Understanding the barriers to blood pressure assessment in cats

Abstract

Objectives

A questionnaire was designed to survey veterinarians and veterinary nurses/technicians on blood pressure (BP) assessment in cats, including ocular examination, encompassing current methodology, indications, uptake and barriers.

Methods

An online questionnaire was produced and promoted to more than 2000 veterinary professionals, of whom 545 answered all questions and 85 answered most questions.

Results

Of the participants, 572 (90.8%) were based in the UK and almost all (n = 613, 97.3%) had access to a BP monitor. Of those that had a monitor, most (n = 550, 88.4%) participants had access to a Doppler monitor; 367 (59.0%) participants had access to multiparameter monitors; fewer (n = 202, 32.5%) had access to oscillometric BP monitors. Where applicable, Doppler monitors were most commonly chosen for conscious cat measurements (n = 337, 72.2%) due to the greater ‘trust’ and ‘reliability’ of these compared with oscillometric machines. Conscious BP measurement typically involved two members of staff (n = 391, 62.9%). Only 156 (29.1%) participants recommended BP assessment at least several times a week in their interactions with cat owners. BP assessment was routinely recommended in cats with ocular target organ damage (n = 365, 87.7%), chronic kidney disease (n = 346, 78.6%), proteinuria (n = 255, 63.0%) and hyperthyroidism (n = 266, 60.9%). Common equipment-related barriers included ‘cuff frustration’ and difficulties hearing the pulse signal for Doppler users (72.2% and 71.6%, respectively), and oscillometric machines failing to give a reading at least some of the time (52.8%). Situational hypertension concerns affected many (n = 507, 92.0%), as did lack of time to do the procedure (n = 402, 73.0%). Significant owner barriers included difficulties persuading the owner to bring their cat in for BP checks (n = 475, 86.2%) and concerns over costs (n = 445, 80.8%). Most participants had access to a direct ophthalmoscope (n = 527, 96.5%); however, 399 (73.1%) reported that they struggled to interpret ocular findings.

Conclusions and relevance

Significant barriers exist to successful BP assessment in cats. Education and support of clinics should focus on improving confidence with equipment and eye examination.

Introduction

Systemic arterial hypertension is considered a common condition of the older cat but is thought to be significantly underdiagnosed in clinical practice. ¹ The assessment of blood pressure (BP) is considered an essential component of the physical examination, especially for cats aged older than 10 years ² , since the risk of hypertension is known to rise with increasing age.^3,4 Hypertension can cause a variety of serious – potentially life-threatening – consequences associated with target organ damage (TOD), including hypertensive injury to the brain, kidneys, eyes, heart and blood vessels. Clinical consequences of TOD include hypertensive chorioretinopathy (presenting as blindness/visual deficits), left ventricular hypertrophy (presenting as heart murmurs, arrhythmias, gallop sounds), progressive renal injury (manifesting as proteinuria and worsening of serum creatinine elevations), and encephalopathy and stroke (presenting as neurological and/or behavioural signs). ⁵ When diagnosed, hypertension is often straightforward to manage, with a choice of veterinary-authorised medications available in most countries. ⁵

Current published studies indicate that BP assessment is underperformed in clinical practice. One study estimated that just 1.34% of cats presenting at UK primary care clinics over a 2-year period received a BP assessment. ¹ In that study, 61% of cats diagnosed with hypertension had their BP assessed due to presenting with clinical signs of TOD, 31% were assessed due to monitoring of concurrent diseases associated with hypertension and just 4% were diagnosed via a ‘geriatric health check’. Many of the cats diagnosed with hypertension were classified with severe hypertension (systolic BP 180 mmHg or higher) and the authors of that study highlighted a lack of early diagnosis through more routine BP assessment of cats aged 10 years and over and those with illnesses known to increase the risk of hypertension. The authors also recommended more research on barriers to successful BP assessment in clinics in order to design educational programmes to support clinical practice. A separate questionnaire-based survey of veterinarians predominantly based in North America similarly indicated that BP assessment was more likely to be recommended in cats with TOD or concurrent diseases predisposing to hypertension, rather than in healthy older cats. ⁶

Very few data exist relating to current knowledge on barriers to performing BP assessment, although concerns over the reliability of equipment and impact of stress and anxiety on conscious cat BP readings have been reported in one study. ⁶

The aims of the present study were to determine current practices, including equipment and protocols, as well as barriers to BP assessment and whether these related to equipment, time, space, the cat, the owner or other factors. This was achieved by designing a questionnaire circulated to veterinary professionals working in small animal clinics.

