mamoronts'ane P Sematle; Matumaole Bane; Makhebe Khomolishoele; Lucia Gonzalez; Ravi Gupta; Stephen McCrosky; Tristan Lee; Frédérique Chammartin; Bailah Leigh; Maja Weisser; Alain Amstutz; Thilo Burkard; Niklaus Daniel Labhardt

doi:10.1016/j.eclinm.2023.102197

Head-to-head comparison of the WHO STEPwise approach with immediate unattended and delayed unattended automated blood pressure measurements during household-based screening: a diagnostic accuracy study in Lesotho

EClinicalMedicine. 2023 Aug 30:63:102197. doi: 10.1016/j.eclinm.2023.102197. eCollection 2023 Sep.

Authors

Emmanuel Firima^{1

2

3}, Lefokotsane Retselisitsoe⁴, Ikhetheleng Leisa⁴, Molulela Manthabiseng⁴, Mamoronts'ane P Sematle⁴, Matumaole Bane⁴, Makhebe Khomolishoele⁴, Lucia Gonzalez^{1

2

3}, Ravi Gupta⁴, Stephen McCrosky^{1

2}, Tristan Lee^{1

3}, Frédérique Chammartin^{1

2}, Bailah Leigh⁵, Maja Weisser^{2

6

7}, Alain Amstutz^{1

2}, Thilo Burkard^{8

9}, Niklaus Daniel Labhardt^{1

2}

Affiliations

¹ Division of Clinical Epidemiology, University Hospital Basel, Basel, Switzerland.
² Department of Clinical Research, University of Basel, Basel, Switzerland.
³ Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
⁴ SolidarMed, Partnerships for Health, Maseru, Lesotho.
⁵ College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Freetown, Sierra Leone.
⁶ Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
⁷ Ifakara Health Institute, Ifakara, Tanzania.
⁸ Medical Outpatient Department and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel, Basel, Switzerland.
⁹ Department of Cardiology, University Hospital Basel, Basel, Switzerland.

Abstract

Background: WHO introduced the STEPwise approach to surveillance (STEPS) to monitor trends in non-communicable diseases. For arterial hypertension, the STEPS protocol takes the average of the last two out of three standard blood pressure measurements (SBPM). This study assesses the diagnostic accuracy of SBPM, same-day and next-day unattended automated measurement (uABP), with 24 h ambulatory measurement (24 h-ABPM) as reference.

Methods: This diagnostic accuracy study was done within a population-based household survey on cardiovascular risk factors in two districts in Northern Lesotho. Adults (aged ≥ 18 years) with elevated SBPM (defined as ≥140/90 mmHg), and 2:1 age- and sex-matched participants with normal SBPM during the survey were recruited. Following SBPM, first uABP readings were obtained on survey day. Afterwards, participants received a 24 h-ABPM device. Second uABP readings were taken 24 h later, after retrieval of the 24 h-ABPM. The main outcome was overall diagnostic accuracy of all screening measurements (SBPM, first uABP, and second uABP), determined using area under the receiver operating characteristic curve (AUROC), with 24 h-ABPM as a reference.

Findings: Between November 2, 2021 and August 31, 2022, 275 participants (mean age 58 years (SD: 16 years), 163 (59%) female) were enrolled, 183 of whom had elevated and 92 had normal SBPM. Mean difference between systolic daytime 24 h-ABPM and screening measurements was highest for SBPM (mean difference: -13 mmHg; 95% CI: -14 to -11). Mean difference between diastolic daytime 24 h-ABPM and diastolic SBPM was -2 mmHg (95% CI: -4 to -1), whereas no difference was found for mean diastolic first uABP (mean difference: -1 mmHg; 95% CI: -2.0 to 0.3); and mean diastolic second uABP (mean difference: 1.0 mmHg; 95% CI: -0.4 to 2.3). White coat hypertension was highest with SBPM (55 [20%]), followed by first uABP (27 [9.8%]), and second uABP (18 [6.5%]). Using systolic daytime 24 h-ABPM as a reference, the uABPs had higher AUROC (first uABP: 87% [95% CI: 83-91]; second uABP: 88% [95% CI: 84-92]); SBPM: (79% [95% CI: 74-85]). This difference was significant between first uABP and SBPM (P = 0.0024), and between second uABP and SBPM (P = 0.0017).

Interpretation: uABP had better diagnostic performance than SBPM. Integration of uABP into STEPS protocol should be considered.

Funding: Swiss Agency for Development and Cooperation under the ComBaCaL project, and the World Diabetes Foundation.

Keywords: Ambulatory blood pressure monitor; Lesotho; STEPS; Sub-Saharan Africa; Survey screen blood pressure; Unattended automated office blood pressure.