Materials and methods

Population of interest

The target population for the questionnaire was veterinarians and veterinary nurses/technicians working in clinical practice with feline patients globally.

Questionnaire design

The questionnaire was made up of 30 core questions with the option to complete an additional four questions if participants were happy to share solutions they had found to commonly encountered challenges to BP assessment. Participants were asked if they were a veterinarian or veterinary nurse/technician, the country they were working in and further information on their clinic, such as whether it was feline only, primary care or referral. Subsequent questions asked whether BP measurement was performed in the clinic or in patients’ homes, what sort of monitor was used, how many staff were required for the assessment and whether owners were typically present. Participants were asked how often they were usually recommending BP assessment, the indications for recommending BP assessment and what proportion of owners allowed them to perform this procedure. Several questions asked about participants’ experience of barriers to BP assessment relating to the equipment, time, procedure, patients, owners and whether the COVID-19 pandemic had impacted BP assessment in their clinic. Pre-visit and in-clinic sedation protocols were also asked about, as was ocular examination to look for TOD due to systemic hypertension.

The initial draft of the questionnaire was piloted with a small group of colleagues who suggested amendments before the launch of the final questionnaire. The final questionnaire was hosted on the Vet Professionals website in full compliance with General Data Protection Regulation (GDPR) (EU) 109 2016/679 and is available as supplementary material.

Questionnaire distribution

The questionnaire was launched on 16 May 2022. An invitation to complete the survey was emailed to veterinarians and vet nurses/technicians on the Vet Professionals database, consisting of 1223 UK-based and 840 non-UK-based individuals. Snowball sampling, where existing respondents help to recruit further respondents by sharing the questionnaire with their acquaintances, was also conducted. The questionnaire was promoted on social media platforms (eg, Facebook and Twitter) alongside promotion by International Cat Care, Cats Protection and Vet Times. The questionnaire was closed to all respondents on 30 July 2022. Data collected from the survey were collated and stored using FormSite (Vroman Systems).

Data management and analysis

Data processing and descriptive statistics were carried out in Microsoft Excel.

Ethical approval

Approval was obtained from the Human Ethical Review Committee (HERC) at The Royal (Dick) School of Veterinary Studies, The University of Edinburgh, for the collection of data through an online questionnaire, and subsequent analysis of these data (approved 7 April 2022, reference no. HERC_2022_28).

Results

In total, 545 completed questionnaires and an additional 85 partially completed questionnaires were received during the study period.

Demographics

Participants were primarily veterinary nurses/technicians (n = 340, 54.0%) or veterinarians (n = 270, 42.9%), with a small number of student nurses, animal care assistants and clinic support staff comprising the remainder (n = 20, 3.2%). The majority of participants were based in England (n = 497, 78.9%), followed by Scotland (n = 48, 7.6%), Wales (n = 20, 3.2%) and Northern Ireland (n = 7, 1.1%). A range of countries outside the UK accounted for the remainder (n = 58, 9.2%). Most participants (n = 552, 87.6%) were based in small animal primary care clinics, with a few (n = 26, 4.1%) working in small animal referral clinics or feline-only primary care clinics (n = 19, 3.0%). The remaining participants were working in other roles, including emergency only, shelter only, small animal and exotics, and peripatetic services. Almost two-thirds of participants (n = 333, 62.4%) were working in a corporate-owned clinic; one-third (n = 216, 34.3%) were working in independent clinics. The remainder were working in university-, charity- or employee-owned clinics. Most participants (n = 557, 88.4%) shared their clinic postcode area (Figure 1).

Figure 1

Geographical distribution of 557 (88.4%) of the survey participants

Blood pressure equipment

Almost all (n = 613, 97.3%) participants worked in a clinic with access to a BP monitor, with nine (1.4%) participants reporting they only ‘sometimes’ had access to a monitor and the remaining eight (1.3%) reporting that they did not have access to a monitor.

Multiparameter monitors were available to 367 (59.0%) participants; and, where people knew the brand name or type of their monitor, it was possible to determine that 550 (88.4%) participants had access to a Doppler monitor and 202 (32.5%) participants had access to an oscillometric BP monitor. A small number of participants (n = 55, 8.8%) had at least one monitor but did not know the brand name or type of their equipment. The most frequently cited Doppler monitor was the Thames Medical Cat or Cat+ Doppler (n = 272, 43.7%); the most frequently cited oscillometric BP monitor was the SunTech series (n = 84, 13.5%).

Around one-fifth of participants (n = 133, 21.4%) only had one monitor available to use. For the remainder, where they knew what type of monitor they had, a Doppler monitor was most commonly chosen for conscious cat BP measurements (n = 337, 72.2%) vs oscillometric or multiparameter monitors (n = 130, 27.8%). The reasons for selecting one monitor as their ‘default’ option for conscious cats are shown in Figure 2. Participants were able to select multiple reasons if they wished. For those choosing to use a Doppler monitor, 66.8% of participants said this was because ‘I trust the results the most with this monitor’ and 58.1% said the Doppler unit was ‘more reliable in getting readings than alternatives’. For those selecting an oscillometric monitor as their default machine, the modal reason was that it was ‘easier to use than alternatives’ (65.2%), with being able to take readings on my own, the speed of obtaining a reading and cats’ preference also commonly cited (Figure 2). Results were very similar for the two most frequently used Doppler monitors (Thames Medical: n = 139; Vet BP: n = 94). More variability was observed between the oscillometric monitors; however, the small numbers (12–33 participants for each type of monitor) prevented meaningful comparison.

Figure 2

Reasons selected for why individual monitors were chosen as the ‘default’ monitor for conscious blood pressure assessment according to ‘default’ monitor. A total of 392 participants had a choice of monitor for conscious patients: 277 participants selected a Doppler machine as their default monitor, while 115 participants selected an oscillometric machine as their default monitor

BP measurement procedure

Conscious BP measurement was reported to most commonly involve two members of clinic staff (n = 391, 62.9%) vs one (n = 220, 35.4%). When asked whether owners were typically present for assessments, there was an even split between those answering no (n = 187, 30.1%) and yes (n = 195, 31.4%), with the remainder reporting that this varied. Where owners were present, they were involved in the restraint of the cat some or all of the time (n = 381, 87.6%). Free-text comments relating to the presence of the owner typically reported the owner as a soothing presence, ‘just stroking/talking to and fussing’, and ‘hands off’ rather than actively restraining the cat.

Only 47 (7.6%) participants were currently offering ‘at-home’ BP assessments to their clients. Optional free-text comments received from 154 participants indicated that cost, lack of clinic staff and COVID-19 had reduced their ability to offer this service or said that this had never been offered.

Frequency of BP assessment recommendations and success of follow-through

Participants were asked, where applicable, how frequently they recommended BP assessment in any of their feline patients and what proportion of cases went on to have a BP assessment. Respondents were asked to answer the question as if working full-time at their current clinic. In total, 84 (13.5%) participants excluded themselves from answering this question by selecting ‘other’, with most commenting that, as vet nurses/technicians, they were not responsible for recommending BP checks, as this was the remit of the vet, or that, as a nurse, they were not seeing clients themselves.

For the remainder, 39.4% (n = 211) of participants reported that they recommended BP assessment to cat owners attending the clinic once a month or less, 31.5% (n = 169) recommended it several times a month and 29.1% (n = 156) recommended it several times a week. Of the participants, 53 (9.9%) reported to be recommending BP assessment at least once a day to owners bringing in their cats. Overall, around one-third of participants (n = 182, 31.8%) reported that 76–100% of owners who were recommended BP assessment for their cat went on to allow this procedure to be performed. A similar proportion of participants (n = 186, 32.5%) reported that 51–75% of owners who were recommended BP assessment for their cat went on to allow this procedure. In total, 68 (11.9%) respondents reported that 25% or fewer of owners who were recommended BP assessment for their cat went on to allow this procedure. Participants recommending BP assessment at least once a day had the highest ‘success’ in converting a recommendation to an assessment, with 45.3% of these respondents stating that 76–100% of owners who were recommended BP assessment for their cat went on to allow this procedure.

When is BP assessment recommended?

The most common potential TOD indication for recommending BP assessment was ocular pathology and/or visual deficits, while the presence of behavioural or neurological signs consistent with TOD was least likely to result in a recommendation for BP assessment (Figure 3). Chronic kidney disease (CKD) was the concurrent disease diagnosis for which the highest level of routine BP assessment recommendations were made (Figure 4), with 78.6% of participants routinely recommending BP assessment in these patients compared with 25.5% of patients receiving erythropoiesis/erythropoietin stimulating agent therapy. Age-related BP assessment screening of older cats was evident, with 44.0% of participants routinely recommending BP assessment in healthy cats aged 15 years and over (Figure 5). Pre-anaesthetic BP screening of apparently healthy cats was routinely recommended by 18.6% of participants. More than 100 participants added further free-text comments, in which many stated that BP was routinely monitored in sedated and anaesthetised patients.

Figure 3

Frequency of blood pressure (BP) assessment recommendation according to clinical signs

Figure 4

Frequency of blood pressure (BP) assessment recommendation according to concurrent disease diagnosis. ESA = erythropoiesis/erythropoietin stimulating agent

Figure 5

Frequency of blood pressure (BP) assessment recommendation in healthy older cats and those requiring anaesthesia (eg, for dental surgery)

Barriers to BP measurement

Equipment-related barriers to BP measurement are shown in Figure 6. The availability of equipment was not a problem for most participants but ‘cuff frustration’ (cuffs pinging off) and difficulties hearing the pulse were experienced at least sometimes by 72.2% and 71.6% of participants, respectively, when using Doppler machines. Failure of the oscillometric machine to give a reading at least sometimes was reported by 52.8% of participants using these machines. Around half of the respondents (n = 261, 47.4%) found BP measurement a hassle or stressful and/or did not trust the equipment or result obtained. When asked which of these barriers had the biggest impact on them, struggling to hear the pulse using the Doppler method had the highest response (n = 152, 27.6%), although 116 participants (21.1%) reported ‘none’ for this question. Participants were asked about barriers relating to the procedure, such as space, time and access to help from colleagues (Figure 7). Lack of time was most problematic, with only 150 (27.2%) participants stating that this was not a problem for them. When asked which of the barriers had the biggest impact on them, 245 (44.5%) participants selected ‘I don’t have enough time’ and 20.0% said ‘none’.

Figure 6

Equipment-related barriers to blood pressure (BP) monitoring

Figure 7

Barriers related to the blood pressure (BP) assessment procedure

Participants were asked about practical barriers relating to the patient, including concerns over situational hypertension and stress (Figure 8). Situational hypertension was a concern, ‘even in cats that appear calm’, for 507 (92.0%) participants, and 478 (86.8%) stated their ‘patients don’t tolerate BP measurement’ at least some of the time. When asked which of the patient-related barriers had the biggest impact, 206 (37.4%) participants stated concerns over situational hypertension causing false high readings, while 158 (28.7%) selected ‘if I see the cat is stressed, I don’t check BP as I assume the readings may be affected’.

Figure 8

Cat-related barriers related to the blood pressure (BP) assessment procedure

Owner-related barriers to BP assessment were also raised (Figure 9). When asked which of these had the biggest impact on the participants, concerns over cost (n = 168, 30.5%), followed by difficulties persuading owners to bring their cats in for BP checks (n = 140, 25.4%) and persuading clients to book a separate appointment for a BP check (n = 104, 18.9%), were reported. Longer consultations were least problematic; 48.8% of participants (n = 269) reported that longer consultations were not a problem for their clients (Figure 9). Optional free-text comments included concerns from respondents regarding ‘excessive fees’, owners not understanding the need for BP assessment and reiteration of previously discussed barriers such as time, stress in the cat and concerns over reliability of the technology.

Figure 9

Owner-related barriers related to the blood pressure (BP) assessment procedure

The COVID-19 pandemic was cited by some participants as having had a negative impact on the number of BP assessments performed (n = 211, 37.1%), primarily due to staff and time constraints, clients unlikely to bring in their cat ‘just for a BP assessment’ and fewer senior clinics.

Pre-visit and in-clinic sedation

Pre-visit gabapentin was being used by 305 (56.6%) respondents, and pre-visit trazodone was used by 57 (10.6%) participants. In-clinic gabapentin and/or butorphanol were used sometimes by 69 (12.8%) participants.

Eye examination

Most participants (n = 395, 72.4%) reported performing an ocular examination at least sometimes (always in 11.0%) as part of the BP assessment in feline patients. Respondents typically had access to a direct ophthalmoscope alone (n = 527, 96.5%), with fewer having access to a tonometer (n = 294, 53.9%), hand lens and light source (n = 134, 24.5%), slit lamp (n = 53, 9.7%) or PanOptic ophthalmoscope (n = 27, 5.0%). Access to equipment was not a common barrier, with only 17 (3.1%) participants reporting this as a consistent issue. However, a lack of confidence and/or ability to interpret ocular findings, at least some of the time, was reported by 340 (62.3%) and 399 (73.1%) participants, respectively (Figure 10). When asked which of the barriers had the biggest impact, ‘I struggle to interpret ocular findings’ was reported by 139 (25.8%) participants. Lack of time was cited by 104 (19.3%) participants.

Figure 10

Barriers related to eye examination to the blood pressure assessment procedure

Solutions identified by participants

A total of 289 participants contributed their tips and solutions for commonly encountered challenges. Frequent suggestions included performing BP assessment as part of the consultation and not charging extra for this; when short of time, admitting the cat to a quiet and calm ward so that measurements could be taken later in the day; and empowering nurses/technicians to get involved with BP assessment checks through nurse clinics or by working alongside vets in their clinics. Client education about hypertension and marketing of senior care packages that included BP assessment were further suggestions. A selection of representative comments is included in Table 1. Utilising nurses/technicians was mentioned by 49 participants and admitting patients to facilitate calm BP assessment at a later time was mentioned by 24 participants. Participants were also asked what support they would appreciate in their clinics: 52 participants requested continuing professional development/training on the use of equipment, general education on hypertension, and tuition on performing eye examinations and interpreting ocular findings. When asked about joining a Task Force to collaborate on finding solutions for commonly encountered problems, 99 participants indicated they would be interested in doing this.

Table 1

Selection of representative comments relating to solutions identified by participants for the challenges experienced

Challenge	Participant-suggested solution
Lack of equipment and/or equipment concerns	Use nurses
	Admit animals to calm them before trying to get blood pressure (BP)
	Have an extra Doppler available, above and beyond what you need for surgery and medical patients that are hospitalised
	Train the team
Lack of space or staff	Use owners to help
	Admit the cat instead of doing it within the consult
	Sit with the cat on my lap so I can measure BP without additional help
	Nurses take BP while the vets carry on consulting
Lack of time	Admit the cat to a quiet ward to check BP when I have time
	Use nurses, book separate appointments, run nurse clinics
	Book double appointments
	Senior cat vaccinations and health checks have longer appointments
Low client uptake	We do not charge extra for checking BP, it is included in the consult fee
	We have included BP in our senior pet screens and try to allocate longer appointment times for these patients
	Client education helps but takes time
	I explain to clients that we don’t want to wait until the cat has a stroke to find out if they have hypertension. Since most people are well aware of how strokes occur in people, they draw the conclusion pretty quickly that it’s valuable in their cat
Other suggestions	Home visits
	Practise, practise, practise!
	Use treats to distract so that no restraint is needed

Discussion

This study set out to investigate what, if anything, was stopping veterinarians and vet nurses/technicians from assessing BP in their feline patients. Sadly, we found that BP was not being assessed nearly as frequently as needed, with 40% of participants currently only recommending BP checks for any of the cats that they saw in their clinic up to once a month.

BP assessment recommendations have not been unanimously agreed. The International Society of Feline Medicine recommends a BP assessment at least every 12 months in cats aged 7 years and over, ⁷ the American College of Veterinary Internal Medicine considers annual BP screening of all animals aged 9 years and over to be reasonable ⁵ and the American Association of Feline Practitioners guidelines state BP assessment to be an essential component of consultations for cats older than 10 years. ²

Participants in this study are likely to be seeing at least several cats in the above age groups each week as, for example, 30–50% of feline patients in the United States are believed to be aged 7 years or older. ⁸ Medical conditions, such as CKD, known to increase the risk of systemic hypertension, are common in clinical practice, especially in older cats, and should also prompt a recommendation for BP assessment.^{9 –13} This study primarily targeted members of the Vet Professionals’ database to complete this questionnaire, and therefore was biased towards individuals with a particular interest in feline medicine (see below). Although it is not possible to confirm how many of the participants derived from the Vet Professionals’ database and therefore a response rate cannot be reported, the authors consider it likely that the majority of participants did come from this source since more than half of the responses were received within 2 weeks of the survey’s launch. Participants recruited via snowball sampling will likely have shared the same interest in feline medicine. Therefore, the authors acknowledge bias in the respondents towards vets and nurses enthusiastic about feline clinical work. Nonetheless, overall, the authors were disappointed with many of the findings, which raises the possibility of even more concerning findings for BP assessment as a whole in clinical practice. For example, while ‘routine’ BP screening of apparently healthy cats aged 15 years and over was evident, fewer cats aged 7–14 years received ‘routine’ BP assessment and less than half of participants recommended pre-anaesthetic BP screening, for example, before dental surgery.

A lack of equipment is not a barrier to BP assessment – fewer than 3% of participants indicated that they only sometimes or never had access to a monitor. While the majority of participants had multiparameter monitors available to them, Doppler devices were most commonly selected for conscious cat BP assessment and the prime reasons for this were greater perceived trust and reliability of this equipment compared with alternatives. Where an oscillometric machine was preferred, this was mainly due to this being easier to use. The current study found the preference and reasoning for use of Doppler methodology to be similar to that reported in a recent survey of veterinarians in the United States. ⁶ However, a recent European survey indicated a more even split between Doppler and oscillometric monitors in conscious cats. ¹⁴ While the current scientific consensus is that no methodology has been validated for measuring BP in conscious small animals, ⁵ for many years, the Doppler methodology has been the preferred technique, especially for conscious cats.^15–18

Opportunities exist for the improved early diagnosis of systemic hypertension by increasing awareness of situations where BP assessment is indicated, primarily in patients presenting with signs consistent with TOD and in patients with underlying diseases/medications/toxicities associated with an increased risk of systemic hypertension. ⁵ In line with other studies, ¹ the current study indicated that BP assessment is not being recommended or performed as frequently as the authors would wish. Fewer than 10% of participants were recommending BP assessment to any cat owners they saw within the course of a day, and 156 (29.1%) participants recommended BP assessment at least several times a week. This compares negatively with a recent US survey, where 49.5% of veterinarians surveyed were recommending BP assessment at least once a week. ⁶ The current survey found that participants prioritised recommendations for BP assessment for certain situations, most commonly ocular TOD, where almost 90% of participants reported that they routinely recommended BP assessment. However, it was much less ‘routine’ to recommend assessment in cats with proteinuria (63.0%), new heart murmurs or arrhythmias (56.1%), or behavioural/neurological signs (42.7%). Similarly, BP assessment was only routinely recommended in 78.6% of cats with CKD, 60.9% of cats with hyperthyroidism and 40.3% of cats with primary hyperaldosteronism.

Much of this study focused on identifying potential barriers to BP assessment and their relative importance. While access to equipment was not a barrier to participants, technical challenges, such as being able to hear a good pulse signal and ‘cuff frustration’, were reported. Since the majority of participants were using Doppler units to assess BP in conscious cats, equipment frustration was biased towards ‘Doppler issues’. Lack of time was a frequent concern (73.0%), and 92.0% of participants expressed concern over situational hypertension, even in cats that appeared calm. Situational hypertension (ie, a transient increase in systolic BP due to excitement or anxiety associated with the clinic visit and/or the measurement process that occurs in an otherwise normotensive patient) is unpredictable. ⁵ It can be severe in some cases, with increases in systolic BP readings of as much as 75 mmHg documented in some cases. ¹⁹ Incorporating a 10-min period of acclimatisation before collecting BP readings typically results in a significant reduction in systolic BP readings of around 20 mmHg ²⁰ and thus is commonly recommended. The current study did not ask participants how much time was allocated for the procedure or whether an acclimatisation period was routinely included.

Eye examinations are helpful in confirming a diagnosis of systemic hypertension. Patients with documented ocular TOD in addition to high BP readings are confirmed to be hypertensive and need to start antihypertensive therapy. While the presence of ocular TOD routinely resulted in a recommendation for BP assessment, the current survey indicated that a lack of confidence and/or ability in eye examination was common and that training and support in this procedure would be of great value to participants.

The current study identified the leading owner-related barrier to BP assessment as being cost, with potential solutions suggested, such as including BP assessment in the standard consultation fee and utilising nurses/technicians instead of veterinarians. It is of note that more vet nurses/technicians completed the questionnaire than vets (54% vs 43%), which suggests that vet nurses are engaged and enthusiastic with respect to BP assessment.

This study has some limitations in that it was promoted via the author’s (SMAC) database and therefore selected enthusiastic feline veterinarians and vet nurses/technicians, who are more likely to work in clinics with equipment for BP measurement and practise high standards of feline medicine. Social acceptability bias is likely to further complicate results in that participants may have been tempted to, for example, exaggerate the frequency with which they were recommending BP assessment. Answers depended on participants’ memory and so recall bias may have featured. Many nurses/technicians participating in the study commented that they did not feel able to make recommendations for BP assessment without a veterinarian’s supervision and this impacted some of the results (Figures 3–5). Since BP assessment is not in itself a diagnosis, it was disappointing to see that some nurses/technicians were hesitant about recommending BP assessment, with many commenting that recommending BP assessment was primarily or solely within the veterinarian’s remit.

Confidence and clinical environment may play a role here since the number of nurses/technicians excusing themselves from answering some questions varied according to indication. For example, in Figure 4, the number of ‘eligible’ participants ranges from 263 (cats receiving erythropoiesis/erythropoietin stimulating agent) to 442 (overweight or obese cats) compared with Figure 5, where around 480 participants commented on the frequency of recommendation of BP assessment for healthy older cats and those requiring anaesthesia.

The final questions asked for participant solutions and suggestions for improving clinical practice, with responses illustrating a demand for more training and support to assist clinics with hypertension assessment. Further studies are warranted to determine whether client uptake can be increased through strategies highlighted by the participants, such as including BP assessment in a standard consultation fee rather than charging extra, staff training and increased use of nurses/technicians to recommend and perform BP checks.

Conclusions

While this study shows good awareness of hypertension as an issue and excellent availability of suitable measurement devices, clear barriers to assessment exist, with fewer than 10% of participants recommending BP assessment in their daily interactions with cat owners. Future support should be oriented towards practical training in obtaining reliable BP readings, performing ocular examinations and recognising the common ocular manifestations of systemic hypertension.

Supplemental Material

sj-docx-1-jfm-10.1177_1098612X231183244 – Supplemental material for Understanding the barriers to blood pressure assessment in cats

Supplemental material, sj-docx-1-jfm-10.1177_1098612X231183244 for Understanding the barriers to blood pressure assessment in cats by Sarah MA Caney, Su Page and Danièlle A Gunn-Moore in Journal of Feline Medicine and Surgery